# Cardiac Auscultation



## VFlutter (Jul 20, 2013)

So, how many of you listen to heart sounds as part of your normal assessment? Do you do it for all patients or only when you have a suspicion of cardiac illness? 

Do you feel you are competent enough to differentiate various sounds or just enough to know if a murmur is present? 

For those of you who do not, why?

A brief overview for those who are new..

Remember the areas you auscultate are no the exact anatomical location of the valves associated with them.







Audio examples of various sounds
http://depts.washington.edu/physdx/heart/demo.html

Another great video 
http://www.youtube.com/watch?v=lFcf5a6BZGw


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## Mariemt (Jul 20, 2013)

EMT b. Not qualified


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## STXmedic (Jul 20, 2013)

Mariemt said:


> EMT b. Not qualified



Why would an EMT-B not be qualified?


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## Mariemt (Jul 20, 2013)

Was not taught to find a murmur. EMT national standards do not teach heart sounds.


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## STXmedic (Jul 20, 2013)

So your knowledge is to be constrained to the very small amount obtained in EMT school? Expanding your knowledge is completely out of the question because NREMT says you don't need to know it?


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## hogdweeb (Jul 20, 2013)

PoeticInjustice said:


> Why would an EMT-B not be qualified?



this is what I was asking in the other thread. We never were even told of cardiac auscultation in class, but not? Can it be that hard, even if on the radio report you say something as simple as "Cardiac sounds are abnormal in this area"? the only one benefiting from this is the patient, the hospital can begin to better formulate what may be actually going on and get a treatment plan going sooner rather then waiting, correct?


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## chaz90 (Jul 20, 2013)

I listen to heart tones on the majority of patients, but I don't believe I'm competent enough to recognize most abnormal variations. I can hear S1 S2, and then "things that are different." I've heard a few murmurs this way. Most of the time, I ask my patient more about their heart history after I hear something odd and they do have a murmur or PFO.


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## STXmedic (Jul 20, 2013)

hogdweeb said:


> this is what I was asking in the other thread. We never were even told of cardiac auscultation in class, but not? Can it be that hard, even if on the radio report you say something as simple as "Cardiac sounds are abnormal in this area"? the only one benefiting from this is the patient, the hospital can begin to better formulate what may be actually going on and get a treatment plan going sooner rather then waiting, correct?



Many paramedic programs don't cover heart sounds either. That doesn't mean you can't learn it yourself. The more information you can obtain on your patient during an assessment, the better picture you can paint of what's going on. Cardiac auscultation can give you a better list of differential diagnosis to apply to your patient. Will it change your treatment, maybe, but most likely not (especially as a basic, but even for a medic). It doesn't mean the information you obtain isn't valuable information, though. Educating yourself is being an advocate for your patient. EMT class should not be the end of your education.


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## VFlutter (Jul 20, 2013)

As an EMT-B I think it is great to learn about heart sounds and listen for them in your patients however I do not think I would use them as part of report unless it is something obviously abnormal. 

I should  mention that it is a skill that is very hard to master. It takes a lot of practice and a lot of patients before you will become competent. I remember reading a study comparing medical students and MDs of various specialties that showed a very poor percentage of accurate recognition.  

For me it took months before I felt comfortable reporting my physical assessment findings to doctors. And I listen to multiple cardiac patients a day. In EMS you have a much larger and diverse patient population and may rarely have these patients. 

It also seems that the importance of murmur recognition is declining. Most MDs will hear a murmur and just order an Echo. There really isn't a need like there once was. Of course in EMS you do not have that luxury.

On a related note: Does anyone listen for carotid bruits?


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## Mariemt (Jul 20, 2013)

PoeticInjustice said:


> So your knowledge is to be constrained to the very small amount obtained in EMT school? Expanding your knowledge is completely out of the question because NREMT says you don't need to know it?


No, but not having any formal education with it. Having no experience in what certain sounds are... I am not qualified, formally or on my own.


