When and how should a pulse check be performed during cardiac arrest?

Pulse Check During Cardiac Arrest

Perform a pulse check for no more than 10 seconds simultaneously with assessing breathing, and if no definite pulse is felt, immediately start CPR without delay. 1

When to Perform Pulse Checks

Initial Assessment

• Check pulse simultaneously while looking for absent or abnormal breathing (only gasping) during the initial assessment of an unresponsive patient 1, 2
• The 10-second time limit is critical—if you cannot definitively feel a pulse within this window, assume cardiac arrest and begin compressions 1
• Healthcare providers should tap the victim and shout to check responsiveness, then immediately assess both breathing and pulse together 1, 2

During Active Resuscitation

• Recheck pulse every 2 minutes during CPR cycles, ideally during rhythm checks to minimize interruption of compressions 1, 3
• For patients receiving rescue breathing (pulse present but no normal breathing), reassess pulse approximately every 2 minutes 1
• Time pulse checks to coincide with AED rhythm analysis or when changing compressors to avoid additional interruptions 3

How to Perform Pulse Checks

Manual Palpation Technique

• Palpate the carotid artery in adults and children 1
• Limit the check to a strict maximum of 10 seconds 1
• If uncertain whether a pulse is present, treat as pulseless and start CPR immediately 1

Critical Pitfall: Manual Palpation Limitations

• Manual pulse palpation has a 100% false negative rate at initial assessment and 28% at subsequent checks, meaning providers frequently miss pulses that are actually present 4
• Manual palpation also has false positive rates of 5.3% initially, potentially delaying necessary CPR 4
• Despite these limitations, manual palpation remains the standard approach in current guidelines 1

Point-of-Care Ultrasound Considerations

Emerging Evidence for POCUS

• Cardiac ultrasound can detect pulse more accurately than manual palpation (4.8 seconds average vs 10.8 seconds) and has zero false negative/positive rates 4
• POCUS pulse checks demonstrate high interobserver reliability (α = 0.874) with 76% of assessments completed within the 10-second guideline 5

Critical Caveat: POCUS Can Harm if Done Wrong

• Unstructured ultrasound use during cardiac arrest nearly doubles pulse check duration to 21 seconds, significantly exceeding the 10-second maximum and reducing survival 6
• However, when providers are trained in the structured CASA (Cardiac Arrest Sonographic Assessment) protocol, POCUS pulse checks become 4 seconds shorter than standard checks 7
• Place the ultrasound probe on the chest BEFORE stopping compressions—this single technique reduces pause duration by 3.1 seconds 7

Practical Algorithm for POCUS Use

• Only use POCUS for pulse checks if you have received specific training in cardiac arrest ultrasound protocols 7
• Position the probe during compressions, then briefly pause to assess 7
• If untrained in structured protocols, stick to manual palpation to avoid dangerous delays 6
• Ultrasound fellowship-trained faculty presence reduces pulse check duration by 3.1 seconds compared to non-trained providers 7

What Constitutes "No Pulse"

• Absence of a definite pulse within 10 seconds = cardiac arrest requiring immediate CPR 1
• Gasping alone without pulse indicates cardiac arrest, not adequate breathing 1, 2
• In pediatrics, heart rate <60 bpm with signs of poor perfusion requires CPR even if a pulse is technically present 8

Key Pitfall to Avoid

Never extend pulse checks beyond 10 seconds under any circumstances—every second of delay in starting compressions reduces survival, and the most common error is spending too much time trying to find a pulse rather than initiating CPR 1, 6. When in doubt, start compressions immediately.