Manual Palpation Or Point-of-care ultrasound for Pulse Determination During Cardiopulmonary Resuscitation
Date First Published:
July 13, 2024
Last Updated:
July 25, 2024
Report by:
Bradley Emmerich, MD; Christian Kolacki MD, EM senior resident; EM core faculty (Corewell Health - Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI)
Search checked by:
Jeffrey S. Jones MD, Corewell Health - Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI
Three-Part Question:
For [adults requiring cardiopulmonary resuscitation] does the use of [point-of-care ultrasound] compared to [manual palpation] [reduce pulse check times]?
Clinical Scenario:
A 64-year-male presents to the emergency department in cardiac arrest. While undergoing cardiopulmonary resuscitation, chest compressions are paused every two minutes to evaluate for the presence of a pulse. As a knowledgeable resuscitationist, you know that minimizing pauses in chest compressions provides the best opportunity for a positive patient outcome. You wonder if using point-of-care ultrasound (POCUS) to evaluate for the presence of a pulse reduces pulse check times.
Search Strategy:
Medline 1966-07/24 using PubMed, Cochrane Library (2024), and Embase
Search Details:
(ultrasonography [All Fields] AND palpation [All Fields] AND pulse [All Fields]). Limit to English language and clinical trials
Outcome:
73 total articles were found, three prospective clinical trials were identified as both relevant and of sufficient quality for inclusion.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The POCUS pulse check: A randomized controlled crossover study comparing pulse detection by palpation versus by point-of-care ultrasound. Badra K, Coutin A, Simard R, Pinto R, Lee JS, Chenkin J. Jun-19 Canada | 111 volunteers underwent a pulse check assessment on two separate live models | Prospective randomized controlled crossover non-inferiority trial | Time to pulse detection by MP compared to US | The mean time to carotid pulse identification with US was 4.22 (SD 3.26) seconds compared to 4.71 (SD 6.45) seconds by MP | Participants assessed ability to detect a pulse in patients who had a normal heart rate and blood pressure, whereas patients in cardiac arrest have some degree of hemodynamic Participants assessed ability to detect a pulse in patients who had a normal heart rate and blood pressure, whereas patients in cardiac arrest have some degree of hemodynamic compromise. Additionally, this study was not blinded to the participants. |
| Number of attempts for each method | Using US, 110 (99.1%) participants were able to successfully identify a pulse on the first attempt compared to 95 (85.6%) by MP (p = 0.0001). | ||||
| Proportion of participants who took longer than five sec | No significant differences in the two groups | ||||
| Point-of-care ultrasound compression of the carotid artery for pulse determination in cardiopulmonary resuscitation. Kang SY, Jo IJ, Lee G, Park JE, Kim T, Lee SU, Hwang SY, Shin TG, Kim K, Shim JS, Yoon H. Oct-22 Republic of Korea | 25 cardiac arrest adult patients and 155 pulse checks were analyzed. | Prospective clinical trial | Time difference for pulse assessment with POCUS-CAC and MP | Average time to carotid pulse identification per patient using POCUS-CAC was 1.62 (1.14–2.14) s compared to 3.50 (2.99–4.99) s with MP | Limited sample size, performed at a single institution, it may not account for the variability in difficulty levels of pulse detection in the population; physicians with varying grades or ultrasound experiences were not included in the study; convenience sampling; selection bias; and there was no gold standard for pulse detection. |
| Time difference in each pulse check between methods | The average POCUS-CAC time for ROSC judgment was significantly reduced to 0.44 times the average MP time (P < 0.001). | ||||
| Proportion of times greater than 5 s and 10 s | The proportion of patients in whom it took > 5 s to identify their pulse was significantly lower when using the POCUS-CAC method (P < 0.001) | ||||
| Comparison of manual pulse palpation, cardiac ultrasonography and Doppler ultrasonography to check the pulse in cardiopulmonary arrest patients Zengin S, Gumusboga H, Sabak M, Eren SH, Altunbas G, Al B. Dec-18 Turkey | 164 adult patients to whom CPR was provided accompanied by cardiac ultrasonography (CUSG) and Doppler ultrasonography (DUSG) | Prospective clinical trial | Duration of pulse checks between the 3 methods | The average duration of CUSG was shorter than the average durations of DUSG and manual pulse palpation (p < 0.001) | Incomplete USG results in some cases and these were excluded from the study; single institution; limited US experience in residents performing ultrasounds |
Author Commentary:
Point-of-care ultrasonography (POCUS) has several advantages during CPR. It may help to understand intra-arrest physiology, identify reversible causes of arrest, and improve the efficiency of pulse checks to increase chest compression fraction (CCF). Clinicians can be inaccurate when performing manual palpation especially during CPR, which can interrupt chest compressions, prolong pulse checks, and decrease CCF. Pulse checks using POCUS require fewer attempts, is more accurate and faster than manual palpation.
Bottom Line:
Clinical palpation of a pulse may not be accurate in cardiac arrest. Point-of-care ultrasound compression of the carotid artery appears to be more reliable and faster than manual palpation.
References:
- Badra K, Coutin A, Simard R, Pinto R, Lee JS, Chenkin J. . The POCUS pulse check: A randomized controlled crossover study comparing pulse detection by palpation versus by point-of-care ultrasound.
- Kang SY, Jo IJ, Lee G, Park JE, Kim T, Lee SU, Hwang SY, Shin TG, Kim K, Shim JS, Yoon H. . Point-of-care ultrasound compression of the carotid artery for pulse determination in cardiopulmonary resuscitation.
- Zengin S, Gumusboga H, Sabak M, Eren SH, Altunbas G, Al B.. Comparison of manual pulse palpation, cardiac ultrasonography and Doppler ultrasonography to check the pulse in cardiopulmonary arrest patients