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## STXmedic (Jul 20, 2013)

Mariemt said:


> No, but not having any formal education with it. Having no experience in what certain sounds are... I am not qualified, formally or on my own.






Chase said:


> A brief overview for those who are new..
> 
> Remember the areas you auscultate are no the exact anatomical location of the valves associated with them.
> 
> ...



3char


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## Summit (Jul 20, 2013)

You don't have to have any letters after you name to use your brain and 5 senses in the course of assessment. What you do not know, learn. Also, I recommend using only 4 senses since patience get weirded out if you incorporate taste into your assesment. 



Chase said:


> On a related note: Does anyone listen for carotid bruits?



Not as often as I should. I found one the other day.


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## Mariemt (Jul 20, 2013)

PoeticInjustice said:


> 3char



OK starting education...
....
  ..

Done. Qualified now


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## Carlos Danger (Jul 20, 2013)

Summit said:


> I recommend using only 4 senses since patience get weirded out if you incorporate taste into your assesment.



Nice.....


I've always listened to heart tones as part of my primary assessment (the "C" part) on trauma patients. Just to make sure the tones don't sound muffled or distant, and to have a baseline. It literally takes like 3 seconds. 

Assessing sounds as part of a cardiac exam is another thing altogether. IMO it is a time consuming yet very low-yield skill. Nice to have, I guess, but unless you get really, really good at them you can never be quite confident your assessment is correct, and more importantly I don't see anyone ever making a treatment decision based on heart sounds. That, and the fact that most paramedic programs simply don't teach the cardiac A&P needed to really understand the different sounds.

Now that we have bedside echo, I think auscultation of heart tones is quickly becoming obsolete, even among physicians.

Lots of respect for any EMT or paramedic who learns them. It's a cool old-school assessment skill and will improve your understanding of cardiac A&P, for sure.


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## Wheel (Jul 20, 2013)

This is something that I don't do, but I'm very interested in learning it. My school wasn't the best about teaching us a good detailed assessment (anything more than the NREMT basically.) That's why I've been reading Bate's Guide to Physical Exam and History Taking. I'm trying to slowly improve my assessment skills, especially in areas I assess often (neuro, cardiac, respiratory, GI.)


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## blindsideflank (Jul 20, 2013)

S3 has been useful in possible CHF patients. but im not comfortable with much more than that.


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## medicsb (Jul 20, 2013)

I'm in my fourth year of medical school and still struggle with interpreting heart sounds, especially since many doctors no longer are experts.  It is my guess that it take many years of listening to many many patients a week to get good at it.  I can only think of one instance where a sound auscultated changed anything (an anesthesiologist picked up a severe mitral regurg and cancelled a case; turned out the patient had suffered a silent MI resulting in a papillary muscle rupture).  I have yet to hear "muffled" heart sounds as heard with pericardial effusions and have yet to hear an S3 or S4.  Most gallop beats are quiet and require the patient to be positioned on the L side to be heard.  To determine the valvular origin of a murmer, you'd need to employ hand grips, squatting, standing, or valsalva maneuvers.  Good luck getting all that down and being able to have the time to do it on a call.  

In this day, the most important benefit is the patient feeling like you're being thorough (even if you're completely faking it).


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## VFlutter (Jul 21, 2013)

medicsb said:


> I have yet to hear "muffled" heart sounds as heard with pericardial effusions and have yet to hear an S3 or S4.



In my experience it has to be a large, usually peri-code tamponade, effusion before you notice "muffled" sounds. I do frequently hear friction rubs with effusions. I have caught a few before being diagnosed.


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## HMartinho (Jul 24, 2013)

I use to compare the apical pulse, with radial pulse. Just that.

Besides, I only listen lungs sounds.


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## Dwindlin (Jul 24, 2013)

I don't listen pre-hospital, in no way affects anything I'm going to do.  In the hospital I generally listen in one area.  The valve region is largely crap.  There is so much transfer of sound waves in the chest that you can't reliably say where the murmur is just by auscultation (even adding in the radiation garbage).  Secondly, I hear a murmur.  If the patient doesn't know they have one I'm ordering an echo, end of story, if they know its there and they are asymptomatic it probably doesn't matter anyways.


