Cardiac arrest: first-responders help to diagnose pulse status.

Clinical bottom line (level 2b)

In patients undergoing coronary artery bypass, presence of a pulse diagnosed by a first-responder may help to rule in a pulse, whereas absence of a responder diagnosed pulse helps to rule it out.
Absence of a pulse diagnosed by a person with only very basic life saving training (EMT-1) helps to rule out presence of a pulse.
Absence of a pulse diagnosed by a person with 10 weeks basic life saving training (EMT-2) rules out presence of a pulse.
Absence of a pulse diagnosed by a training paramedic (PM-1) rules out presence of a pulse, and presence of a pulse helps to rule out pulselessness.
Presence of a pulse diagnosed by a trained paramedic helps to rule out pulselessness.

Eberle et al: Resuscitation 1996; 33 : 107-116

Expires December 2003

The study

Setting: operating theatre of a general hospital, Germany

16 patients (aged mean 59 years, 88% male) undergoing coronary artery bypass surgery

Excluded if

previous surgery or cannulation attempts in the left neck area
thyroid enlargement
sonographic evidence of carotid plaques or stenoses
history or clinical signs of cerebrovascular insufficiency

hypersensitive carotid sinus reflexes

Four groups of first responders with different levels of CPR training and no prior exposure to cardiac surgical operating theatres or cardiopulmonary bypass techniques were randomly allocated to an assessment period during spontaneous circulation or during non-pulsatile cardiopulmonary bypass. The participants were EMT-1 (laypersons, ie. emergency medical technician students with a basic life saving course); EMT-2 (EMTs in training, ie. after 4 weeks of theoretical training and 6 weeks practical instruction); PM-1 (paramedics in training); PM-2 (certified paramedics after 2 years)
Independent blinded reference standard, applied in all patients from a ?consecutive inappropriate spectrum.
Reference standard:

objective pulse status determined by cardiac monitors and other instrumentation

Diagnostic test: First responders diagnosis of pulse status by performing carotid pulse checks, without the aid of cardiac monitors and other instrumentation (all covered with drapes) and access to the left side only. First responders were to count out the pulse if it was found and only needed to state whether or no there was a pulse or not, as quickly as possible.

First responders were blinded to whether the patient was pulsatile or pulseless. There was no guidance from the surgeons and no contact between responders who were coming out of the operating theatre and those going in.
206 participants performed pulse checks in 16 patients.

The evidence

diagnostic test	sensitivity for absence of pulse (95% CI)	specificity for absence of pulse (95% CI)	LR+	LR-
EMT-1 diagnosis	84.0% (% to %)	36.0% (% to %)	1.3
EMT-2 diagnosis	100% (% to %)	30.0% (% to %)	1.4	0.0
PM-1 diagnosis	100% (% to %)	76.0% (% to %)	4.2	0.0
PM-2 diagnosis	% (% to %)	89.0% (% to %)
overall diagnosis	90.0% (% to %)	55.0% (% to %)	2.0	0.18
total

There were only 9 PM-2s and 0/0 diagnosed pulselessness.
In 10%, an absence of p-ulse was not recognised, and in 45% a pulse was not identified. 15% of all participants produced correct diagnoes within 10 seconds.

Comments

Numbers used in the analysis were of the 206 participants who were to establish whether or not there was a pulse.
Sensitivity and to a certain extent specificity of first-responder diagnosis of pulselessness increases with increased training.

Citation

Eberle B, Dick WF, Schneider T, et al: Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation 1996; 33 : 107-116

Contributor: Clare Wotton, December 1999
Reviewer:

_{Clinical
Question.}

_Patient	_{undergoing heart surgery}
_{Intervention or Exposure}	_{presence of pulse with first responders}
_Comparison	_{absence of pulse}
_Outcome	_{cardiac arrest}