Elsevier

Resuscitation

Volume 80, Issue 1, January 2009, Pages 61-64
Resuscitation

Clinical paper
Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest☆

https://doi.org/10.1016/j.resuscitation.2008.10.002Get rights and content

Abstract

Aim

To determine the reliability of pulse palpation to diagnose paediatric cardiac arrest.

Materials and methods

With all cardiovascular information obscured, 209 doctors and nurses (rescuers) were requested once each to determine if a pulse was present in 1 of 16 infants and children (average age 1.8 years, range 1 week–13 years) provided with non-pulsatile circulation with veno-arterial extracorporeal membrane oxygenation or left ventricular assistance for cardiac arrest or failure. Rescuers did not know the stage of recovery of the heart and did not if a true pulse was present or absent. Rescuer decisions “pulse absent” or “pulse present” were compared with concurred decisions of investigators and bedside nurse who knew cardiovascular data and had unlimited time to palpate pulses.

Results

Rescuer pulse palpation accuracy was 78% (95% CI 70–82), sensitivity 0.86 (95% CI 0.77–0.90) and specificity 0.64 (95% CI 0.53–0.74). When investigators diagnosed cardiac arrest pulse pressure was 6 ± 5 mmHg (range 0–20) compared with 9 ± 8 mmHg (range 0–29) with rescuers (p = 0.0004). With pulse pressure zero, rescuer accuracy was 89% and sensitivity 0.89. Sixty per cent of rescuers chose a brachial pulse, 33% a femoral pulse with respective accuracies of 78% and 77%, sensitivities 0.86 and 0.85 and specificities 0.67 and 0.56.

Conclusions

Pulse palpation is unreliable to diagnose paediatric cardiac arrest. Rescuers misdiagnose on 22% of occasions and which may lead them to withhold external cardiac compression on 14% of occasions when needed and on 36% to give it when not needed. Brachial palpation is slightly more reliable than femoral palpation.

Introduction

Pulse palpation (“pulse check”) over 5–10 s is universally recommended to healthcare personnel by resuscitation authorities1 to aid the assessment of the circulatory status of collapsed infants and children. However, the reliability of this test to determine the diagnosis of cardiac arrest is unknown since no studies have been performed on collapsed children and it remains a gap in the knowledge in the science of resuscitation.2 All previous studies on pulse detection have been performed on mildly hypotensive infants3 or in healthy infants and children with the purpose of determining the correct heart rate or the ability to detect a pulse when known to be present.4, 5, 6, 7, 8, 9

We evaluated the accuracy of pulse detection by blinded doctors and nurses in collapsed infants and children whose circulation was supported by extracorporeal circulatory life support (ECLS) for circulatory arrest or failure. In these circumstances blood flow was non-pulsatile until the patient's heart recovered to resume spontaneous ejection and generate a pulse. Depending upon the stage of recovery, and unknown to blinded rescuers, a true pulse was absent or present. This simulates the circumstance of a suspected cardiac arrest in which rescuers aim to determine whether a pulse is absent or present before giving or withholding external cardiac compression.

Section snippets

Materials and methods

Approval for the study was given by our Human Ethics Committee and permission sought from parents of patients. The study was conducted during April 2007–January 2008 in the intensive care unit of the Royal Children's Hospital, Melbourne which is a tertiary referral hospital with 250 beds for a population of approximately 6 million of whom approximately 1.5 million are children.

Without forewarning, we requested doctors and nurses entering the intensive care unit for other reasons or recruited

Results

Two hundred and eleven healthcare personnel (110 doctors and 101 nurses) were requested separately to participate in the study. Ten rescuer candidates were recruited from the emergency department, all others (95%) had entered the ICU for other reasons—commonly in the case of nurses to accompany a patient to or from ICU, and in the case of doctors to examine other patients in the unit. All potential rescuers readily agreed to participate and all except two doctors completed the study. One doctor

Discussion

The reliability of a pulse check by doctors and nurses for infants and children in suspected cardiac arrest has not been validly determined. Although a number of studies of pulse palpation have been conducted, all were in healthy4, 5, 6, 7, 8, 9 or mildly hypotensive infants3 and thus known by the rescuers to have a circulation. Thus, these studies do not permit a valid conclusion about the reliability of this test to diagnose cardiac arrest.

In this study 78% of doctors and nurses correctly

Conclusions

This study suggests that pulse palpation is an unreliable method by healthcare personnel to determine the presence or absence of a circulation when cardiac arrest is suspected in children. An erroneous assessment is made of the pulse one occasion in five, and a false decision will lead to withholding external cardiac compression when it is needed on approximately one occasion in seven and giving it when not needed on approximately one occasion in three.

Conflict of interest

None declared.

Acknowledgements

We thank numerous doctors and nurses who agreed, at short notice, to act as potential rescuers and nurses who cared for the patients on ECLS. The research was not funded.

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☆

A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2008.10.002.

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