Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable
The following Task Force members and other authors declared an intellectual conflict of interest, and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable
CoSTR Citation
Stephan Katzenschlager,Barney Scholefield, Allan de Caen, Jason Acworth on behalf of the International Liaison Committee on Resuscitation Pediatric Life Support Task Force. Pulse check accuracy in pediatrics during resuscitation – Pediatric Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Pediatric Advanced Life Support Task Force, 2024 October xxxxx. Available from: http://ilcor.org
Methodological Preamble and Link to Published Systematic Review
The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of pediatric life support (Katzenschlager, 2024, PROSPERO CRD42024549535) with the help of an information specialist (Lars Eriksson) and clinical content experts. Evidence of pediatric literature was sought and considered by the Pediatric Life Support Task Force group. These data were taken into account when formulating the Treatment Recommendations.
Systematic Review
Katzenschlager et al. Pulse check accuracy in pediatric during resuscitation – in preparation
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Infants and children in any setting (out of hospital or in-hospital) with suspected cardiac arrest when assessing whether to start or continue CPR
Intervention: any other site for pulse check (eg. femoral pulse, etc) OR method (not exclusively, cardiac auscultation, pulse oximetry, ultrasonography, rise in end-tidal CO2 values above specific thresholds, invasive monitoring, etc)
Comparators: pulse check as per current guidelines by healthcare providers (brachial pulse for infants and carotid pulse for children and adolescents)
Outcomes: Any outcome including but not limited to:
- accuracy, defined as sensitivity and specificity of detecting a perfusing rhythm
- duration of cardiac compression pauses
- any clinical outcome
The PLS TF prefers outcomes defined in the P-COSCA publication. (1)
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) that directly concern the population and intervention described above are eligible for inclusion. If it is anticipated that there will be insufficient studies from which to draw a conclusion, case series may be included in the initial search. The minimum number of cases for a case series to be included was set by the taskforce at 5. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded. All relevant publications in any language are included as long as there is an English abstract.
Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to April 24th, 2024.
PROSPERO Registration CRD42024549535
Consensus on Science
- Accuracy
For the critical outcome of accuracy (defined as sensitivity and specificity), this systematic review identified three studies with 39 patients and 376 pulse checks, providing very low certainty of evidence. All studies had a serious risk of bias. Two studies were further downgraded for imprecision and indirectness as they were performed on children not in cardiac arrest. (2), (3) The study by Tsung et al. was performed by two physicians on 14 patients. (4) In the included studies, sensitivity ranged at 76% to 100%, while specificity was lower at 64% to 79%. Because of the indirectness and the scarcity of studies, no meta-analysis was performed, and a narrative summary of individual studies is provided.
- Duration of cardiac compression pauses
No studies in infants and children were identified that directly assessed this outcome. One study evaluated the time until a decision was made about whether a pulse was present or not. However, this study was performed in children on left ventricular assist devices (LVAD) or extracorporeal membrane oxygenation (ECMO). (3) In this study, only 39% (60/153) of the participants decided on the presence of a pulse within ten seconds. The median duration until any decision was made was 18 seconds, with an accuracy of 85%. Inexperienced providers took longer to make their decisions. This indirect evidence indicates that there is a reasonable concern about prolonged chest compression pauses, especially in inexperienced clinicians. This evidence was gained in a less critical setting with perfused children with warm skin temperature and brisk capillary refill time.
- Any clinical outcome
No studies in infants and children were identified that assessed any clinical outcome.
Treatment Recommendations-Good Practice Statement
We suggest that the palpation of a pulse (or its absence) is unreliable as the sole determinant of cardiac arrest and the need for chest compressions. [weak recommendation, very low certainty on evidence]In unresponsive children, not breathing normally and without signs of life, lay rescuers and clinicians should begin CPR.
Justification and Evidence to Decision Framework Highlights
The PLS Task Force prioritized this topic based on an Evidence Update (EvUp) in 2023 (5), which included two studies. This EvUp was the basis for the current recommendation, alongside expert opinion. This is the first systematic review of this topic, so the weighting of previously reviewed literature will be different from previous evidence updates.
All studies were identified using the PICOST search strategy provided by an information specialist. The task force discussed including the two previously included studies. (2, 3) It was determined that their inclusion was justified by downgrading those studies for indirectness in the GRADE process.
In addition to the EvUp, one case series showed good accuracy when ultrasound is performed by trained providers for emergency department resuscitation of children with cardiac arrest during pulse checks. (4) The task force discussed that this case series, in which very experienced providers performed the intervention, is insufficient evidence upon which to make a treatment recommendation. The duration of pulse checks was not reported in this case series.
The treatment recommendation in 2010, including the same evidence as in this CoSTR, generated the recommendation to limit the pulse check duration to ten seconds. (6)
In one study, only 39% (60/153) of the participants decided on the presence of a pulse within ten seconds. (3) The median duration until any decision was made was 18 seconds, with an accuracy of 85%. Inexperienced providers took longer to make their decisions. This indirect evidence indicates that there is a reasonable concern about prolonged chest compression pauses, especially in inexperienced clinicians. The task force discussed whether this indirect evidence was enough to withdraw the ten-second recommendation. Given the evidence from the 2010 treatment recommendation and the indirect evidence in this systematic review, we removed the treatment recommendation: “Clinicians should continue CPR unless they can palpate a pulse within 10 seconds.”.
This time limit has not been met in the indirect studies and its effect has not been studied.
Knowledge Gaps
No randomized controlled trials were identified comparing the intervention with standard care in the pediatric population. Prehospital and in-hospital studies comparing point-of-care ultrasound (vascular or cardiac) during rhythm analysis are ethical, necessary, and critically important to help guide clinicians in making these complex decisions. As different resuscitation councils recommend varying pulse check locations, this may provide an opportunity for an international comparative study.
Further examination of the potential longer hands-off time and their impact on outcome would also be helpful.
Future studies would benefit from including outcome measures consistent with the P-COSCA recommendations.
EtD Table: PLS 4080 18 Et D Table Pulse Check Accuracy
References
1. Topjian AA, Scholefield BR, Pinto NP, Fink EL, Buysse CMP, Haywood K, et al. P-COSCA (Pediatric Core Outcome Set for Cardiac Arrest) in Children: An Advisory Statement From the International Liaison Committee on Resuscitation. Resuscitation. 2021;162:351-64.
2. Tibballs J, Russell P. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation. 2009;80(1):61-4.
3. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation. 2010;81(6):671-5.
4. Tsung JW, Blaivas M. Feasibility of correlating the pulse check with focused point-of-care echocardiography during pediatric cardiac arrest: a case series. Resuscitation. 2008;77(2):264-9.
5. Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, et al. 2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Resuscitation. 2024;195:109992.
6. Kleinman ME, de Caen AR, Chameides L, Atkins DL, Berg RA, Berg MD, et al. Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010;122(16 Suppl 2):S466-515.