Sunday, November 13, 2016

Slaying Prehistoric Practice - Killing off the Routine Pulse Check

The Gist: It's time to kill off the routine pulse check every two minutes. While some providers and systems have moved away from routine pulse checks, perfunctory cessation in compression to identify pulses happens as 'the norm' across the United States. Check the rhythm as indicated - without halting compressions if you have a monitor that is able to sense despite compressions or if there is a spike in end tidal capnography (etCO2) or another compelling reason such as gain on arterial line tracing, or during a brief, <10 second pause, if compressions interfere with rhythm analysis [1].

Most of us recognize that, to the best of our knowledge, interruptions in chest compression may be deleterious to return of spontaneous circulation and, theoretically, neurologic outcome [2]. We may even devise complicated ways of reducing time without compressions including mechanical compressions and hands-on defibrillation. These interventions are not evidence based and the yield is minimal. A more simple fix exists - stop checking for pulses routinely.  This isn't some novel wild idea.

The American Heart Association guidelines do not recommend any specific interval for pulse check after the first initial pulse check for healthcare providers [3].  Beginning in 2010,  however, the AHA guidelines begin discouraging routine pulse checks:
"Because of difficulties with pulse assessments, interruptions in chest compressions for a pulse check should be minimized during the resuscitation, even to determine if ROSC has occurred" [4].

It's really difficult to identify pulselessness in < 10 seconds
. Few people can determine the presence of pulselessness in 10 seconds. Dick et al performed a study of patients placed on cardiopulmonary bypass, and providers were blinded to the presence of pulsatile flow. Only two percent of experienced providers (n=209) were able to determine that a patient was pulseless in under 10 seconds [5].
Enforcement of time between compressions may be mitigated by having someone count down from 10 during the rhythm analysis. We often have the individual performing chest compressions do this and they are trained and reminded at the beginning of the resuscitation to resume compressions when they reach zero.

Pulse checks are inaccurate. A study by Tibaballs et al again had providers assess for a pulse in patients on bypass with and without pulsatile flow. They found 78% accuracy in identification of the presence or absence of a pulse [6]. While an accuracy of 78% may seem high, this means that approximately one in four times we are wrong. This means we may feel the reverberation of our own pulse and the truly pulseless patient may have an unnecessary and perhaps deleterious delay in chest compressions. Cardiac ultrasound and arterial line tracings demonstrate contractility and flow with superior diagnostic characteristics, although each has their limitations [7].

Why would we undertake a diagnostic strategy if we know it it is inaccurate and insensitive? Changing practice is difficult. In critical situations we default to what is familiar, what we know.  It is time to move away from the pulse check. We may still need to check for rhythm analysis at periodic intervals, and this is supported by the AHA guidelines. Some monitoring systems allow for this concurrently with compressions (filter out the baseline), while others do not. Many of us are also compelled to search for reversible causes of arrest with ultrasound, many of which do not require an interruption in compressions.

If you're curious about why we are so stubborn to let go of our practices, check out this post on unlearning practices we adore.

1. Soar J et al. "European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support." Resuscitation, October 2015, Pages 100 - 1472.
2. Eftestøl T, Sunde K, Steen PA.  Effects of Interrupting Precordial Compressions on the Calculated Probability of Defibrillation Success During Out-of-Hospital Cardiac Arrest. Circulation.2002; 105: 2270-2273.
3. Link MS, Berkow LC, Kudenchuk PJ et al. Part 7: Adult Advanced Cardiovascular Life Support. Circulation. 132(18 suppl 2):S444-S464. 2015
4.Berg RA, Hemphill R, Abella BS et al. Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 122(18_suppl_3):S685-S705. 2010.
5. Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: what if there is no pulse? Crit Care Med. 2000 Nov;28(11 Suppl):N183-
6. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation. 81(6):671-5. 2010.
7. Gaspari R et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation 2016 Sep 27