25a7ae55-60e9-4881-92a7-d553a885c50a.doc Page 1 of 12 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT WORKSHEET for PROPOSED Evidence-Based GUIDELINE RECOMMENDATIONS NOTE: Save worksheet using the following filename format: Taskforce.Topic.Author.Date.Doc where Taskforce is a=ACLS, b=BLS, p=Pediatric, n=neonatal and i=Interdisciplinary. Use 2 or 3 letter abbreviation for author’s name and 30Jul03 as sample date format. Worksheet Author: Arno Zaritsky, M.D. Home Taskforce/Subcommittee: __BLS __ACLS _X_PEDS __ID __PROAD __Other: Author’s Home Resuscitation Council: _X_AHA __ANZCOR __CLAR __ERC __HSFC Date Submitted to Taskforce/Subcommittee: November 30, 2003; revised __HSFC __RCSA ___IAHF ___Other: December 22, 2004 STEP 1: STATE THE PROPOSAL. State if this is a proposed new guideline; revision to current guideline; or deletion of current guideline. Existing guideline, practice or training activity, or new guideline: The guideline is stated on page I-40 and I-270 in the Guidelines 2000 publication. The current statement is: “Therefore, the lay rescuer should not rely on the pulse check to determine the need for chest compressions or use of an AED. Lay rescuers should not perform the pulse check and will not be taught the pulse check in CPR courses (Class IIa). Instead, lay rescuers will be taught to assess for “signs of circulation,” including normal breathing, coughing or movement, in response to the rescue breaths. This guideline recommendation applies to victims of any age. Healthcare providers should continue to the use the pulse check as one of several signs of circulation. Other signs of circulation include breathing, coughing or movement.” Step 1A: Refine the question; state the question as a positive (or negative) hypothesis. State proposed guideline recommendation as a specific, positive hypothesis. Use single sentence if possible. Include type of patients; setting (in- /out-of-hospital); specific interventions (dose, route); specific outcomes (ROSC vs. hospital discharge). Lay rescuers and healthcare providers cannot reliably and accurately determine the presence of a pulse in a cardiac arrest victim. Step 1B: Gather the Evidence; define your search strategy. Describe search results; describe best sources for evidence. ECC EndNote library search using “pulse” and “check” yielded 22 citations PubMed search using textwords “pulse check” yielded 22 citations Pubmed search using “pulse” AND “cardiopulmonary resuscitation” as MeSH terms yielded 37 citations I reviewed the citations identified from the previous evidence evaluation. There were no relevant studies in the Cochrane database of systematic reviews The references of all selected citations were reviewed to assure that no relevant citations were missed Search was updated December 2004 List electronic databases searched (at least MEDLINE (http://igm.nlm.nih.gov/), Embase, Cochrane database for systematic reviews and Central Register of Controlled Trials, and hand searches of journals, review articles, and books. Pubmed, AHA Endnote library, Cochrane Database of Systematic reviews • State major criteria you used to limit your search; state inclusion or exclusion criteria (e.g., only human studies with control group? no animal studies? N subjects > minimal number? type of methodology? peer-reviewed manuscripts only? no abstract-only studies?) Only human studies were included. Reviews and discussions not related to a specific study were not included except for one citation (Cummins) that detailed the rationale for the current guideline statement. I also did not include abstracts. • Number of articles/sources meeting criteria for further review: Create a citation marker for each study (use the author initials and date or Arabic numeral, e.g., “Cummins-1”). . If possible, please supply file of best references; EndNote 6+ required as reference manager using the ECC reference library. A total of 14 citations were selected. Most of the references published since the previous evidence guideline were related to the guideline change and did not provide any new data. There were six relevant citations since the previous evidence evaluation. STEP 2: ASSESS THE QUALITY OF EACH STUDY Step 2A: Determine the Level of Evidence. For each article/source from step 1, assign a level of evidence—based on study design and methodology. Level of Definitions Evidence (See manuscript for full details) Level 1 Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects Level 2 Randomized clinical trials with smaller or less significant treatment effects Level 3 Prospective, controlled, non-randomized, cohort studies Level 4 Historic, non-randomized, cohort or case-control studies Level 5 Case series: patients compiled in serial fashion, lacking a control group Level 6 Animal studies or mechanical model studies Level 7 Extrapolations from existing data collected for other purposes, theoretical analyses Level 8 Rational conjecture (common sense); common practices accepted before evidence-based guidelines 25a7ae55-60e9-4881-92a7-d553a885c50a.doc Page 2 of 12 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Step 2B: Critically assess each article/source in terms of research design and methods. Was the study well executed? Suggested criteria appear in the table below. Assess design and methods and provide an overall rating. Ratings apply within each Level; a Level 1 study can be excellent or poor as a clinical trial, just as a Level 6 study could be excellent or poor as an animal study. Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study. For more detailed explanations please see attached assessment form. Component of Study and Rating Excellent Good Fair Poor Unsatisfactory Design & Highly appropriate Highly appropriate Adequate, Small or clearly Anecdotal, no sample or model, sample or model, design, but biased population or controls, off randomized, proper randomized, proper possibly biased model target end-points controls controls Methods AND OR OR OR OR Outstanding Outstanding accuracy, Adequate under Weakly defensible in Not defensible in accuracy, precision, and data the its class, limited its class, precision, and data collection in its class circumstances data or measures insufficient data collection in its or measures class A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpoint B = Survival of event D = Intact neurological survival Step 2C: Determine the direction of the results and the statistics: supportive? neutral? opposed? DIRECTION of study by results & statistics: SUPPORT the proposal NEUTRAL OPPOSE the proposal Outcome of proposed guideline Outcome of proposed guideline Outcome of proposed guideline Results superior, to a clinically important no different from current inferior to current approach degree, to current approaches approach Step 2D: Cross-tabulate assessed studies by a) level, b) quality and c) direction (ie, supporting or neutral/ opposing); combine and summarize. Exclude the Poor and Unsatisfactory studies. Sort the Excellent, Good, and Fair quality studies by both Level and Quality of evidence, and Direction of support in the summary grids below. Use citation marker (e.g. author/ date/source). In the Neutral or Opposing grid use bold font for Opposing studies to distinguish them from merely neutral studies. Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study. Supporting Evidence Lay rescuers and healthcare providers cannot reliably and accurately determine the presence of a pulse in a cardiac arrest victim Excellent Eberle, 1996E Lapostolle 2004E Quality of Evidence Good Owen 2004E Graham, 2002E Moule, 2000E Bahr, 1997E Fair Cavallaro, 1983E,* Mather, 1996E Lee, 1991E,* Ochoa, 1998E 1 2 3 4 5 6 7 8 Level of Evidence 25a7ae55-60e9-4881-92a7-d553a885c50a.doc Page 3 of 12 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpoint B = Survival of event D = Intact neurological survival * = pediatric study Neutral or Opposing Evidence Lay rescuers and healthcare providers cannot reliably and accurately determine the presence of a pulse in a cardiac arrest victim Excellent Quality of Evidence Good Fair Inagawa, 2003E,* Tanner, 2000 E,* 1 2 3 4 5 6 7 8 Level of Evidence A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpoint B = Survival of event D = Intact neurological survival Note: The Cummins, 2000 publication was not classified—it is not a study. The Whitelaw, 1997 report is a letter to the editor and cannot be classified as evidence since it did not undergo peer review. STEP 3. DETERMINE THE CLASS OF RECOMMENDATION. Select from these summary definitions. CLASS CLINICAL DEFINITION REQUIRED LEVEL OF EVIDENCE Class I • Always acceptable, safe • One or more Level 1 studies are present (with rare Definitely recommended. Definitive, • Definitely useful exceptions) excellent evidence provides support. • Proven in both efficacy & effectiveness • Study results consistently positive and compelling • Must be used in the intended manner for proper clinical indications. Class II: • Safe, acceptable • Most evidence is positive Acceptable and useful • Clinically useful • Level 1 studies are absent, or inconsistent, or lack • Not yet confirmed definitively power • No evidence of harm • Class IIa: Acceptable and useful • Safe, acceptable • Generally higher levels of evidence Good evidence provides support • Clinically useful • Results are consistently positive • Considered treatments of choice • Class IIb: Acceptable and useful • Safe, acceptable • Generally lower or intermediate levels of evidence Fair evidence provides support • Clinically useful • Generally, but not consistently, positive results • Considered optional or alternative treatments Class III: • Unacceptable • No positive high level data Not acceptable, not useful, may be • Not useful clinically • Some studies suggest or confirm harm. harmful • May be harmful. • Research just getting started. • Minimal evidence is available Indeterminate • Continuing area of research • Higher studies in progress • No recommendations until • Results inconsistent, contradictory further research • Results not compelling STEP 3: DETERMINE THE CLASS OF RECOMMENDATION. State a Class of Recommendation for the Guideline Proposal. State either a) the intervention, and then the conditions under which the intervention is either Class I, Class IIA, IIB, etc.; or b) the condition, and then whether the intervention is Class I, Class IIA, IIB, etc. 25a7ae55-60e9-4881-92a7-d553a885c50a.doc Page 4 of 12 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Indicate if this is a __Condition or __Intervention Final Class of recommendation: __Class I-Definitely Recommended _X_Class IIa-Acceptable & Useful; good evidence __Class IIb-Acceptable & Useful; fair evidence __Class III – Not Useful; may be harmful __Indeterminate-minimal evidence or inconsistent REVIEWER’S PERSPECTIVE AND POTENTIAL CONFLICTS OF INTEREST: Briefly summarize your professional background, clinical specialty, research training, AHA experience, or other relevant personal background that define your perspective on the guideline proposal. List any potential conflicts of interest involving consulting, compensation, or equity positions related to drugs, devices, or entities impacted by the guideline proposal. Disclose any research funding from involved companies or interest groups. State any relevant philosophical, religious, or cultural beliefs or longstanding disagreements with an individual. I am a pediatric intensivist. I have been associated with the American Heart Association (AHA) beginning in 1983 and have participated in each guideline revision since the 1986 guidelines. I was a paid AHA editor for the pediatric resuscitation materials produced in 2000 and 2001. I have no conflicts of interest. REVIEWER’S FINAL COMMENTS AND ASSESSMENT OF BENEFIT / RISK: Summarize your final evidence integration and the rationale for the class of recommendation. Describe any mismatches between the evidence and your final Class of Recommendation. “Mismatches” refer to selection of a class of recommendation that is heavily influenced by other factors than just the evidence. For example, the evidence is strong, but implementation is difficult or expensive; evidence weak, but future definitive evidence is unlikely to be obtained. Comment on contribution of animal or mechanical model studies to your final recommendation. Are results within animal studies homogeneous? Are animal results consistent with results from human studies? What is the frequency of adverse events? What is the possibility of harm? Describe