Rebranding the ‘Pulse Check’ in CPR

• More than a decade ago, because of the complexity of palpating a pulse and time off the chest, the American Heart Association (AHA) began discouraging routine pulse checks CPR. 
• The first step in our practice is changing the verbiage from ‘pulse check’ to ‘rhythm check’ during a resuscitation effort. 
• Limit the pauses, limit the time off the chest. For every pause greater than twenty seconds, your patient’s survival decreases. The delivery of a shock and cessation of cardiopulmonary resuscitation affect survival.
  

Rebranding the ‘Pulse Check’ in CPR

More than a decade ago, because of the complexity of palpating a pulse and time off the chest, the American Heart Association (AHA) began discouraging routine pulse checks during cardiopulmonary resuscitation (CPR). Yet, if you observe CPR in most institutions today, holdouts of this practice exist.  

Is the ingrained behavior, despite the documented inaccuracies, which continues to plague our resuscitative efforts? Regardless of the reasons, the emphasis of  CPR has shifted from complex algorithms to a primary focus on minimizing interruptions in chest compressions.  

Cardiac arrest is often unpredictable. In a perfect world, your team assembles bedside, you brief the room, assign roles, verbalize the patient’s information, and lay out a rough plan for the first few minutes of resuscitation. When emergencies arise, and pre-planning is not a workable option, there are steps to improve patient outcomes

The success rate of CPR ranges from 5% to 10% based on several factors, including the underlying causes, preexisting health conditions, elapsed time between arrest and CPR and CPR techniques. 

Where can we improve? Despite the vast technology at our fingertips, reduced hands-off time on the chest along with high-quality chest compressions and early identification of lethal rhythms improve outcomes. Even with high-quality chest compressions, cardiac output is 20% to 30% of the normal output.  

Chest compressions and use of electricity are life-saving interventions we can improve in the hospital setting. Outside the hospital environment, the numbers are staggering. The American Heart Society’s reports that of the over 356,000 out-of-hospital cardiac arrests, 90% of them are fatal.  

From ‘Pulse Check’ to ‘Rhythm Check’

The first step in our practice is changing the verbiage from ‘pulse check’ to ‘rhythm check’ during a resuscitation effort.  

What is the average length of a pulse check? It is around 20 seconds. For improving survival, it should be less than 10 seconds, but to maximize outcomes, less than 5 seconds is ideal.  

Denoting a perfusing rhythm is more efficient than an individual attempting to palpate a pulse. Not everyone checks for a pulse.  

To maximize efficiency, team lead designates a single individual as the pulse checker. After two minutes of high-quality CPR, identify the rhythm (organized perfusing or disorganized non-perfusing). If the rhythm is non-perfusing, resume CPR.  

Limit the pauses, limit the time off the chest. The risk of harm from unnecessary chest compressions is far less than withholding chest compressions. 

 For every pause greater than twenty seconds, your patient’s survival decreases. The delivery of a shock and cessation of cardiopulmonary resuscitation affect survival.  

A pause greater than 20 seconds, the patient’s survival is half than if that interval was less than 10 seconds. To decrease interruptions, novel methods such as hands-on defibrillation (HOD) appear efficacious in improving outcomes, though protective mechanisms for safety are required. 

Is POCUS the Answer?

While point of care ultrasound (POCUS) can offer information during the arrest, this diagnostic tool is not available at every institution. What answers can POCUS give? In the hands of a skilled provider, POCUS can assess the quality of compressions during CPR, find possible underlying causes, and help in the decision-making.

With an overall goal of shortening the interval between compression and rhythm checks, POCUS has drawbacks. The average pulse check duration with ultrasound was longer than the pulse checks without POCUS. If POCUS is to offer value, preparation is key. Prior to and during resuscitation, POCUS requires skill and coordination to be effective and not increase time off the chest.

How We Improve

Our primary goal is to develop uniformity in our approach to resuscitation through high performance CPR. Decades of research have identified high-quality chest compressions as a key part of survival for in hospital and out of hospital CPR.  

Studies comparing out of the hospital compression-only CPR to standard CPR found there was no significant difference in survival rates.  

The essential components of high-quality CPR include minimizing compression interruptions, adequate compression rate and depth, and avoiding excessive ventilation. Despite the validity of these components mixed data exists.  

In out-of-hospital cardiac arrest, continuous chest compressions during CPR performed by EMS providers did not result in higher rates of survival though any form of CPR doubled survival rates in comparison with NO-CPR. 

The Bottom Line

For now, to maintain oxygenation to the brain, heart, lungs, will we continue to value high quality compressions and limited interruptions in the hospital setting. 

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