Keeping a Probe on the Pulse
Author: Anthony Anzano, MD PGY2 and Katherine Godfrey, MD PGY2
Peer Reviewer: Lauren Gruffi, MD PGY3, Gregory Han, MD PGY4 and Amy Hembree MD, PGY3
Faculty Editor: Andres Arredondo Santana, MD
“PULSE CHECK: Does anyone feel a pulse…?”
It’s a “yes” or “no” question that, in the chaos of a cardiac arrest, doesn’t always have a “yes” or “no” answer. Unfortunately, this moment of indecision is where lives hang in the balance. The American Heart Association (AHA) recommends a manual pulse check “for at least five seconds, but no longer than 10 seconds” as the standard for determining return of spontaneous circulation (ROSC) (Berg et al., 2010). For a question that literally has life or death consequences, there should be no room for uncertainty.
The traditional manual palpation method for checking a pulse has significant limitations. Manual pulse checks are highly dependent on an individual rescuer’s skills, as well as a patient’s specific physiological state (Cohen et al., 2022). Oftentimes, during a resuscitation, there is no single, dedicated person assigned to perform a pulse check. In the commotion of an arrest, it is not uncommon to have a medical student, nurse, intern, and attending physician all assessing for a pulse simultaneously.
As early as 1992, research has shown that healthcare providers are surprisingly poor at successfully palpating a pulse (Özlü et al., 2023). Studies have even demonstrated a strong negative correlation between the reliability of a manual pulse check and both the patient’s systolic blood pressure and the provider’s years of experience (Tibballs & Russell, 2009). The accuracy of manual palpation has been reported to be as low as 54%, underscoring the urgent need for a more reliable, consistent method (Kang et al., 2022). The decision to continue or stop cardiopulmonary resuscitation (CPR) should not be left to chance, as we know that high-quality, uninterrupted compressions are critical for maintaining blood flow to vital organs. Time is tissue. Time is brain.
This is where point-of-care ultrasound (POCUS) comes in. The ultrasound machine is already an indispensable component of our resuscitation efforts. It is used to rule-out life threatening pathology, to place central lines, and to confirm endotracheal tube placement. It is also being used to help confirm the presence or absence of arterial blood flow during the sonographic pulse check. Although arterial line monitoring is still considered the gold standard, POCUS offers a more accessible and mobile solution (Smith et al., 2021). Studies have demonstrated sonographic pulse detection accuracy as high as 95.3%, compared to 54% with manual palpation (Cohen et al., 2022).
The technique for sonographic pulse check is simple. First, select the linear probe. Secondly, choose the vessel that is most readily accessible in the moment, either the carotid or femoral artery (Vojnar et al., 2025). Of note, there has been no specific study comparing the superiority of the carotid versus femoral site for the use of sonographic pulse check (Hillerbrand et al., 2025).
POCUS provides a real-time, visual assessment of blood flow. There are three key methods to assess for a pulse using ultrasonography:
1) Compression (B-mode): A simple, yet effective method. Start by applying light pressure with the probe on the artery. If a pulse is present, the artery will not completely collapse. If it does collapse completely, there is likely no pulsatile flow (Howell et al., 2023) (see Figure 1).
Figure 1. An example of an attempt to compress the carotid artery with light pressure. The internal jugular vein is seen collapsed; however the carotid artery remains patent suggesting arterial flow
2) Color flow Doppler: Color Doppler should be activated to visualize blood flow. A flash of color with each cardiac cycle indicates pulsatile flow (Hillerbrand et al., 2025) (See figure 2).
Figure 2. Color flow through two vessels. The red color doppler signal suggests flow towards the probe while the blue doppler signal represents flow away from the probe. Intermittent flashes of color suggest arterial flow, while a continuous color signal suggests venous flow.
3) This is the ultrasound technique with the most evidence for its superior accuracy over manual pulse checks. A peak systolic velocity (PSV) is easy to obtain and correlates strongly with a pulse. To obtain a PSV, identify the target artery first. Once the artery is identified, enable the pulse-waved Doppler function and place the indicator in the center of the artery in short-axis. The doppler angle can be left on the control settings and need not be rotated. You should see an arterial tracing. Adjust the scale if needed to view the entire peak and trough of the arterial waveform. Then measure the highest point of the spectral Doppler tracing during systole (See figure 3). A PSV greater than 20cm/s is a reliable indicator of a perfusing blood pressure (Corresponding roughly to an arterial line pressure of SBP ≥ 60mmHg (Cohen et al., 2022).
Figure 3. PSV of Femoral Artery in Transverse Orientation (Cohen et al).
There are many benefits of the sonographic pulse check. It offers a direct, visual confirmation of arterial flow that is much more reliable than tactile palpation. The presence of a pulsatile waveform is an objective finding, reducing the inter-observer variability associated with manual pulse checks. POCUS is also associated with faster ROSC confirmation (Kang et al., 2022). A quick, targeted scan can potentially confirm ROSC in just a few seconds, thus minimizing interruptions to life-saving chest compressions.
While sonographic pulse checks clearly offer a significant advantage during cardiac arrests, their quality and accuracy are highly dependent on the operator’s training and experience. This emphasizes the importance of integrating the skill into emergency medicine and critical care providers’ POCUS training curricula. Providers must also be mindful of probe selection, as simply using the wrong probe or improper settings can lead to inaccurate readings. Finally, the sonographic pulse check should be viewed as an adjunct to the standard ACLS algorithm, not a replacement. When used correctly, it is a tool that eliminates guesswork, enhances team communication, and improves patient outcomes.
In the high-stakes environment of a cardiac arrest, the question “Does anyone feel a pulse?” should never be met with a chorus of uncertain answers. The limitations of manual pulse checks underscore the urgent need for a more reliable approach. Sonographic pulse check offers that solution. In the resuscitation bays, remember while grabbing your probe:
The three techniques for sonographic pulse check: compressibility, color Doppler, pulsed-wave Doppler.
There is no known difference between the carotid or femoral artery site.
As with all critical POCUS, an experienced sonographer is key (so it’s time to equip every resuscitation team with the training and tools to make the sonographic pulse check a standard practice).
References
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Howell, K., Desai, A., Martin, D., & Nagdev, A. (2023, Sept 7, 2023). How To Safely Incorporate Ultrasound Into Cardiac Arrest Resuscitation. ACEPNow.
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