Point-of-care ultrasound compression of the carotid artery for pulse determination in cardiopulmonary resuscitation

doi:10.1016/j.resuscitation.2022.06.025

Resuscitation

Volume 179, October 2022, Pages 206-213

https://doi.org/10.1016/j.resuscitation.2022.06.025 Get rights and content

Abstract

Aim

To identify whether a novel pulse check technique, carotid artery compression using an ultrasound probe, can reduce pulse check times compared to manual palpation (MP).

Methods

This prospective study was conducted in an emergency department between February and December 2021. A physician applied point-of-care ultrasound–carotid artery compression (POCUS-CAC) and assessed the carotid artery compressibility and pulsatility by probe compression during rhythm check time. Another clinician performed MP of the femoral artery. The primary outcome was the difference in the average time for pulse assessment between POCUS-CAC and MP. The secondary outcomes included the time difference in each pulse check between methods, the proportion of times greater than 5 s and 10 s, and the prediction of return of spontaneous circulation (ROSC) during ongoing chest compression.

Results

25 cardiac arrest patients and 155 pulse checks were analyzed. The median (interquartile range) 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. In all 155 pulse checks, the POCUS-CAC time to determine ROSC was significantly shortened to 0.44 times the MP time (P < 0.001). The POCUS-CAC approach never exceeded 10 s, and the number of patients who required more than 5 s was significantly lower (5 vs. 37, P < 0.001). Under continuous chest compression, six pulse checks predicted the ROSC.

Conclusions

We found that emergency physicians could quickly determine pulses by applying simple POCUS compression of the carotid artery in cardiac arrest patients.

Introduction

Accurate pulse checks by healthcare providers during cardiopulmonary resuscitation (CPR) are crucial for the appropriate management of arrest patients. To minimize interruptions in chest compression, it is vital to check a patient’s pulse as rapidly as possible.1., 2. However, several studies have shown that manual palpation of the central arterial pulse is not reliable3., 4., 5. and frequently exceeds the recommended 10 s window.6., 7., 8. Therefore, while the Advanced Cardiac Life Support (ACLS) guidelines by the American Heart Association (AHA) eliminated the pulse check process in 2015,⁹ manual pulse palpation remains the standard pulse check method used by healthcare providers during CPR.

Point-of-care ultrasound (POCUS) is increasingly used to help manage cardiac arrest patients.¹⁰ In addition to identifying the reversible cause of cardiac arrest, POCUS is used to determine visible cardiac activity and predict short-term survival.11., 12., 13., 14. However, there were concerns that cardiac ultrasound was associated with longer interruptions in chest compressions¹⁵ and that it had only moderate agreement when determining cardiac activity.¹⁶ Recently, some studies have attempted to determine the return of spontaneous circulation (ROSC) by detecting blood flow using carotid artery ultrasound.17., 18., 19. Carotid ultrasound is relatively easy to perform during CPR without interfering with chest compression. It also demonstrated a high inter-observer reliability (α = 0.874) and more than 90% sensitivity and specificity in detecting the presence or absence of a pulse.18., 20.

In a recent case study, a novel pulse-check technique was presented to check the compressibility and pulsatility of the carotid artery using ultrasound probe compression.¹⁷ This approach can assess the pulse quickly and clearly in cases where palpation is either indeterminate or incorrect. This technique was also attempted in a case report,²¹ and ROSC was predicted by confirming the change in which the carotid artery did not collapse, despite probe compression under ongoing chest compression. However, these are all preliminary proof-of-concept case studies. Therefore, this study aimed to identify the utility of the carotid artery pulse check technique using POCUS compression by determining whether it can reduce the time required to evaluate ROSC compared to manual palpation.

Section snippets

Study design and setting

This single-center prospective study was conducted in the emergency department (ED) of a tertiary academic medical center with an annual volume of 70,000 patients in South Korea from February 2021 to December 2021. This study was approved by the Samsung Medical Center Institutional Review Board as a consent waiver (IRB file number 2020–11-116–002) and registered at ClinicalTrial.gov (ID NCT04793386).