any value or utility judgments you may have made, separate from the evidence. For example, you believe evidence-supported interventions should be limited to in-hospital use because you think proper use is too difficult for pre-hospital providers. Please include relevant key figures or tables to support your assessment. The most convincing study showing the inability of health care providers to rapidly and accurately identify the presence of a carotid pulse in adults was by Eberle et al[Eberle, 1996]. This study was unique because they were able to test for correct assessment of both the presence and absence of a pulse by using patients undergoing cardiopulmonary bypass and blinding the investigator. Other studies typically used a normal, healthy volunteer [Ochoa, 1998; Bahr, 1997], young volunteers[Graham, 2002], or ASA I anesthesia adults [Mather, 1996] or infants[Inagawa, 2003] to assess the presence of a pulse. These latter studies show that many healthcare providers require at least 10 seconds to identify the pulse with a reasonable degree of reliability (80% sensitivity) in a normal, well perfused person. Lay rescuers performed less well [Bahr, 1997]. More recently, Lapostolle (2004) used a computerized manikin and confirmed that fewer than 50% of 64 prehospital healthcare providers could accurately determine the absence of a pulse within 10 seconds or 30 seconds. Rapid recognition of the presence of a pulse will avoid inappropriate chest compressions, but more importantly, failing to recognize the absence of a pulse will lead to certain death if chest compressions and/or AED application is not provided because the lay rescuer thought a pulse was present. This type of error (type II) led to the current recommendation.[Cummins, 2000] The only available data on the ability to identify a pulse in children are in infants; there are no studies examining the ability to detect the carotid pulse in children. Cavallaro  reported that 21/25 parents could detect their infant's brachial pulse, which was much improved over their ability to palpate the apical impulse. Lee, however, reported that less than 50% of CPR-certified individuals could palpate the brachial pulse in infants. Whitelaw trained 28 BLS students and found that 5 (18%) could not palpate a brachial pulse and 8 (29%) could not palpate the femoral pulse in a single infant. Moreover, only 18% could palpate the brachial pulse within 10 seconds. Several studies suggest that auscultation for the heart beat is superior to palpation for a pulse in terms of more rapid recognition.[Inagawa, 2003; Tanner, 2002] These studies, however, are inadequate in this reviewer’s opinion since they provide the ideal circumstance for detecting cardiac activity in an infant. It is not clear how they would work in an infant with shock or apnea who had a weak but present pulse. A recent randomized trial in newly born infants again confirmed that experienced healthcare providers could not reliably detect and quantitate the pulse of 60 infants by palpation of the brachial or femoral artery or palpation of the umbilical cord.(Owen 2004) The latter was most accurate, but was still much worse than confirming the presence of an adequate pulse by auscultation using a stethoscope. Although one study included 200 parents asked to identify their infants’ pulse or heart beat[Tanner, 2000], most studies include potential rescuers. It seems reasonable to conclude, however, that the difficulty documented in locating a brachial pulse in a well perfused, normal infant will only be magnified in a seriously ill infant or child. Moreover, the frequency of bystander CPR is low in children [Sirbaugh, 1999-not reviewed here but in the ECC library] and the complexity of mastering the current BLS techniques may be partly responsible for this. Therefore, the recommendation to eliminate lay rescuer pulse check from pediatric BLS training is reasonable. It also is likely that health care providers, especially prehospital providers and non-pediatric providers, will have difficulty reliably identifying a pulse. There are insufficient data, however, to recommend elimination of the pulse check in the 25a7ae55-60e9-4881-92a7-d553a885c50a.doc Page 5 of 12 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT healthcare provider course. Unfortunately, there are no data on the effect on outcome and potential morbidity resulting from the elimination of the pulse check. The rationale to eliminate the pulse check is both educational, as well as the desire to eliminate false negatives (Type II errors)[Cummins, 2000]. (Level IIa) The major caveat regarding the elimination of the lay rescuer pulse check is the potential to produce harm to patients by the application of chest compressions in a victim who still has a perfusing rhythm. There are reports of various injuries from CPR, such as rib fractures, pulmonary contusion, pneumothorax, gastric perforation and hepatic trauma (see BLS worksheets or harm to victim from CPR). Conversely, failure to provide bystander CPR is highly associated with poor outcome. The elimination of the pulse check in lay rescuer CPR should simplify education and will hopefully increase the confidence of lay rescuers to perform CPR. It is difficult to assign a level of evidence since no study has specifically examined the effect of eliminating the pulse check on outcome or morbidity. The rationale for making the change is most strongly an educational one. (Level IIa) The other point of discussion in the evidence evaluation of pulse check in BLS training is the lack of data showing that healthcare providers perform much better than lay rescuers. I can find no documentation on the ability of healthcare providers to accurately palpate a pulse while wearing gloves, as recommended in the universal precaution guidelines. It seems likely that wearing gloves will make pulse detection even more difficult. It certainly makes palpating the pulse in perfusing victims more difficult. Finally, as discussed below, several studies suggest that healthcare providers are not properly taught to assess the carotid pulse. Indeed, one study suggested that an alternate method was superior and associated with a lower risk of arrhythmias when compared with the traditional method of carotid pulse detection.