Monday, 30 September 2019

Comparison of manual pulse palpation, cardiac ultrasonography and Doppler ultrasonography to check the pulse in cardiopulmonary arrest patients


This study aimed to determine which method of pulse check is the best during CPR. Should we do the traditional manual pulse check, use our ultrasound to look at the heart (POCUS) or use a Doppler on the femoral artery.

Of course, to do such a study would require comparison against a gold standard and calculation of test performance by reporting sensitivity and specificity.

This study did none of this.

In addition, the manuscript is incredibly poorly presented and should not have been published in its current form (example below). Given the sloppiness of the paper, one should really question the veracity of the research conducted.

A more detailed USG was performed when the rhythm returned to normal or when the patient accepted exitus.

As this study looks to be fatally flawed, I should probably stop here… but I will mention a few things.

This study allegedly enrolled 137 patients in a single very busy Turkish ED. Two ED residents with a year of POCUS experience did all of the echo’s. All three methods to check the pulse were performed at the same time; at the start of resuscitation, at 15 minutes and at the end of efforts or ROSC. They tried to maintain blinding by curtain set up as seen in the picture.

They claim the echo’s only took 4 seconds to perform. Contrasted with doppler taking 8 seconds and manual palpation 10 seconds. This sounds impressive (and contrary to other published reports) until you consider the two ED residents were not blinded to the study aims. Nor did they mention how the times were measured.

The study claims the echo was the best (as it was always right by design) and there were a bunch of false positive and negatives with the Doppler and manual palpation.

I’m a big proponent of POCUS and have already incorporated echo as my default pulse check. I can get the images quickly and I feel a I get a better sense of cardiac contractility than with other methods. I occasionally find important pathology such as tamponade, RV strain, dissection, catastrophic valvular regurgitation or cardiac standstill.

AHA/ACC, ILCOR and ERC guidelines support POCUS in arrest, but caution it should not interfere with high quality CPR. To be fair, there has been little high-quality research. There is no doubt we should encourage further formal study with robust methods and design. 

We don’t want our patients to accept exitus.


Covering:

Zengin S, Gumusboga H, Sabak M, et al. Comparison of manual pulse palpation, cardiac ultrasonography, and Doppler ultrasonography to check the pulse in cardiopulmonary arrest patients. Resusitation 2018;133:59-64. [link toarticle]


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