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
Evaluation and treatment of patients in cardiopulmonary arrest has progressed
significantly in the last four decades with the advent of cardiac resuscitation protocols,
endotracheal intubation, central line placement and electric cardioversion. 1-4 However,
clinicians managing cardiopulmonary resuscitations are typically doing so blindly. While
electrocardiographic monitoring provides a glimpse of the electrical activity of the heart,
it tells the clinician little about actual myocardial function. 5 Thus, pulse checks are critical
and help determine if spontaneous circulation has resumed. In addition pulse checks will
typically decide whether chest compressions continue or not and if resuscitation is
Typically, invasive arterial blood pressure monitoring is not available in patients
arriving to an emergency department or resuscitation area. Similarly, hospitalized
patients that are not in an intensive care unit are unlikely to have any invasive monitoring
in place. Since pneumatic blood measuring devices are inaccurate, slow to result and
have difficulty picking up low blood pressures, physicians typically have to rely on
manual pulse palpation during resuscitation. 6 However, there is growing evidence that our
ability of accurately palpate a pulse is quite poor in these critically ill patients. 7,8 Some
studies indicate that physicians may accurately palpate a pulse in as low as 50% of
patients. 9 This likely results from the innate inaccuracy of pulse palpation, the tense
environment of a cardiac arrest and also the trend toward obesity and morbid obesity in
westernized countries. In addition, low blood pressure and low flow states which require
vasopressor support, but not continued chest compressions, may be too difficult to detect
by human hands in many cases.
Many intensivists, emergency physicians, surgeons and other clinicians have
found great utility in utilizing bedside echocardiography during cardiopulmonary arrest
management. 10-12 This reflects the ability of ultrasound to identify treatable causes of
arrest as well as aid in managing patient resuscitation. 13 Anecdotal experience, as well as
previous published studies suggest that there may be a discordance between
echocardiographic findings and electrocardiographic findings as well as detection of
pulses. 14 This study sought to evaluate the frequency of apparent discordance between
pulse detection by manual palpation and finding on echocardiography.
This was a retrospective quality assurance log review using de-identified patient
data of ultrasound findings during cardiac arrest pulse palpation breaks. The study was
conducted at busy emergency department with a large high acuity cardiac population and
annual census of approximately 80,000 patients. This study was IRB exempted due to its
retrospective quality assurance nature and use of de-identified data.
All patients arriving in, or experiencing cardiopulmonary arrest while in the
emergency department, without an indwelling arterial pressure monitor, were eligible for
enrollment if they had complete data in the quality assurance logs. As part of standard
practice all cardiopulmonary resuscitations were managed with bedside emergency
echocardiography, when hospital credentialed physicians were available. Patients with
incomplete quality assurance log data were excluded from the study. Quality assurance
logs were reviewed for cardiac arrest entries with completed EF estimate and
corresponding pulse check results by an experienced point of care ultrasound program
Arrest Echo Protocol
Each patient in cardiopulmonary arrest was scanned by a study physician during
pulse breaks. The treating physician was advised of echo finding as part of standard
practice, but the study physician did not make treatment recommendations. Bedside
ultrasound examinations were performed only during pulse checks, which were
conducted by a nurse and treating physician or second nurse. In all cases, at least two
healthcare providers assessed for pulses at the same time. All pulse checks were made
either at carotid artery or femoral artery locations. All efforts at performing an echo were
ceased when the pulse check was stopped by the treating physician. Echo checks
continued during pulse checks for the duration of the resuscitation as long as they did not
interfere with resuscitation efforts.
Left ventricular function on echocardiography was graded into distinct categories:
normal ejection fraction (EF), mildly (approximately 40 to 50%), moderately
(approximately 20 to 40%), severely depressed (approximately 10 to 20%) and negligible
function (EF below 10%) as previously defined in the literature. 15 If Echo suggested
sufficient EF to generate blood flow but pulse check revealed no palpable pulses, the
carotid arteries were evaluated with Doppler, color and pulse wave, when interference
with resuscitative efforts could be avoided.
All ultrasound examinations of the heart during pulse checks were videotaped
using either SVHS video tape or DVD and stored for quality assurance review. In
addition, ultrasound quality assurance logs were filled out with ultrasound findings and
clinical outcome as part of standard practice. Emergency sonologists utilized phased
array transducers with a range of 2.5 to 4 MHz using either as SonoSite 180 Plus, Titan,
Micromaxx or M-Turbo compact ultrasound machines. Standard echocardiography
windows were utilized to image the heart. The subxiphoid window was utilized
preferentially in order to avoid interference with resuscitation, the parasternal long and
apical four chamber views were used if no useful subxiphoid image was obtainable.