Study population

The inclusion criteria were patients aged 18 years or older with out-of-hospital cardiac arrest

Characteristics of the study participants

Between February 2021 and December 2021, the study involved 25 patients and 20 physicians, with 16 performing manual palpation and 4 conducting carotid ultrasound. We excluded patients aged < 18 years (n = 2), those who had neck trauma (n = 11) or anatomical deformities (n = 2), and those who could not undergo ultrasound due to early cessation of CPR (n = 49), manpower shortage (n = 35), infection risk (n = 7), or delay of ultrasound preparation (n = 8) (Fig. 3). The median age of the patients

Discussion

This study evaluated the usefulness of a novel method for pulse check, carotid artery compression using an ultrasound probe, by comparing with manual palpation. The time for ROSC judgement by POCUS-CAC was less than half that of MP, and there were no cases that exceeded 10 s. Ultrasound is called the “stethoscope of the twenty-first century” as it is widely used for the diagnosis and treatment of patients by visualizing what was evaluated via auscultation and palpation.²⁴ Likewise, by visually

Conclusions

We found that emergency physicians could quickly determine pulses by applying simple POCUS compression of the carotid artery in patients with cardiac arrest. Large-scale prospective studies are needed to determine whether patient outcomes can be improved by using this method.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

This research received no external funding.

CRediT authorship contribution statement

Soo Yeon Kang: Methodology, Data curation, Writing – original draft, Writing – review & editing. Ik Joon Jo: Methodology, Writing – review & editing. Guntak Lee: Data curation, Writing – review & editing. Jong Eun Park: Writing – review & editing. Taerim Kim: Writing – review & editing. Se Uk Lee: Writing – review & editing. Sung Yeon Hwang: Writing – review & editing. Tae Gun Shin: Writing – review & editing. Kyunga Kim: Formal analysis. Ji Sun Shim: Formal analysis. Hee Yoon:

Acknowledgements

None.

Institutional Review Board Statement

This study was approved by the Institutional Review Board of Samsung Medical Center (IRB file number 2020-11-116-002).

Informed Consent Statement

This study was exempted from consent through the Institutional Review Board.

Data Availability Statement

Data related to this study cannot be released due to the information security policies of the hospitals.

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Cited by (11)

