Monday, December 29, 2014

Femoral pulse during CPR - Arterial or Venous?

There are many uncertainties about how each of us will die.

Based on my experience in the ED, however, many of us will spend our last minutes on Earth with a stranger's hand shoved into our groin.

Your own hand? Fine.
I'm talking about the checking the femoral pulse during CPR, of course. It's a well-enshrined part of our resuscitation practices, but what it is it actually telling us?

The Theory
The idea, of course, is that effective CPR will produce an arterial pulse, albeit weak, that will generate a cardiac output about 20% of normal. Palpating a femoral pulse during compressions supposedly verifies that the CPR is being effectively delivered.

Evidence that the femoral pulse is venousHowever, there is some uncertainty about what a palpable femoral pulse actually represents. Hilty used ultrasound in a study of central line placement during cardiac arrest, and noted that 9/20 patients appeared to have femoral venous pulsations, rather than arterial.
Note that this was in the dark ages of ED ultrasound (1997), back before Christian Doppler was born. 

Based on this finding, as well as on a case report of two kids getting open-chest cardiac compressions, many people now believe that the femoral pulse during CPR is just the venous back-flow. A video posted by an emergency physician in Qatar supports this view, where he demonstrates interrogation of the femoral vessels with power doppler during CPR:



The femoral vein shows much brighter signal than the artery, suggesting that the venous flow far exceed the arterial. Of course, since this is power doppler, we don't know the direction of the flow.

Evidence that the femoral pulse is arterial?
Cardiac arrest, asystole when EMS arrived in the ED, the LUCAS dutifully chugging along.  

Probe placed in the right groin, angled cephalad slightly. First, with color doppler:


The femoral artery seems to show a fairly well-defined arterial pulse, while the femoral vein has a turbulent, almost "yin-yang-like" character, that does not suggest effective flow. So based on this clip, it seems like the femoral pulse indeed reflects arterial impulses, not venous.

(BTW, here's a clip of the same view, while the LUCAS was taking a break. Just so you know that there was no spontaneous cardiac activity mucking up the doppler.)



So, what does the femoral pulse tell us about CPR quality?
Not much, probably.
The scanty and conflicting "evidence" (i.e. collection of anecdotes) reviewed here doesn't make it clear if pulsations in the groin are coming from the artery, the vein, or perhaps even both. This looks like a promising avenue for an emergency ultrasound study!

In the meantime, assessing the quality of CPR is likely best done with end-tidal CO2, although a recent Ultrasound Podcast episode suggested using focused echo  to optimize compressions. 










9 comments:

  1. Thanks for sharing your ideas, I am also giving some ideas to get goods leads and sales With E-Health Care Lists you will access to the most recently updated Chest and Cardiac mailing list & email list. Our database can help you to target prospects to get high response rates and guaranteed results. Chest and Cardiac Surgeons mailing list

    ReplyDelete
  2. I really like your post so much.. Thank you for sharing! :)
    hip pain treatments

    ReplyDelete
  3. Nice message with lots of information included in the posting.Please find our link
    if you may be interested in ,please refer to
    Chest and Cardiac Mailing list & Email list

    ReplyDelete
  4. Try not to talk about legislative issues, sex or religion. Keep concentrated on the workmanship in the display. Blend and have a ton of fun. certified organic skincare

    ReplyDelete
  5. The article is beautifully written. It has all the valid points and is very impressive. We at Narwhal Data Partners provide you a wide range of Chest and Cardiac Surgeons Email List

    that you are looking for, guaranteeing you the data accuracy.
    We help you to plan for the future business campaigns by offering you a segmented and targeted Chest and Cardiac Surgeons Email List
    which mentions about the customer taste so you can approach them with the product they want.

    ReplyDelete
  6. I am bold enough among many others to state that there is now a potent cure to this sickness but many are unaware of it. I discovered that I was infected with the virus 3 months ago, after a medical check-up. My doctor told me and I was shocked, confused and felt like my world has crumbled. I was dying slowly due to the announcement of my medical practitioner but he assured me that I could leave a normal life if I took my medications (as there was no medically known cure to Herpes). I went from churches to churches but soon found that my case needed urgent attention as I was growing lean due to fear of dying anytime soon. In a bid to look for a lasting solution to my predicament, I sought for solutions from the herbal world. I went online and searched for every powerful trado-medical practitioner that I could severe, cos I heard that the African Herbs had a cure to the Herpes syndrome. It was after a little time searching the web that I came across one Dr Itua(A powerful African Herbal Doctor), who offered to help me at a monetary fee. I had to comply as this was my final bus-stop to receiving a perfect healing. My last resolve was to take my life by myself, should this plan fail. At last it worked out well. He gave me some steps to follow and I meticulously carried out all his instructions. Last month, to be precise, I went back to the hospital to conduct another test and to my amazement, the results showed that negative,Dr Itua Can As Well Cure The Following Desease…Cancer,Hiv,Herpes, Hepatitis B,Liver Inflammatory,Diabetis,Fribroid, Dercum,Get Your Ex Back, You can free yourself of this Herpes virus by consulting this great African Herbal Doctor via this e-mail: drituaherbalcenter@gmail.com or call and whatsapp him on +2348149277967 He will help you and his herb medication is sure. he has the cure on all disease .You can talk to me on INSTAGRAM..tashamoore219....

    ReplyDelete
  7. Thanks for sharing the valuable information. Your article gave me a lot of information. We at Techno Data Group would like to introduce to you about our organization. We are the leading database providers for b2b marketing across the globe. we provide you with the readymade as well as the personalized email list and connect you with the right client or decision-makers. Please refer our Chest and Cardiac Surgeons Email List for further details.

    ReplyDelete
  8. very useful post. We have CPR Manikin for sale in malaysia. Contact IBSMEDIC for more details.

    ReplyDelete
  9. DR Lucky HERBAL REMEDY CURE HIV WITHIN TWO WEEKS (drluckysolutionhome1@gmail.com OR Add him on WhatsApp
    +2349065749952
    I just wanted to take the time to say that i was heartbroken and depressed when I was diagnosed of Genital herpes .. I have been taking these disgusting Vaccines , even made me more sick and gave me headaches to the point of me puking. i searched everywhere for a solution. I came across this herbal doctor on internet called Dr Lucky who gave me hope that he can cure me totally from the virus so i gave a try believe me it was Amazing now am tested negative. contact email: drluckysolutionhome1@gmail.com Just wanted to share. Hope it helps someone, I'll be posting this to hopefully help anyone who needs help.

    ReplyDelete