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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
(ultrasonography [All Fields] AND palpation [All Fields] AND pulse [All Fields]). Limit to English language and clinical trials

Search Outcome

73 total articles were found, three prospective clinical trials were identified as both relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Badra K, et al June 2019 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
Kang SY, et al October 2022 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)
Zengin S, et al. December 2018 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

Comment(s)

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.

Clinical 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

1. 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. Resuscitation 2019 Jun;139:17-23
2. 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. Resuscitation 2022 Oct;179:206-213.
3. 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 Resuscitation 2018 Dec;133:59-64.