Handheld Doppler to improve pulse checks during resuscitation of putative pulseless electrical activity arrest.

1042 April 2014 T difficulty in determining pulselessness via manual palpation in simulated cardiopulmonary resuscitation (CPR) has been well documented in the literature. Previous studies have suggested that trained medical personnel demonstrate a specificity of only 55% for the manual diagnoses of pulselessness.1 Other research has confirmed the poor diagnostic accuracy of manual pulse checks in a wide spectrum of test subjects—from nonmedical personnel to critical care physicians.1–4 These data, along with accumulating evidence for the importance of early, highquality chest compression to improve outcomes from outof-hospital cardiac arrest, have led the American Heart Association to eliminate pulse checks from their algorithm for bystander CPR.* In this context, the Advanced Cardiac Life Support algorithm for the treatment of pulseless electrical activity (PEA) arrest presents an interesting dilemma, as the very diagnosis of the PEA condition is predicated, by definition, on the finding of pulselessness. Although unnecessary chest compressions during bystander CPR are considered a relatively benign intervention, the failure to promptly diagnose the return of spontaneous circulation during in-hospital PEA Arrest may delay the institution of more targeted and appropriate care modalities. Ambiguity about the presence of spontaneous circulation during resuscitation is among many factors that contribute to the challenging task of “running a code.” Therefore, to assess possibilities for improving the detection of the return of spontaneous circulation during in-hospital resuscitation, we conducted a prospective case series (N = 8) during which handheld Doppler pulse checks were performed in parallel with standard Advanced Cardiac Life Support procedures during resuscitation of adults with putative PEA arrest or on whom electrocardiogram pads had not yet been placed in an academic tertiary care hospital. The outcomes of interest were (1) to measure the incidence of Doppler-positive-palpation-negative pulse in patients undergoing resuscitation for putative PEA arrest and (2) to measure blood pressure in discordant cases of Doppler-positive-palpation-negative putative PEA arrest. This prospective study was approved by the Yale Human Investigation Committee, including a waiver of informed consent. Investigators applied a portable Doppler (Dopplex Pocket Doppler D900 Vascular Ultrasound with 8 MHz probe; Huntleigh Healthcare Ltd. [Diagnostic Products Division], Cardiff South Glamorgan, Wales, United Kingdom) to an available femoral artery during in-hospital resuscitation attempts for putative PEA arrest or in situations of unknown cardiac rhythm before electrocardiogram lead placement. The Dopplex D900 with associated probes has been deemed by the Food and Drug Administration to be substantially equivalent to other portable ultrasound devices routinely used for blood flow monitoring. Although this technology has been in existence for several decades, the sensitivity and specificity of such devices for detecting pulsatile flow during CPR remain unknown. For inclusion in the study, a putative PEA rhythm was defined as an organized rhythm in the absence of a manual pulse, excluding ventricular tachycardia and ventricular fibrillation.† To be included in the case series, subjects also had to meet the following criteria: (1) aged more than 18 yr,