[Graham, 2002] Preliminary draft/outline/bullet points of Guidelines revision: Include points you think are important for inclusion by the person assigned to write this section. Use extra pages if necessary. Publication: Chapter: Pages: Topic and subheading: The current guideline statement, as quoted on page 1 of this evidence evaluation, is appropriate and does not need revision. The only question I have regarding the new guideline is the appropriateness of continuing to recommend the pulse check for 10 seconds as the method to determine when chest compressions are needed in BLS by a healthcare provider. Most data suggest that more than 10 seconds is needed to accurately make this determination, especially when a pulse is absent. For healthcare providers, it may be most appropriate to initiate chest compressions in a patient who remains lifeless after rescue breaths, especially in the monitored patient in whom ECG or arterial pressure data are consistent with cardiac arrest. In this setting, there may not be any reason to delay starting chest compressions to check for a pulse. For infants, auscultation of the heart beat may be appropriate in lieu of a pulse check. Although case reports suggest that pulseless electrical activity may be incorrectly identified, based on the presence of intra-arterial pressures or documentation by pulse doppler detection of a pulse, it is not clear that a patient is harmed by providing chest compressions in this setting of low output. This assumes that the patient’s cardiac output is sufficiently low in this setting that the patient appears lifeless with no movement, breathing or cough in response to rescue breaths. Finally, based on the data regarding the inability to quickly detect carotid pulses,[Moule, 2000; Eberle, 1996; Bahr, 1997; Graham, 2002; Ochoa, 1998; Lapostolle, 2004] it seems that more attention should be placed on proper training of healthcare providers to detect the carotid pulse in children and adults. Moreover, additional analysis of the alternative method of carotid pulse detection seems appropriate.[Graham, 2002] I don’t think this one study provides sufficient data to make a change in guideline recommendation. Consensus on Science: Data from LOE 2, 4, 5 and 6 studies show that both lay rescuers and healthcare providers are unable to rapidly and accurately detect the presence of a pulse in infants or adults. 25a7ae55-60e9-4881-92a7-d553a885c50a.doc Page 6 of 12 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Citation List Citation Marker Full Citation* Note: Comments on citations are noted in italic text after the citation abstract. Bahr, J., H. Klingler, et al. (1997). "Skills of lay people in checking the carotid pulse." Bahr, 1997 Resuscitation 35(1): 23-26. American Heart Association as well as European Resuscitation Council require the carotid pulse check to determine pulselessness in an unconscious victim and to decide whether or not cardiopulmonary resuscitation (CPR) should be initiated. Recent studies on the ability of health professionals to check the carotid pulse have called this diagnostic tool in question and led to discussions. To contribute to this discussion we performed a study to evaluate skills of lay people in checking the carotid pulse. A group of 449 volunteers (most had participated in a first aid course) were asked to check the carotid pulse in a young healthy, non-obese person by counting aloud the detected pulse rate. Time intervals until correct detection of the carotid pulse were registered. Overall the volunteers needed an average of 9.46 s, ranging from 1 to 70 s. Only 47.4% of the volunteers were able to detect a pulse within 5 s, and 73.7% within 10 s. A level of 95% volunteers detecting the pulse correctly was reached only after 35 s. Based on these findings we conclude that the intervals established for carotid pulse check may be too short and that perhaps the value of pulse check within the scope of CPR needs to be reconsidered. LOE 4 study: not historic, but was non-randomized and used a convenience sample without a control patient (i.e., patient without a pulse). Weak methodology for its applicability to cardiac arrest. Cavallaro, 1983 Cavallaro, D. L. and R. J. Melker (1983). "Comparison of two techniques for detecting cardiac activity in infants." Crit Care Med 11: 189-190. In the 1980 Standards and Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care, the recommended method for determining cardiac arrest in infants was changed from palpation of the apical impulse to palpation of the brachial pulse. The importance of adequately assessing the heart beat before initiating chest compressions due to the potential hazards is well established. This study was designed to ascertain which pulse parents could palpate most readily and accurately count within a given time. The results demonstrated the brachial pulse was much easier to palpate and more accurately counted by parents than the apical impulse. These findings formed the basis for the 1980 revised recommendation for determining cardiac arrest in infants. LOE 4: not historic, but it was non-randomized and lacked a control group. Only 11 of 25 parents (44%) who had undergone training could palpate the apical impulse in their healthy infants ranging in age from 3 weeks to 12 months, within 10 seconds, and only 3 of these could count it accurately. When the brachial pulse was palpated, 21 of 25 (84%) could palpate the pulse, and 10 could accurately count it. It is not clear how the investigators knew that the subjects were accurately palpating the pulse since only 10/20 could count a pulse. Thus, the reported success rate may be even lower than stated. Cummins, 2000 Cummins, R. O. and M. F. Hazinski (2000). "Guidelines Based on Fear of Type II (False-Negative) Errors : Why We Dropped the Pulse Check for Lay Rescuers." Circulation 102(90001): 377I--379. The new guidelines for CPR and ECC strongly emphasize evidence as the basis for all new clinical recommendations. The level of evidence may range from a high of Level 1 (one or more randomized, controlled clinical trials) to a low of Level 8 (rational conjecture, common sense, or accepted historically as standard practice). Nonevidence factors can influence the selection