Written by Chris Thom
Spoon Feed
This review article discusses the role of POCUS for pediatric cardiac arrest, including a protocol for the detection of carotid or femoral pulses.
A sound way to check a pulse?
Manual palpation of pulses has been shown to be unreliable yet represents a critical junction in determining management actions in cardiac arrest. The authors present the PULSE (Pediatric Ultrasound for Life-Supporting Efforts) protocol, which consists of using POCUS for the detection of femoral or carotid pulses during the arrest. The authors recommend placement of the linear probe over the central pulse during CPR. If there are enough personnel, this can be kept in place throughout the resuscitation to assess for the effectiveness of compressions and to obtain immediate visualization of the presence or absence of a central pulse. This leads to a more rapid and accurate determination of the pulse presence. The cardiac assessment can then be used for the detection of organized cardiac activity, as well as determination of potentially reversible causes (pulmonary embolism, pericardial tamponade, pneumothorax).
How does this change my practice?
Thoughtful use of POCUS in cardiac arrest can be a powerful diagnostic tool that allows for targeted therapies beyond that of PALS and ACLS. The clearest example is the identification of pericardial effusions in cardiac arrest, wherein the rate of ROSC and survival is much higher (1). Recent literature has developed around the use of POCUS for detection of pulses given the known inaccuracy of manual pulse checks. One can see the physical movement of the arterial wall when probe pressure is applied, and this has been shown to be more reliable than manual checks (2-4). When the personnel are available, I’ve incorporated this into my practice for arrest patients, as it provides a more accurate determination of true PEA versus pseudo-PEA.
Pro clips and tips
In children, the chest wall is small, which limits real estate for scanning. Given this, the apical 4 or subcostal views are often preferred and can be obtained during chest compressions to minimize the time needed for analysis during the pulse check. The subcostal view has been shown to be more successful to obtain within 10 seconds on pediatric patients (5). It is important to put POCUS findings of pulse presence in context. A small amount of central artery flow with no mechanical pulses palpated might still benefit from ongoing compressions, though these patients are likely just profoundly hypotensive and may need to transition to postarrest care (norepinephrine or epinephrine titration). An arterial line can be very helpful in these cases to help adjudicate the degree of arterial flow, vasopressor titration, and the ongoing presence or absence of arterial pulses.
Source
A Protocol for Using Point-of-Care Ultrasound as an Adjunct in Pediatric Cardiac Arrest: Pediatric Ultrasound for Life-Supporting Efforts. Pediatr Emerg Care. 2024 Nov 1;40(11):835-838. doi: 10.1097/PEC.0000000000003239. Epub 2024 Jul 23. PMID: 39043130
Additional References
- Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016;109:33-39.
- Cohen AL, Li T, Becker LB, et al. Femoral artery Doppler ultrasound is more accurate than manual palpation for pulse detection in cardiac arrest. Resuscitation. 2022;173:156-165.
- Leviter JI, Walsh S, Riera A. Point-of-Care Ultrasound for Pulse Checks in Pediatric Cardiac Arrest: Two Illustrative Cases. Pediatr Emerg Care. 2023;39(1):60-61.
- Gaspari RJ, Lindsay R, Dowd A, Gleeson T. Femoral Arterial Doppler Use During Active Cardiopulmonary Resuscitation. Ann Emerg Med. 2023;81(5):523-531.
- Leviter JI, Chen L, O’Marr J, Riera A. The Feasibility of Using Point-of-Care Ultrasound During Cardiac Arrest in Children: Rapid Apical Contractility Evaluation. Pediatr Emerg Care. 2023;39(5):347-350.