Transesophageal echocardiography was used when available, either on a Sonosite
Micromaxx or M-Turbo.
Main Outcome Measures
Physicians filled out standardized quality assurance logs. They recorded the
results of the pulse checks by team members and the corresponding emergency echo
findings. For secondary measures, if left ventricular ejection fraction was felt to be above
10% in the setting of absent pulses on palpation and the study physician was able to
Doppler a carotid artery, presence of absence of flow was recorded. In addition, when
pulse wave Doppler was used the peak systolic velocity was recorded. Sonologists also
recorded when manual pulse palpation revealed a palpable pulse, but emergency echo
showed either negligible that could not generate flow or complete absence of myocardial
Data were kept in an Access database (Microsoft Corporation, Seattle
Washington). Prior to analysis, data were exported to an Excel spreadsheet and
commercially available statistical software was used to perform analyses. Statistical
analysis included descriptive statistics and agreement analysis using Cohen Kappa
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 check and electrocardiographic monitor tracing. A total
of 178 (25.7%) Echo checks revealed EF of severely depressed or better and were felt to
likely generate a detectable blood pressure. In 47% (83.66) of these Echo checks, no
pulses were palpable. Conversely, in 31 (6%) pulse checks on 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.
Carotid Doppler was obtained in 37% of cases when Echo showed severely depressed or
better EF but no pulses were palpable. In these cases, all patients showed flow in the
carotid on both color and pulse wave Doppler. Echo results and pulse palpation during
pulse checks showed poor correlation. Echo results and pulse checks showed poor
agreement with a correlation coefficient of 0.52. Comparing only the 178 patients noted
to have echo based findings of adequate cardiac output the Cohen Kappa decreased to
Cardiopulmonary arrest has many etiologies, some of which are correctable
through interventions such as pericardiocentesis and many that are not. However,
identification of these correctable processes may be difficult simply based on physical
examination and electrocardiographic evidence. The focus of many resuscitation efforts
are patients with apparent electrical activity on a monitor, as they may hold out the
highest hope for successful resuscitation. 16 Over the past two decades, the use of Point of
Care Ultrasound to manage resuscitation has greatly improved the ability of clinicians to
accurately identify correctable causes of cardiac arrest in a variety of settings. 17 Recent
studies suggesting that focused ultrasound checks of the heart during CPR interfere with
quality chest compression are likely to push more providers to relying on pulse palpation
only. 18,19 However, prior data has repeatedly suggested pulse checks are unreliable for
resuscitation management, leaving providers who chose not to use ultrasound blinded to
cardiac function in many cases.
Pulseless electrical activity (PEA) occurs when a patient appears to have electrical
activity on a monitor, but no pulse can be palpated. Once thought to strictly indicate
mechanical asystole in the presence of electrical activity, it is now clear that a portion of
these patients have mechanical cardiac activity with blood pressures too low to result in a
palpable pulse, in that specific individual. One study demonstrated that up to 41% of
patients presenting with electrical activity but no pulse actually had mechanical
contractions of the heart. 20 While survival rates for patients in PEA are poor, with one
large study reporting 11% survival rate with only 62% of survivors having a good
neurological outcome, this group of patients are typically thought to have a higher
likelihood of survival than asystolic patients. 21 As the team managing the patient in
cardiopulmonary arrest strives to resuscitate the patient they are also seeking reversible
causes of cardiac arrest. In PEA patients these include tension pneumothorax,
hypovolemia, toxins, hypoglycemia, hypoxemia, acidosis, hypokalemia, hyperkalemia,
hypothermia, cardiac tamponade, cardiac ischemia, pulmonary embolism, and trauma. 22
Ultrasound can aid the resuscitation team by allowing visual assessment of
cardiac function as well are a more accurate evaluation for some the treatable causes of
PEA that are listed by both the AHA and European Council on Resuscitation. 23 Cardiac
tamponade from pericardial effusion can be readily identified by focused emergency
echo. 24 At the same time the provider can image the inferior vena cava to estimate
intravascular fluid volume and even monitor change in volume during ongoing
resuscitation. Cardiac contractility can be evaluated by emergency echo and may greatly
aid in goal directed resuscitation. Pneumothorax has been proven to be very accurately
ruled out and identified in multiple studies by point of care ultrasound. In cases of large
pulmonary emboli, point of care ultrasound may detect intra-cardiac thrombosis, venous
thrombosis or particular echo findings such as right heart strain on TAPSE and McConell
sign, which may strongly point toward presence of PE. 25 In such cases, the resuscitation
director may be more included to thrombolyse the patient given the evidence provided by
ultrasound. When complete mechanical cardiac stand still is noted on echo despite
several rounds of chest compressions and medications there is strong support that
successful resuscitation is extremely unlikely. Terminating the resuscitative efforts earlier
in such patients may save resources without compromising care.