of the final class of recommendation, such as the expense of interventions, the ease of teaching, and the consequences of error. A technique that might improve resuscitation outcomes based on animal evidence, eg, open-chest CPR, turns out to be complex, difficult to learn, and difficult to implement. Such a technique would not merit as strong a recommendation as a technique that produced more modest improvements in survival but did so with superior ease of teaching, learning, and implementing. This is not a study, but instead provides a good overview of the rationale for the current guideline 25a7ae55-60e9-4881-92a7-d553a885c50a.doc Page 7 of 12 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT statement based on the desire to avoid type II (false negative) errors. Eberle, B., W. F. Dick, et al. (1996). "Checking the carotid pulse check: diagnostic accuracy of first Eberle, 1996 responders in patients with and without a pulse." Resuscitation 33(2): 107-116. International guidelines for cardiopulmonary resuscitation (CPR) in adults advocate that cardiac arrest be recognized within 5-10 s, by the absence of a pulse in the carotid arteries. However, validation of first responders' assessment of the carotid pulse has begun only recently. We aimed (1) to develop a methodology to study diagnostic accuracy in detecting the presence or absence of the carotid pulse in unresponsive patients, and (2) to evaluate diagnostic accuracy and time required by first responders to assess the carotid pulse. In 16 patients undergoing coronary artery bypass grafting, four groups of first responders (EMT-1: 107 laypersons with basic life support (BLS) training; EMT-2: 16 emergency medical technicians (EMTs) in training; PM-1: 74 paramedics in training; PM-2: 9 certified paramedics) performed, single-blinded and randomly allocated, carotid pulse assessment either during spontaneous circulation, or during non- pulsatile cardiopulmonary bypass. Time to diagnosis of carotid pulse status, concurrent haemodynamics and diagnostic accuracy were recorded. In 10% (6/59), an absent carotid pulse was not recognized as pulselessness. In 45% (66/147), a pulse was not identified despite a carotid pulse with a systolic pressure > or = 80 mmHg. Thus, although sensitivity of all participants for central pulselessness approached 90%, specificity (ie, ability to recognize that a pulse was present in a patient with a perfusing rhythm) was only 55%. Both sensitivity and, to a lesser degree, specificity improved with increasing training; blood pressure or heart rate had no significant effect. The median diagnostic delay was 24 s (minimum 3 s). When no carotid pulse was found, delays were significantly longer (30 s: minimum 13 s), than when a carotid pulse was identified (15 s; minimum 3 s) (P <0.0001). Of all participants, only 15% (31/206) produced correct diagnoses within 10 s. Only 1/59 (2%) identified pulselessness correctly within 10 s. Our cardiopulmonary bypass model of carotid pulse assessment proved to be feasible and realistic. We conclude that recognition of pulselessness by rescuers with basic CPR training is time-consuming and inaccurate. Both intensive retraining of professional rescuers and reconsideration of guidelines about carotid pulse assessment are warranted. LOE 2: Single blinded, randomly allocated to patient with or without a pulse. This is the best methodologic study evaluating the ability of healthcare providers with various levels of training to detect a pulse. They appeared to study these adults prior to cooling. Also, all had carotid artery sonograms to assure they did not have carotid artery disease that would impair the ability to palpate a pulse. Their data shows that confirming the presence of a pulse is easier and requires less time than identifying the absence of a pulse with certainty. They also raise concern about over-diagnosis of post defibrillation PEA--how often is a pulse present but not detected, especially since it may require more than 10 seconds for the heart to regain a reasonable contractile force? If PEA is presumed, the ischemic myocardium may be exposed to unnecessary and potentially toxic drug therapy, especially with epinephrine. Graham, 2002 Graham, C. A. and N. F. Lewis (2002). "Evaluation of a new method for the carotid pulse check in cardiopulmonary resuscitation." Resuscitation 53(1): 37-40. BACKGROUND: The ability to determine the presence or absence of a central pulse remains a key skill in cardiopulmonary resuscitation (CPR) for healthcare providers, despite studies showing that they perform this poorly. The aim of this study was to evaluate a modified technique for palpation of the carotid pulse. METHODS: Sixty seven undergraduate dental students were taught the standard method of carotid pulse detection during a basic life support session and were also taught a modified method. Each student was asked to palpate the carotid pulse of a volunteer in two positions (neck neutral and neck extended) with the volunteer on the floor and on a trolley. The time taken to identify the pulse was measured and the scenarios compared. RESULTS: The time to detect the carotid pulse was reduced in three of the four scenarios (floor, neck extended P=0.0053, trolley neck neutral P=0.0070, trolley neck extended P=0.0024). The final scenario (floor, neck neutral) showed no improvement (P=0.36). CONCLUSION: The new method of carotid pulse palpation results in a more rapid determination of the carotid pulse when it is present in all positions except with the neck neutral on the floor. This will only be clinically significant if trauma is suspected. 