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## TheLocalMedic (Jul 25, 2013)

Dwindlin said:


> I don't listen pre-hospital, in no way affects anything I'm going to do.  In the hospital I generally listen in one area.  The valve region is largely crap.  There is so much transfer of sound waves in the chest that you can't reliably say where the murmur is just by auscultation (even adding in the radiation garbage).  Secondly, I hear a murmur.  If the patient doesn't know they have one I'm ordering an echo, end of story, if they know its there and they are asymptomatic it probably doesn't matter anyways.



Bingo.  Even if I was listening to enough hearts to be able to definitively say that I was hearing something that wasn't right, it still isn't going to affect anything I'm going to do.  

Besides, why would you stop everything else that you _should_ be doing on a call to listen to a patient's heart for a few minutes?  Yes, please delay care of a STEMI patient for a few minutes while you play with your stethescope and pretend that you're some cool whiz kid that who will have some kind of "aha!" moment after intently listening to your patient's chest.  I know for a fact that nobody I work with actually listens to heart sounds, and if I met a medic on the street who professed to actually include them in his assessment I'd either believe him to be either very new or very naive for thinking that they could diagnose anything or use what they heard to help them make a diagnosis.


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## Handsome Robb (Jul 25, 2013)

chaz90 said:


> I listen to heart tones on the majority of patients, but I don't believe I'm competent enough to recognize most abnormal variations. I can hear S1 S2, and then "things that are different." I've heard a few murmurs this way. Most of the time, I ask my patient more about their heart history after I hear something odd and they do have a murmur or PFO.



I'm in the same boat. If it is pertinent (ie cardiac and trauma...sometimes breathers just because I'm already right there listening anyways)  I'll listen but beyond s1-s2 it's usually limited to "abnormal heart tones" in my report to the RN/Physician in my face to face report, I don't include them in my radio report. I've had physicians ask me about them when I haven't listened and I've had physicians surprised when I did and reported an abnormal finding. Never had one tell me not to listen to them. Still working on this whole education thing and furthering it.

I don't think you can argue it's detrimental to the patient due to delaying definitive care, it's a down and dirty quick listen and like someone, Halothane maybe, said, it only takes a couple seconds to do.

I don't understand how people harp on how EMS education focuses too much on rapid transport and that "seconds matter" then the same people do a 180 and argue against a full and thorough assessment because you're delaying definitive care but that's just my opinion.

I can think of three conditions where seconds really count. Those being cardiac arrest, complete FBAO and anaphylaxis.


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## Aprz (Jul 25, 2013)

Well, since we are talking about it. I actually did watch videos on it a long time ago, and I just kinda chickened out and never did practice it on patients.

s3 is like lub-dub-pause-another sound here.

s4 is another sound here-pause-lub-dub?

I never really understood whether s3, s4, or both are associated with congestive heart failure, and I don't get why the sounds exist.

I am gonna go watch that heart murmor revised video right now. I probably won't be able to respond until tomorrow morning.

*Edit* Wow, this video makes it seem easy so far.

*Edit* Very informative video.

*Edit* Prehospital 12-lead ECG on Facebook just asked a question that had S3 as one of the possible answers. It was pretty much in congestive heart failure (CHF), what sign would be most likely found in left sided failure? A) JVD B) Rales C) Pedal edema D) S3.

*Edit* Been listening to myself. I am kinda hesitant to try on patients since I am usually not managing patient care (I don't work BLS). If I do happen to do BLS, I might start listening to heart tones to see if I can pick up anything different. Seems to be really hard just trying to listen to the videos. The video describes it easily, but actually listening to the tone (when, shape, pitch) is hard. I'll be sure to check heart sounds on the patient's chart as a way to see if I can hear what they are describing.


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