The 3-point pulse check, cardiac arrest & patient safety: An ALS myth or best practice?


Has anyone out there encountered the teaching of the 3-point pulse check? This is the practice whereby the simultaneously manual palpation of 2 femoral arteries and 1 carotid artery is conducted to verify the absence or presence of a pulse during cardiac arrest. It is a technique that appears to have surfaced within Resuscitation Council Advanced Life Support (ALS) course teaching in recent years. Appearing as a simple, common-sense intervention it seems to have developed a momentum that holds appeal to ALS instructors and some appear to consider it as best practice. However, in the interests of clinical & professional clarity and the promotion of better outcomes for patients, it is perhaps timely to take a critically analytical gaze at the published evidence. Accordingly, this review commences with a brief resume of the published evidence around pulse-checking in cardiac arrest, which is then followed by a section that considers the utilisation of the pulse-check at the point-of-care, in the heat of the moment during the crisis of the cardiac arrest.

Pulse checking in cardiac arrest It has long been recognised that the confirmation of an absent pulse in a collapsed person in cardiac arrest is unreliable (Assar et al, 2000) and further studies have indicated that even experienced healthcare professionals find pulse checking challenging in both adult (Perkins et al, 2005) and paediatric resuscitation (Tibballs & Russell, 2008). The publication of Eberle and co-workers (1996) provided very powerful insights into the nature of our technical inadequacies when using manual palpation to ascertain the presence or absence of a pulse, particularly during the initial assessment of the collapsed patient. This evidence has been reflected in contemporary resuscitation guidelines in that successive guideline statements progressively de-emphasised pulse-checking during the initial assessment to the extent that it is no longer recommend in basic life support (Koster et al, 2010). Furthermore, in order to minimise the harmful pauses associated with deleterious outcomes (Edelson et al, 2006), current ALS guidelines strongly emphasise brevity in pulse checking to the extent that it is only recommended in the presence of organised heart rhythms (Nolan et al, 2010). In recognition of the problem, researchers have attempted to provide educational, procedural and technological solutions to provide diagnostic accuracy. In recognition of some of the human factors elements, the work of Perkins and colleagues (2005) aimed at simplifying the assessment process, more recently Tsung & Bliavas (2008) have suggested point-of-care echocardiography as a method of verifying the apparent absence of a pulse. It is interesting to note that the use of multiple point pulse checking by two or more persons palpating an artery was not considered or discussed.

Performing technical skills in medical emergency care

Those who are interested and acknowledge the importance of human factors in the nature and source of error are likely to be familiar with the evidence that indicates that the frequency of slips, lapses and mistakes increases amongst those subject to duress during critical care conditions (Bucknall, 2010). The complexities and limitations of training and performance regarding the human factor basis of error that arises in the situation of crisis resource management are also widely evidenced (Catchpole, 2013). Marsch and colleagues (2005) clearly demonstrated that under simulated conditions, highly trained & experienced ICU staff significantly under-performed when presented with cardiac arrest scenarios and that failure was linked to poor leadership and poor task allocation. It would appear that the addition of un-familiar, non-evidence based processes, such as a 3-point pulse check are unlikely to enhance cardiac arrest management and benefit patient outcome.

Maxims and myths

With regards to the dangers of using personal maxims, many will recall people singing of ‘Nellie the Elephant’ when teaching and practicing chest compressions, another example of one of those common-sense ideas that became a widely accepted ALS myth, far fewer are aware that when tested the use of ‘Nellie the elephant’ in CPR teaching significantly reduced effective compression depth (Rawlins et al, 2009) and the authors recommended that the practice should cease. Others may be interested in the dangerous inaccuracy of the trauma myth of palpating pulses to estimate blood pressure, a technique that over-estimates the systolic… (acknowledgements to R.E.B.E.L. EM)


My personal experiences of witnessing the 3 point pulse check in clinical practice was disturbing as it was poorly co-ordinated, distracting to the running of the event and delayed definitive care in the context of a defibrillatory shock. Furthermore, having conducted a literature search of both PubMed and Web of Science (using the PICO method) it appears that there is a complete absence of any evidence to support the 3-point pulse check.


Whilst the evidence is overwhelmingly convincing that manual palpation of major pulses in cardiac arrest is unreliable, there remains a paucity of peer reviewed literature that addresses the ergonomic, bio-semiotic, human factors issues associated with how such techniques are conducted under the duress of cardiac arrest, which merits robust research. Currently there is no evidence to support the deployment of the 3-point pulse check in CASTeach simulation stations, and certainly not in clinical practice. One is therefore drawn to conclude that the 3-point pulse check is a resuscitation myth and its presence in education and clinical practice should be curtailed with immediate effect. If or when you encounter this dogma, I challenge you to be a professional, informed practitioner and politely request the protagonist(s) to provide the evidence-base rationale to support this so-called best practice. For those of you who are the protagonists, may I challenge you to submit / present an abstract / paper outlining a comprehensive, evidence-based, scientifically tested rationale to support the procedure, perhaps at the ERC meeting in October, or the RCUK meeting in November?


Assar, D., Chamberlain, D.A., et al. (1998). A rationale for staged teaching of basic life support. Resuscitation. 39.137-143.

Bucknall, T. (2010) Medical error and decision making: Learning from the past and present in intensive care. Australian Critical Care. 23. 150-156.

Catchpole, K. (2013). Spreading human factors expertise in healthcare: untangling the knots in people and systems. Quality and Safety in Health Care. 0:1–5.

Eberle, B., Dick, W.D. et al, (1996). Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 33. 107-116.

Edelson, D.P., Abella, B.S., et al, (2006). Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 71. 137-145.

Koster, R.W., Baubin, M.A. et al, (2000). European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation. 81. 1277-1292.

Marsch, S., Müller, C., et al. (2004). Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation. 60. 51-56.

Nolan, J.P., Soar, J., et al, (2010). European Resuscitation Council Guidelines for Resuscitation Section1. Executive Summary. Resuscitation. 81.1219-1276.

Perkins, G.D., Stephenson, B., Hulme, J. and Monsieurs, K.G. (2005). Birmingham assessment of breathing study (BABS). Resuscitation. 64. 109-113.

Rawlins, L., Woollard, M., Williams, J. and Hallam, P. (2009). Effect of listening to Nellie the Elephant during CPR training on performance of chest compressions by lay people: randomised crossover trial. BMJ. 339. b4707.

Tibballs, J. & Russell, P. (2008). Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation. 80. 61–64.

Tsung, J.W. & Bliavas, M. (2008) Feasibility of correlating the pulse check with focused point-of-care echocardiography during pediatric cardiac arrest: A case series. Resuscitation. 77. 264—269.


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