25a7ae55-60e9-4881-92a7-d553a885c50a.doc Page 8 of 12 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Images captured from paper show new technique on the left and the traditional technique on the right. LOE 4: nonrandomized study Used healthy, young (<30 years old) volunteers so it was not surprising that the dental students could rapidly identify the pulse. The authors emphasize the importance of teaching how to palpate the carotid pulse since delay in palpation delay appropriate intervention, such as CPR or AED application. Although not a part of this study, they reported that over half the volunteers were noted to have rhythm disturbances (PVC or salvos of VT!) with the traditional palpation technique verus none when the new method was used. This needs to be further studied to determine if there is an important adverse effect from the traditional method of palpation and if their new method is superior. Inagawa, G., N. Morimura, et al. (2003). "A comparison of five techniques for detecting cardiac Inagawa, 2003 activity in infants." Paediatr Anaesth 13(2): 141-6. BACKGROUND: The new guidelines for cardiopulmonary resuscitation recommend that laypersons should begin chest compressions without checking for a pulse because the pulse check has serious limitations in accuracy. We determined the efficacy of the most suitable method to search for cardiac activity in infants. METHODS: Twenty-eight nurses tried to detect infants' cardiac activity and determined their heart rates with five different techniques: palpation of brachial pulse, carotid pulse, femoral pulse, apical impulse and auscultation of apical impulse with the naked ear (direct auscultation technique). RESULTS: The mean time interval required to find the pulse within 30 s in the auscultation, the apical, the brachial, the carotid and the femoral were 2.4 +/- 1.2, 3.5 +/- 2.7, 4.0 +/- 2.7, 9.9 +/- 7.0 and 9.1 +/- 5.9 s, respectively. The required time was significantly shorter in the auscultation method than in the palpation of carotid and femoral pulses. The percentage and 95% confidence intervals (95% CI) of pulses identified within 10 s (= the number of the correct identified within 10 s/the number of all cases) in auscultation, apical, brachial, carotid and femoral palpations were 100.0% (95% CI 51.8, 100), 75.0% (95% CI 28.9, 89.3), 73.1% (95% CI 52.2, 88.4), 50.0% (95% CI 30.6, 69.4) and 42.9% (95% CI 24.5, 62.8), respectively. These values were greater in the auscultation method than in all the palpation methods. CONCLUSIONS: The direct auscultation technique was more rapid and accurate than any other techniques to determine cardiac activity without instruments. It is suggested that a direct auscultation technique is also superior to the palpation of brachial artery in cardiopulmonary resuscitation in infants. LOE 4: nonrandomized study They used 13 anesthetized infants (1 month to 1 year of age; 3 to 10.8 kg). Although their study shows that the apical auscultation, palpation or brachial palpation are equivalent, I don't know that this study contributes much to lay rescuer CPR teaching since the trained healthcare providers (all experienced OR nurses) knew that these were hemodynamically stable infants with normal perfusion. The real question is whether auscultation has a lower false negative rate than palpation or just using the current guidelines of doing chest compression when the child appears lifeless after the rescue breaths. To their credit, the authors did use a model that is probably closer to reality in 25a7ae55-60e9-4881-92a7-d553a885c50a.doc Page 9 of 12 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT that all of the infants were paralyzed as opposed to trying to hear a heart rate in an awake infant who would move with the attempt to listen to the heart. Lapostolle, F., P. Le Toumelin, et al. (2004). "Basic Cardiac Life Support Providers Checking the Carotid Lapostolle 2004 Pulse: Performance, Degree of Conviction, and Influencing Factors." Acad Emerg Med 11(8): 878-80. The American Heart Association recently abolished the carotid pulse check during cardiopulmonary resuscitation for lay rescuers, but not for health care providers. Objectives: The aim of the study was to evaluate health care providers' performance, degree of conviction, and influencing factors in checking the carotid pulse. Methods: Sixty-four health care providers were asked to check the carotid pulse for 10 or 30 seconds on a computerized mannequin simulating three levels of pulse strength (normal, weak, and absent). Health care providers were asked whether they felt a pulse and how certain were they that they felt a pulse. Performance was evaluated, as well as degree of conviction about the answer, using a visual analog scale. Data were compared by using a general linear model procedure. Results: In the pulseless situations, the answers were correct in 58% and 50% when checking the pulse for 10 and 30 seconds, respectively. In the situation with a weak pulse, the answer was correct in 83% when checking the pulse for 10 seconds. In situations with a normal pulse, the answers were correct in 92%, 84%, and 84%, respectively, when checking the pulse for 10 (twice) and 30 seconds. The exactitude of the answer was correlated with the pulse strength (p < 0.05). The degree of conviction about the answer was correlated with the exactitude of the answer (p < 0.01) and the pulse strength (p < 0.0001). Conclusions: These results question the routine use of the carotid pulse check during cardiopulmonary resuscitation, including for health care providers. LOE 6. This study used prehospital EMS providers with a mean of 3 years of experience to detect the pulse in a computerized (Laerdal ALS Skillmaster) manikin. Of note, as seen in the table below, the ability to correctly identify the absence of a pulse (ie, the need to perform resuscitation) was poor, even when the pulse check was extended for 30 seconds. Indeed, the degree of conviction about the presence or absence of a pulse was worse as the provider was given more time to decide. This data again illustrates that the decision to initiate CPR by healthcare providers may be delayed because of their uncertainty about the presence or absence of a pulse. The limitation of the study is that it was performed in a manikin, so the relevance of the simulated pulse in this setting is not certain. Lee, C. J. and L. J. Bullock (1991). "Determining the pulse for infant CPR: time for a change?" Mil Lee, 1991 Med 156(4): 190-193. The accepted standard for determining cardiac arrest in infants is the use of palpation of the brachial pulse to detect pulselessness. The investigators have observed that CPR-certified individuals have difficulty locating the brachial pulse in infants. Therefore, the purpose of this study was to determine if a more effective way exists for assessing the pulse in an infant. Of the 102 subjects tested, 84 