Pulse Check Accuracy in Infants and Children During Resuscitation
Red Cross Guidelines
- In unresponsive children or infants, not breathing normally and without signs of life, lay providers and healthcare professionals should not delay cardiopulmonary resuscitation (CPR) to perform a pulse check. UPDATED
- In a child or infant with no signs of life (unconscious/unresponsive) and with abnormal or no breathing, healthcare professionals may consider checking for a carotid pulse (children) or a brachial pulse (infants) in situations where alternative means are simultaneously in place for detecting a pulse or adequate perfusion. Determination of a pulse and adequate perfusion using a pulse plus a secondary method (e.g., end-tidal carbon dioxide, ultrasound) should take no more than 10 seconds and if absent, CPR should be initiated. (Good practice statement)
Insights
Pulse palpation has long been taught as a method for healthcare professionals to identify or confirm cardiac arrest during resuscitation of infants and children. For laypersons, a pulse check is not recommended. If an infant or child is unresponsive, not breathing normally, and shows no signs of life, CPR should be started immediately.
For healthcare professionals, the available evidence shows that pulse palpation in children is of low accuracy and uncertain reliability, with sensitivities ranging from 76% to 100% but specificity only 64% to 79%. Pulse checks also take too long. In one study of children not in arrest but supported with extracorporeal membrane oxygenation or left ventricular assist devices, only 39% of providers could make a decision about the presence of a pulse within 10 seconds. The median decision time was 18 seconds—well beyond the recommended 10-second limit—with longer delays among inexperienced providers. This limited and indirect evidence suggests that pulse palpation, by itself, is unreliable as the sole determinant of cardiac arrest. In unresponsive infants and children who are not breathing normally and without signs of life, CPR should not be delayed for a pulse check by laypersons or healthcare professionals.
In the in-hospital setting, however, additional monitoring may be available, including cardiac point-of-care ultrasound, oximetry, capnography or invasive arterial blood pressure monitoring. Evidence on correlating pulse checks with these advanced modalities is limited to small case series, and further research is needed. Despite this, the Red Cross recognizes that in settings where such secondary advanced methods are immediately available, experienced healthcare professionals may consider performing a simultaneous pulse palpation for no more than 10 seconds. If a pulse is not detected within that window, CPR should be initiated or resumed without delay.