Discordance Between Pulse Palpation And Focused EchocardiographyFindings In Adult Cardiopulmonary Arrest Patients
AUTHOR: Dr Michael Blaivas, MD, MBA
Department of Emergency Medicine, St. Francis Hospital, Columbus, Georgia, USA
Objectives: Define the frequency of agreement between focused bedside
echocardiography (Echo) and pulse checks during cardiopulmonary resuscitation (CPR).
Methods: This was a retrospective review of multi-year quality assurance logs on cardiac
arrest patients evaluated with point-of-care Echo during CPR, over a seven year period.
All patients in cardiopulmonary arrest that presented when physicians trained in Echo
were availabile and had quality assurance documentation completed, were eligible for
enrollment. Patients for whom incomplete data was present in the logs were excluded
from the study. This study took place at a busy emergency medicine department with a
large cardiac population and an approximate annual census of 80,000 visits per year.
Emergency physicians (EPs), with hospital credentialing in point-of-care Echo, routinely
used ultrasound as part of their standard management of CPR patients. During all pulse
checks, nurses and physicians attempted to locate pulses while one EP performed a brief
Echo of the heart with a compact ultrasound machine. Echo checks were limited to the
time available during pulse checks and ended when the treating EP ordered resumption of
chest compressions. Myocardial function was graded into normal ejection fraction (EF),
mildly, moderately, severely depressed, negligible function and asystole as previously
defined in the literature. If Echo suggested sufficient EF to generate blood flow but pulse
check was negative, the carotid arteries were evaluated with Doppler when interference
with resuscitative efforts could be avoided. Statistical analysis included descriptive
statistics and Cohen Kappa coefficient for agreement analysis.
Results: A total of 693 pulse checks occurred concomitantly with Echo checks in 226
patients. Of the 226 patients, 59 (26.1%) had resumption of spontaneous circulation at some point in their resuscitation based on pulse palpation and electrocardiographic
monitor tracing. A total of 178 (25.7%) Echo checks revealed an EF felt to likely
generate a detectable blood pressure. In 47% (84) of those Echo checks, no pulses were
palpable. Conversely, in 31 (6%) pulse checks (when electrical cardiac activity was noted
on the monitor) and a healthcare provider felt palpable pulses, the echo showed either
myocardial standstill or negligible EF. Echo results and pulse palpation during pulse
checks showed poor correlation with a Kappa of 0.52.
Conclusions: In this study, Echo findings and pulse palpation results periodically
disagreed when myocardial activity was present. When Doppler analysis of carotid flow
was possible in patients with adequate EF but no pulses, flow was always noted. Very
concerning, in 6% of patients apparent palpable pulses occurred when Echo showed no
myocardial contraction or negligible EF
- This is a sponsored post from FUJIFILM SONOSITE -
OCULAR Ultrasound by dr luke Philips
FACEM, MBBS, BSC(BIOMED)(HONS), CCPU
EMERGENCY CONSULTANT - ALFRED HEALTH
CO-DIRECTOR OF EMERGENCY MEDICINE TRAINING (THE ALFRED HOSPITAL
CO-CHAIR OF THE EMERGENCY MEDICINE ULTRASOUND GROUP BOARD OF DIRECTORS
75yo Female presents to the ED with sudden onset right visual loss.
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