326 Manual Palpation Versus Femoral Arterial Doppler Ultrasound for Comparison of Pulse Check Time During Cardiopulmonary Resuscitation

Abstract

The two critical components of effective cardiopulmonary resuscitation (CPR) are high-quality chest compressions and minimizing interruptions in chest compressions. While cardiac point-of-care ultrasound (POCUS) is frequently used during pulse checks, a recent study showed that employing cardiac POCUS nearly doubled the maximum recommended 10-second pause during pulse checks. Manual palpation (MP) is frequently employed for pulse checks, but prior studies have shown that trained medical personnel can only identify pulselessness using MP accurately 55% of the time. Femoral arterial doppler ultrasound (FADU) in contrast, has the benefit of avoiding the critical area of the neck and the airway, as well as avoiding the precordium where CPR is performed. There is sparse data supporting the use of FADU for pulse checks during CPR. The objective of this study was to observe emergency physicians during resuscitations in the emergency department (ED) while CPR was performed to assess the length of pulse checks with comparison of MP and FADU techniques. A prospective blinded observational study was conducted from October 2018 to May 2019 at an urban community emergency department with approximately 42,000 visits per year. Using convenience sampling, patients arriving at the emergency department who received CPR, or patients who decompensated during their ED stay and received CPR were enrolled in our study. Patients under the age of 18, patients with leg amputations, patients who had arterial lines already in place, or patients with abnormal femoral anatomy met exclusion criteria. A trained research assistant, who passed a CPR pretest module with a minimum inter-observer agreement with Cohen’s kappa>0.7, observed each code and recorded the length of each pulse check with a stopwatch, as well as the modality used to look for a pulse. Prior to the start of the study, an email with best practice CPR recommendations was sent to our faculty, including details on how to perform both femoral color and spectral doppler ultrasound to identify pulsatile arterial flow in the femoral artery. Faculty and research assistants were blinded to the primary outcomes of our study. Our ED faculty includes 23 full-time physicians and 7 part-time physicians. For continuous data means and confidence intervals (CI) were calculated, and means were compared using an unpaired Student’s t-test. During this 8-month observation period 56 eligible patients were enrolled. 125 pulse checks via MP and 35 via FADU were recorded. MP observations had a mean of 13.6 seconds (95% CI 11.9-15.4) while FADU had a mean of 10 seconds (95% CI 8.1-11.9). There was a difference between the two means of 3.6 seconds (95% CI 0.1-7.2 p<0.05). Of our sample, only one patient survived to be discharged from the hospital. In this small observational study, the use of FADU was superior to MP towards reducing pulse check times. Further research is needed to confirm the accuracy of FADU for confirming ROSC in patients receiving CPR in the ED as well as to determine if FADU can provide a significant improvement in clinical outcomes.