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Pulse Checks with CPR

/ ACLS, BLS, Compressions, CPR, PALS, Pulse Checks / By

𝐏𝐔𝐋𝐒𝐄 𝐂𝐇𝐄𝐂𝐊𝐒 with CPR.......𝗪𝐇𝐀𝐓 𝐈𝐒 𝐓𝐇𝐄 𝐁𝐈𝐆 𝐃𝐄𝐀𝐋?!?!?!

In this blog I wanted to discuss pulse checks with CPR….when its recommended and when it is not and why. 

During training, working with other instructors, and in general conversations with the community, I’m finding that a lot of of people are confused as to what the recommendations are for pulse checks.  So, I wanted to take time to look at the recommendations and why the American Heart Association (AHA) has different recommendations based on what course is being taken.  

I will primarily be discussing the recommendations from the American Heart Association (AHA) regarding pulse checks.  Their recommendations are based on the course being taken: Heartsaver, BLS, ACLS, or PALS. These recommendations will be similar to the American Red Cross (ARC) courses: ALS, PALS, BLS, and First Aid/CPR/AED.

Types of Courses/Learners

We can break down the types of courses into 3 main categories

While numerous certification and non certification courses are available, they can be divided into 3 main categories for what is taught: lay rescuers, BLS providers, and ACLS/PALS providers. 

Lay rescuers – are those individuals not in the healthcare setting. These recommendations will be seen in the AHA Heartsaver Certification Courses: First Aid/CPR/AED; CPR/AED; Pediatric First Aid/CPR/AED, or First Aid. You will also see these recommendations in the non-certification training:  Family and Friends CPR & Hands-Only CPR.  

Please note: Red Cross also has specialized training for Life Guards. Some may still refer to them as a “lay rescuers” while others may refer to them as a “professional rescuer”. Their training will be more in line with a BLS course then a “lay rescuer” CPR/AED course. They are taught a special skills set, for this higher risk environment, that is specific to the work they are doing and the lives they could be saving.  Additionally, those who have had wilderness survival training will learn a different skills set. These groups should not confuse this information with the training they learned in those courses.  

BLS Providers  – are typically in a healthcare setting (although anyone can take this course). For example: nurses, physicians,  dental hygienist, dentist, occupational therapist, speech therapist, physical therapist, EMS professionals, etc…just to name a few.

ACLS (ALS)/PALS Providers – are providers in the healthcare setting operating at the most advanced level of cardiopulmonary resuscitation. For example: nurses, physicians, physician assistants, oral surgeons, anesthesiologists, etc.

 
For All the wonderful Instructors out there

We should strive to know what the different recommendations are (for the courses we teach) and not confuse the learner because we may be more experienced, in our field, and do things differently.  

For example, critical care providers who teach ACLS/PALS, we should not expect a lay rescuer or BLS provider to operate like we do in the critical care setting. They do not have the knowledge, training, or available resources to operate at that level. Therefore, different recommendations are presented in those courses. One is not necessarily better than another.  The recommendations are based on the best that person can do with the given set of circumstances. It will always be best for a cardiac arrest to happen in critical care (ICU, CCU, ER, etc).

What are the recommendations for pulse checks with CPR?

lets look at what the recommendations are
As stated previously the recommendations for pulse checks with CPR are different based on the learner and the course that is being taken.
 

Lay rescuers – are NOT taught to check a pulse…..EVER. You are to assume cardiac arrest if a person is unresponsive and not breathing. Call 911 and start CPR immediately. 

 
BLS providers – are taught to check for a pulse PRIOR to starting CPR…….NOT EVERY 2 MINUTES. Once you start CPR you continue performing CPR until you see signs of life, then reassess the person.
 

ACLS/PALS providers – are taught are taught to check a pulse with a rhythm check every 2 minutes. We are adjusting our treatment of the patient based on the type of rhythm and presence of pulse. However, in effort to reduce long delays with these frequent checks, AHA started teaching in 2020 to identifying the pulse, with CPR, then stop to see if pulse remains or goes way. 

Every 1 minute without CPR, when needed, decreases a persons survival by
7-10%

So why the different recommendations?

Goal is to increase survivability by reducing time wasters
The goal of CPR is always to increase a persons chance of survival. One of ways we can do this is by reducing time wasters.
 
While many time wasters have been identified one of the top time wasters, for excessive pausing of compressions, is difficulty discerning a pulse. Therefore, it is recommended:
 

1)  Don’t spend more than 10 seconds trying discern a pulse to initiate CPR. Start compressions as quickly as possible as we know that every 1 minute that CPR is not started, when needed, a persons chance of survival decreases by 7-10%.

 
2)  Provide quality compressions that focus on spending more time on the chest, doing compressions, then pausing excessively for “time wasters”.
 
 

Yes……some pauses, during CPR,  are necessary. The aim is reduce how long and how often those pauses occur. Lets be honest, discerning a pulse can be difficult, even for the experienced healthcare provider.

Lay rescuers –  NO pulse checks….EVER.  The goal here is to ensure that we don’t delay the start of compressions. Therefore, you are to assume cardiac arrest when a person is unresponsive and not breathing.  It can be scary and intimating but doing nothing will surely make the situation worse.
 
 
BLS Providers – check pulse prior to starting compressions…NOT EVERY 2 MIN. You are to continue CPR until you see signs of life. The goal here in increase the amount of time we spend on the chest by avoiding unnecessary pauses in CPR to check a pulse.  There is no data to support checking a pulse every 2 minutes is helpful (unless you are an ACLS/PALS provider who is determining treatment based on a rhythm and presence of a pulse). 
 
 
ACLS/PALS providers –  check a pulse with a rhythm check every 2 minutes as we are adjusting our treatment based on the rhythm and presence of pulse. However, in effort to reduce long delays with these frequent checks, we should be identifying the pulse, with CPR, then stop to see if pulse remains or goes way. Additionally, the role of the CPR Coach was added. Their job is to ensure high quality CPR is being performed and ensure that we do not have excessive pauses/delays in compressions. The goal is to achieve a chest compression fraction (CCF) of greater than 80%. This is the amount of time during the code we actually spent doing compressions when needed. 
 

Identifying a pulse is difficult, even for the experienced healthcare provider

Is finding a pulse that difficult?

so now you may be asking yourself……is finding a pulse that difficult?!?!?!

The answer is yes and no. 

If you take your own pulse, right now, then maybe not. But have you ever been in an emergency situation with adrenaline flowing? Your pulse is rapid and pounding. Your thought process is not as clear.  

This has been found to lead to major delays in clearly discerning a pulse as:
1) The person may feel their own pulse
2) They may be pressing to hard
3) They  may not have the training to properly locate the pulse
 
Many people have panicked and did not initiate CPR because they could not decide if there was a pulse or not, so they waited until someone with more experience arrived (I have seen this with medical providers as well).
 
 
Let me tell you…I am an experienced nurse of 17 years with a lot of that being in the critical care setting.  I have a TONS of practice checking pulses and running codes and I have no issue admitting, when adrenaline is flowing, it not the ideal time to try and discern a pulse…much less a weak and slow one.    
 

I have also witnessed countless delays in compressions surrounding difficulty discerning a pulse. This is one reason a lot of us will use a doppler (ultrasound) during cardiac arrest codes. So lets face it….identifying a pulse is difficult even for the experience healthcare provider.  This is why AHA implemented several changes to BLS, ACLS, and PALS in 2020 to reduce these delays. 

So, in summary:
Pulse checks can be difficult.

There are different recommendations for who does pulse checks and when.

The goal is to avoid delays or prolonging compressions for pulse checks with CPR.

THANK YOU

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