Hands-free continuous carotid Doppler ultrasound for detection of the pulse during cardiac arrest in a porcine model
2023, Resuscitation Plus
Pulse palpation is an unreliable method for diagnosing cardiac arrest. To address this limitation, continuous hemodynamic monitoring may be a viable solution. Therefore, we developed a novel, hands-free Doppler system, RescueDoppler, to detect the pulse continuously in the carotid artery.
In twelve pigs, we evaluated RescueDoppleŕs potential to measure blood flow velocity in three situations where pulse palpation of the carotid artery was insufficient: (1) systolic blood pressure below 60 mmHg, (2) ventricular fibrillation (VF) and (3) pulseless electrical activity (PEA). (1) Low blood pressure was induced using a Fogarty balloon catheter to occlude the inferior vena cava. (2) An implantable cardioverter-defibrillator induced VF. (3) Myocardial infarction after microembolization of the left coronary artery caused True-PEA. Invasive blood pressure was measured in the contralateral carotid artery. Time-averaged blood flow velocity (TAV) in the carotid artery was related to mean arterial pressure (MAP) in a linear mixed model.
RescueDoppler identified pulsatile blood flow in 41/41 events with systolic blood pressure below 60 mmHg, with lowest blood pressure of 19 mmHg. In addition the absence of spontaneous circulation was identified in 21/21 VF events and true PEA in 2/2 events. The intraclass correlation coefficient within animals for TAV and MAP was 0.94 (95% CI. 0.85–0.98).
In a porcine model, RescueDoppler reliably identified pulsative blood flow with blood pressures below 60 mmHg. During VF and PEA, circulatory arrest was rapidly and accurately demonstrated. RescueDoppler could potentially replace unreliable pulse palpation during cardiac arrest and cardiopulmonary resuscitation.
Comparison of carotid artery ultrasound and manual method for pulse check in cardiopulmonary resuscitation
2023, American Journal of Emergency Medicine
The success of the manual pulse check method frequently employed during cardiopulmonary resuscitation (CPR) is controversial due to its subjective, patient- and operator-dependent, and time-consuming nature. Carotid ultrasound (c-USG) has recently emerged as an alternative, although there are still insufficient studies on the subject. The purpose of the present study was to compare the success of the manual and c-USG pulse check methods during CPR.
This prospective observational study was conducted in the critical care area of a university hospital emergency medicine clinic. Pulse checks in patients with non-traumatic cardiopulmonary arrest (CPA) undergoing CPR were performed using the c-USG method from one carotid artery and the manual method from the other. The gold standard in the decision regarding return of spontaneous circulation (ROSC) was the clinical judgment made using the rhythm on the monitor, manual femoral pulse check, end tidal carbon dioxide (ETCO₂), and cardiac USG instruments. The success in predicting ROSC and measurement times of the manual and c-USG methods were compared. The success of both methods was calculated as sensitivity and specificity, and the clinical significance of the difference between the methods' sensitivity and specificity was evaluated Newcombe's method.
A total of 568 pulse measurements were performed on 49 CPA cases using both c-USG and the manual method. The manual method exhibited 80% sensitivity and 91% specificity in predicting ROSC (+PV: 35%, −PV: 64%), while c-USG exhibited 100% sensitivity and 98% specificity (+PV: 84%, −PV: 100%). The difference in sensitivities between the c-USG and manual methods was −0.0704 (95% CI: −0.0965; −0.0466), and the difference between their specificities was 0.0106 (95% CI: 0.0006; 0.0222). The difference between the specificities and sensitivities was statistically significant at analysis performed adopting the clinical judgment of the team leader using multiple instruments as the gold standard. The manual method yielded an ROSC decision in 3 ± 0.17 s and c-USG in 2.8 ± 0.15 s, the difference being statistically significant.
According to the results of this study, the pulse check method with c-USG may be superior to the manual method in terms of fast and accurate decision making in CPR.
Cardiopulmonary Resuscitation: The Importance of the Basics
2023, Emergency Medicine Clinics of North America
Managing Cardiac Arrest Using Ultrasound
2023, Annals of Emergency Medicine
Citation Excerpt :
To shorten the time for assessment, we recommend locating the carotid or femoral arteries prior to the pulse check. Evidence suggests that this technique is feasible, accurate, reliable, quickly performed, and easily learned by emergency physicians.116-124 However, it remains unclear whether the presence of a pulse by Doppler alone is sufficient to indicate perfusion.
Doppler ultrasound peak systolic velocity versus end tidal carbon dioxide during pulse checks in cardiac arrest
2023, Resuscitation
An accurate, non-invasive measure of return of spontaneous circulation (ROSC) is needed to improve management of cardiac arrest patients.
During a pulse check in Emergency Department (ED) cardiac arrest patients, we compared the correlation between 1) end tidal carbon dioxide (ETCO₂) and systolic blood pressure (SBP), and 2) Doppler ultrasound peak systolic velocity (PSV) and SBP. Additionally, we assessed the accuracy of PSV ≥ 20 cm/sec in comparison to previously suggested ETCO₂ ≥ 20 or ≥ 25 mmHg thresholds to predict ROSC with SBP ≥ 60 mmHg.
This was a secondary analysis of a previously published prospective observational study of ED cardiac arrest patients with an advanced airway and femoral arterial line in place. During each pulse check, highest SBP, highest PSV, and ETCO₂ at the end of the pulse check were recorded. Spearman correlation coefficients were calculated and compared using a Fisher Z-transformation. Accuracy of previously determined PSV and ETCO₂ thresholds for detecting ROSC with SBP ≥ 60 mmHg were compared using McNemar’s tests.
Based on data from 35 patients with 111 pulse checks, we found a higher correlation between PSV and SBP than ETCO₂ and SBP (0.71 vs 0.31; p < 0.001). Diagnostic accuracy of PSV ≥ 20 cm/sec for detecting ROSC with SBP ≥ 60 mmHg was 89% (95% CI: 82%-94%) versus 59% (95% CI: 49%-68%) and 58% (95% CI: 48%-67%) for ETCO₂ ≥ 20 and ≥ 25 mmHg, respectively.
During a pulse check, Doppler ultrasound PSV outperformed ETCO₂ for correlation with SBP and accuracy in detecting ROSC with SBP ≥ 60 mmHg.
Time is running out for manual pulse checks as ultrasound races past
2022, Resuscitation

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Clinical paperPoint-of-care ultrasound compression of the carotid artery for pulse determination in cardiopulmonary resuscitation

Abstract

Aim

Methods

Results

Conclusions

Introduction

Section snippets

Study design and setting

Study population

Characteristics of the study participants

Discussion

Conclusions

Conflict of interest

Funding

CRediT authorship contribution statement

Acknowledgements

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Chin J Traumatol

Resuscitation

Resuscitation

Ann Emerg Med

J Emerg Med

Resuscitation

Am J Emerg Med

Resuscitation

J Biomech

Resuscitation

Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Circulation

Clinical paper
Point-of-care ultrasound compression of the carotid artery for pulse determination in cardiopulmonary resuscitation