In most situations of cardiopulmonary resuscitation, the code is continued until
further efforts are deemed futile and the resuscitation stopped or, in the minority, when
resumption of spontaneous circulation is noted. Unless the patient has already been in
the hospital or emergency department for some time and received an indwelling arterial
blood pressure monitor, the only commonly accepted method of determining resumption
of spontaneous circulation is palpating a pulse.
While patients with no cardiac output receive chest compressions and epinephrine
a hypotensive patient may be taken along a different pathway of resuscitation. Not only is
the treatment of a hypotensive patient different from that of a patient in PEA, but CPR
itself is not a benign intervention and may cause injury to the patient. Unnecessary
trauma to a critically ill patient could further complicate recovery if the patient survives
the resuscitation. Frequent findings in patients having undergone CPR include lesions of
tracheal structures and bony chest fractures. Less frequently encountered are lesions of
the pleura, pericardium, myocardium and other internal organs and vessels. 26
As this data indicates, disagreements between the ultrasound machine monitor
screen and manual pulse palpation are surprisingly common. The concept of actually
checking the carotid artery for blood flow on color and pulse wave Doppler came out of
multiple situations when disagreement occurred between staff that insisted on resuming
chest compressions and physicians who ordered them stopped because of adequate
estimated ejection fraction on focused echo. Such patients are most likely to be treated
with vasopressors and fluids in order to elevate their blood pressure, but may be difficult
to manage if providers are blind to their cardiac function. Our data further supports that
pulse palpation is inaccurate, in arrest situations, suggesting that providers may want to
add focused echo for additional information. In 37% of patients physicians were able to
access the carotid artery after the echo, which reflected an ejection fraction felt to be
consistent with perfusion of the brain. In each case color Doppler confirmed the presence
of spontaneous blood flow with measurement on pulse wave Doppler ranging from 60 to
Vascular ultrasound and neurology literature indicates that normal common
carotid artery peak systolic flow velocities vary considerably, but tend to range from 55
to 100 cm/sec. 27 Mean values in normal patients from the internal carotid are typically 54
to 88 cm/sec, but some normal individuals can have peak systolic velocities up to 120
cm/sec. 28 Values increase considerably for carotid stenosis. Regardless, the typical flow
velocity recorded in this study was quite near normal as previously defined. Multiple
other factors affect carotid peak systolic velocities, such as potential stenosis in the
vertebral arteries or the contralateral carotid. However, such fine details probably have
little bearing in gauging if adequate circulation is produced by a beating heart, while no
pulses are palpable. It is at this point that chest compressions may be terminated and
pressors instituted or adjusted as in any critically ill, hypotensive patient.
Exceedingly shocking was the fact that in 6% of cases a team member called out
“I have a pulse” leading to cessation of chest compressions, when the heart was in
mechanical standstill or had no viable contractile activity. We have noted anecdotally and
repeatedly that such confusion causes delays measured in minutes that may even last until
a pneumatic blood pressure cuff finally fails to obtain a blood pressure and another
provider realizes no pulses are palpable. While additional evidence will need to be
produced, it is more and more compelling that ultrasound should be present at the bedside
of every patient undergoing cardiopulmonary resuscitation whenever possible. This can
be achieved in the most unlikely settings. The introduction of highly compact devices has
enabled clinicians outside of the intensive care units and emergency departments to use
ultrasound for evaluation of cardiopulmonary arrest patients. Focused ultrasound
utilization has been documented in the settings of pre-hospital ground and air ambulances
as well as disaster scenes and even sporting events.
Limitations of the study include no invasive monitoring to compare pulse
palpation to actual arterial blood pressure. The study population was typical of diverse
western body habitus distributions and may not reflect findings in other populations
around the world where pulse palpation may be more or less accurate. The retrospective
nature of the study is also an inherent limitation, although data was collected
prospectively for quality assurance tracking.
In summary, data from this study suggests that disagreement between focused
echo and pulse palpation is a common occurrence. As suggested by previous studies and
resuscitation algorithms hypotension and asystole have different treatment pathways and
there may even be potential harm from unnecessary chest compressions. While more
studies are needed, the inclusion of focused echocardiography into cardiopulmonary
resuscitation may provide valuable additional information not accurately obtained from
palpation of pulses.
In this study, Echo findings and pulse palpation results frequently disagreed when myocardial activity was present. When Doppler analysis of carotid flow was possible in
patients with a gradable EF but no pulses, flow was always noted. In a small percentage of patients apparent palpable pulses occurred when Echo showed no myocardial contraction or negligible EF.
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