correctly assessed the apical pulse by placing a naked ear against the chest wall, whereas only 48 correctly palpated the brachial pulse. The study results demonstrated that there was a statistically significant (p less than 0.001) difference between the two methods for assessing pulses in infants. This indicates that the apical pulse method is a faster and more accurate method for locating the pulse in an infant, and should be used during cardiopulmonary resuscitation. LOE 4: non-randomized trial without a control group Although this study contradicts the study by Cavallaro, it confirms that pulse check (brachial pulse) in infants is difficult for the lay person with <50% able to detect the brachial pulse. I also don't think the ability to hear the heart beat by direct auscultation would be a reliable method to confirm 25a7ae55-60e9-4881-92a7-d553a885c50a.doc Page 10 of 12 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT absence of a pulse. In the anxiety and commotion surrounding an emergency event it is likely that extraneous noise would makes this impossible. Mather, C. and S. O'Kelly (1996). "The palpation of pulses." Anaesthesia 51(2): 189-191. Mather, 1996 In 554 anaesthetised patients, the times taken to separately palpate and identify each of the carotid, radial, brachial and femoral pulses were recorded. The patients were divided into three groups based on the form of airway management chosen (tracheal tube, facemask or laryngeal mask airway). Our results demonstrate that in the operating theatre environment the identification of the radial pulse is the most rapid and reliable; by 5 s, 98% and by 10 s, more than 99% of radial pulses were identified. The carotid pulse was not so easily identified, requiring 10 s to enable an identification rate of greater than 95%. The presence of a laryngeal mask airway or a tracheal tube did not hinder the identification of carotid pulse. LOE 5: adult case series. Study application to BLS and pulse check determination is limited. The investigators were all anesthesiologists and not lay rescuers. Lower age limit was 16, and all patients were well perfused, being chosen because they were undergoing elective surgery. The major finding of the study is that at least 10 seconds is required to accurately palpate the pulse in well perfused patients. Clearly, the ability to palpate the pulse accurately will be less in a patient in shock, and it will likely require more than 10 seconds to make that determination confidently. Their data also showed that the carotid pulse was more difficult to palpate than peripheral pulses in this setting. Moule, P. (2000). "Checking the carotid pulse: diagnostic accuracy in students of the healthcare Moule, 2000 professions." Resuscitation 44(3 SU -): 195-201. This study evaluated the competence of students of the healthcare professions to locate the carotid pulse using a computerised manikin, within 10 s. A sample of 105 students from physiotherapy, radiography, midwifery and nursing participated in measuring diagnostic accuracy in a single attempt at pulse check using a computerised manikin, timed to an accuracy of ±1 s. All had received basic life support instruction, and one group had advanced life support skills. The mode and median diagnostic delays were calculated for each group. Comparisons of mean rank values for the groups were determined, and comparisons of previous training and accuracy in diagnosis were calculated. Forty (38%) students were able to give an accurate diagnosis within 10 s. The results identified significant differences between the performance of the groups (2 16.74, P<0.01), with the advanced life support course students demonstrating most competence. Previous training did not affect performance in the skill (2 0.29, P=0.58). Carotid pulse check skills should be emphasised and tested as part of cardiopulmonary resuscitation instruction. LOE 6: mechanical model The author's data agrees with previous studies showing that more than 10 secs is required to accurately detect a pulse. Only 38% of the students could provide an accurate answer about the presence or absence of a pulse within 10 seconds. in 31/56 assessments when a pulse was present in the manikin, the student could detect this in 10 seconds. Of note, 12/56 times, the participant could not confirm the presence of a pulse. In 49 instances where the pulse was absent, only 9 (18%) of the time was this confirmed within 10 seconds; in another 35 (71%) this was confirmed after more than 10 seconds and in 5 cases the participant could not tell. The authors argue that more attention should be given to training on how to detect a carotid pulse if this is going to remain a part of the BLS guidelines for healthcare providers. Ochoa, F. J., E. Ramalle-Gomara, et al. (1998). "Competence of health professionals to check the carotid pulse." Resuscitation 37(3): 173-175. Ochoa, 1998 Our objective was to establish the proportion of Emergency Room and Intensive Care doctors and nurses able to locate the carotid pulse in less than 5 s, and identify the variables that influence this ability. The method followed was locating the carotid pulse in a healthy male adult volunteer with normal blood pressure in two situations (stretcher or floor) and with the neck in either a neutral or in an extended position. We recorded the gender, age, and previous training in cardiopulmonary resuscitation (CPR) of each participant and the time spent in detecting the pulse in each of the four possible positions. A model of logistic regression was constructed to determine if the patient's position had any influence on the proportion of health workers capable of finding the pulse within 5 s. The average age of the 72 subjects studied was 33.4 years (SD = 6.6); 80% of the 25a7ae55-60e9-4881-92a7-d553a885c50a.doc Page 11 of 12 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT participants had CPR training. Thirty-one participants (43.1%; CI 95%, 31.4-55.3%) required more than 5 s to detect the pulse, although only three (4.2%; CI 95%, 0.9-11.7%) required more than 10 s. The variable 'no CPR training' was associated with the inability to detect the pulse within 5 s. The detection of the pulse was easier with an extended neck. A significant proportion of nurses and