Pulse Checks During CPR — Are They Really Reliable?

As clinicians working in emergency care, we’ve all been there. The code is in full swing, chest compressions are underway, and someone calls out, “Good pulse with CPR!” It’s an instinctive thing to do — we want reassurance that our efforts are making a difference.

But here’s what many of us have learned through experience and evidence: A palpable pulse during CPR is often misleading.

Carotid pulse check

While one rescuer continues high-quality compressions, another may attempt to feel for a carotid or femoral pulse. Studies have shown that what we’re feeling is frequently retrograde venous pulsation — blood being pushed backwards through the venous system — rather than true forward arterial flow from effective cardiac compressions. In roughly 50% of cases, a palpable femoral pulse during CPR does not correlate with meaningful perfusion to the heart or brain.

Why This Matters

This creates a real risk in the heat of a resuscitation. We might unintentionally reduce compression depth or rate because “they’ve got a pulse with your compressions,” when in reality, the patient is still inadequately perfused. It gives us false confidence at exactly the moment we need to stay focused on delivering the highest possible quality CPR.

Current ANZCOR and international guidelines have moved away from routine pulse checks during CPR for this very reason. They are no longer considered a reliable method for assessing the effectiveness of chest compressions.

The Better Alternative: Waveform Capnography

The preferred tool for monitoring CPR quality is continuous waveform capnography (ETCO2). A sustained ETCO2 value above 10 mmHg — and ideally trending upwards — tells us far more about the effectiveness of our compressions than intermittent pulse checks ever can.

When ETCO2 suddenly rises (often into the 35–40 mmHg range), it is one of the earliest and most reliable signs that Return of Spontaneous Circulation (ROSC) may have occurred (but continue the full cycle of CPR prior to a rhythm check). This is significantly more useful than relying on what we feel with our fingers.

This principle sits at the heart of high-quality resuscitation. For more on building a strong foundation in resuscitation, see our article on Priorities in Resuscitation.

Clinical Takeaway

The next time you’re in a resuscitation and someone says they can feel a pulse with compressions, check the bigger picture — especially the ETCO2 waveform. A pulse check might feel reassuring, but it is frequently unreliable. Our job is to stay focused on delivering consistent, high-quality compressions and using the best available monitoring tools to guide us.

In resuscitation, what we feel with our fingers can sometimes deceive us. What the capnograph shows rarely lies.

Check out more on this topic in the video:

https://youtu.be/NrEOFJ4Jw6I

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Image credit: Carotid pulse demonstration by Rama / Wikimedia Commons / CC BY-SA 3.0

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Originally published at https://lifesupportinstitute.com.au.