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Pulse Checks in Cardiac Arrest: Your Fingers Are Not Reliable.
Summary: Whenever possible, use an ultrasound or an arterial line for pulse checks. Our fingers are not reliable.
Key points:
- It is very difficult to obtain a palpable pulse in a hypotensive patient, even in the best of conditions. In cardiac arrest patients specifically, manual pulse checks are not a reliable method to detect return of spontaneous circulation (ROSC).
- Yet manual pulse checks remain the standard of care in ACLS algorithms.
- Better options to determine ROSC include ultrasound and arterial lines.
- End title CO2 is a useful adjunct, but should not replace ultrasound and arterial lines to determine ROSC.
- There is a lack of evidence to determine a measured arterial pressure in which it is safe to stop chest compressions, but in the absence of an evidence based, established standard, a MAP > 50 or SBP > 60 can be used as a tentative guide.
Multiple studies have demonstrated that manual pulse checks are not a reliable method to determine ROSC. Arterial lines and ultrasound are far more reliable methods. However, using more accurate measures of circulation lead to an additional dilemma: at what MAP, SBP, or ultrasound measured flow should we stop chest compressions? There is no agreed upon number, and as with most dilemmas in clinical medicine, the best answer is, “it depends”. However, a MAP > 50 or SBP > 60 for most patients is a reasonable choice to stop chest compressions. MAP < 50 or SBP < 60 are unlikely to provide adequate perfusion to the brain, and chest compressions should be resumed.
References:
- https://pubmed.ncbi.nlm.nih.gov/35131404/
- https://pmc.ncbi.nlm.nih.gov/articles/PMC6042301/
- https://pubmed.ncbi.nlm.nih.gov/30902687/
- https://pubmed.ncbi.nlm.nih.gov/36646373/
- https://pubmed.ncbi.nlm.nih.gov/35792305/
- https://emcrit.org/emcrit/further-disambiguating-pea/
- https://emcrit.org/emcrit/pea-is-stupid/