doctors were slow to locate the carotid pulse on a healthy, young volunteer with normal blood pressure. No relation was found between gender or age of the participants. More attention should be given to carotid pulse detection in CPR training. LOE 4: non-randomized study without a control patient without a pulse I think this study is limited by the use of a single healthy adult volunteer. Again, the applicability to the arrest situation is limited since there was no pulseless patient evaluated. Even under this ideal situation, it required up to 10 s to accurately identify the pulse. Owen, C. J. and J. P. Wyllie (2004). "Determination of heart rate in the baby at birth." Resuscitation 60(2): 213-17. The International Liaison Committee on Resuscitation (ILCOR) publishes guidelines on neonatal Owen 2004 resuscitation, which are evidence-based where possible. Initial assessment of heart rate, breathing and colour is an essential part of newborn resuscitation and the guidelines state that heart rate may be assessed using a stethoscope, or palpating the umbilical, brachial or femoral pulse. This study aimed to assess the most effective method(s) of heart rate assessment in the newborn baby. Healthy term newborn babies were randomised to femoral, brachial or cord pulse assessment, within 5 min of birth. The heart rate (beats per minute (bpm)) was categorised as either not detectable, <60 bpm, 60-100 or >100 bpm. In all cases, the heart rate was >100 bpm when assessed using a stethoscope. The femoral pulse identified the heart rate as >100 bpm in 20%, <100 bpm in 35%, and undetectable in 45%. The brachial pulse identified the heart rate >100 bpm in 25%, <100 bpm in 15% and undetectable in 60%. Umbilical cord palpation was more reliable with 55% identified as >100 bpm, 25% <100 bpm and 20% undetectable. This data suggests that in healthy newborn babies, brachial and femoral pulses are not reliable for determining heart rate. Umbilical pulsations must not be relied upon if low or absent. In assessing heart rate in newborn resuscitation only the stethoscope is likely to be completely reliable. In the absence of a stethoscope only the umbilical pulse should be used with an awareness of its limitations. LOE 2: Randomized evaluation of the ability of experienced midwives and senior house officers to accurately detect and determine the heart of newly born infants. 60 newly born infants randomized to femoral pulse check, brachial pulse check or umbilical cord check (20 in each group); heart rate determined by pulse check correlated to heart rate determined by auscultation by a stethoscope. This study once again clearly demonstrates that the femoral and brachial pulse are unreliable, even when performed by experienced healthcare personnel who have up to 30 seconds to determine the presence of a pulse and its rate. The figure from the paper below shows that the cord pulse was most accurate, but in 20% of the infants an umbilical pulse could not be palpated. Since this study is in newly born infants, its results may be extrapolated to older infants, suggesting that the pulse check is not reliable even when performed by healthcare providers. Tanner, 2000 Tanner, M., S. Nagy, et al. (2000). "Detection of infant's heart beat/pulse by caregivers: a 25a7ae55-60e9-4881-92a7-d553a885c50a.doc Page 12 of 12 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT comparison of 4 methods." J Pediatr 137(3): 429-30. Parents (n = 200) were asked to find and then count their infant's pulse using 4 methods: listening to the apex, palpating the apex beat, and palpating the carotid and brachial pulses. Listening to the apex method was the fastest and most accurate method of heartbeat detection. LOE 4: Although method of detection was randomized there was no comparative group without a pulse. These were all normal infants of the caretakers; the latter had various degrees of training in BLS. The data from this study are consistent with other studies showing that auscultation is accurate and superior to apical impulse palpation, but was not superior to palpation of the brachial pulse, at least in normal infants. It was quicker to find the pulse by auscultation than by brachial palpation. Whitelaw, C. C. and L. J. Goldsmith (1997). "Comparison of two techniques for determining the Whitelaw, 1997 presence of a pulse in an infant." Acad Emerg Med 4: 153-154. Purpose was to determine the ability of lay rescuers to find a pulse in an infant by palpation of the brachial vs the femoral artery. They could not find a previously published article addressing this question. Methods: Prospective study comparing the time interval until adult CPR trainees could locate the pulse at the brachial and femoral artery in a single infant. Adults from BLS courses; excluded were peds medical personnel, <18 yrs, if they could not find the radial artery in another adult (never told how many were excluded here). Subjects were taught how to palpate the brachial and femoral pulse with a manikin then asked to find pulse in the infant and tap their finger at the pulse rate they detected (note, this was not confirmed to be the correct rate by the author). Assessed level of activity in a single infant who was 5-8 months old during this study. Results: 28 subjects; randomized to brachial first or femoral first. Within an initial 10-second interval, only 5 (18%, 95% CI 6-37%) palpated the brachial pulse vs 6 (21%,CI: 8-41%) could palpate the femoral pulse. Median interval to find the brachial pulse was 35 seconds (IQR 15-64 seconds) vs 35 (16-120 seconds) for the femoral pulse. 8 (29%) of femoral pulse searches and 5 (19%) brachial artery searches were unsuccessful. Authors conclude that pulse checks in either location are not of reliable in infants. LOE: cannot really assess since this was published as a letter rather than a peer reviewed publication. This “study” applies only to infant pulse check. A single infant was used with no description of infant's size. We do not know how many adults were considered for the study and were excluded for some reason. It is concerning that the percentages of pulse detection were so low in an awake infant. Why was this submitted as a letter? It is not clear who the investigator knew that the detected pulse was correct?