Auscultation of cardiac sounds in prehospital environment?

Maple Flag · 06-14-2005, 23:47

Hi again all,

It's been a while since I last posted here. I've been swamped with life, and the load is lifting as summer comes on. I hope to pay my dues with 1 or 2 more aid bag reviews to make up for lost time. In the mean time, I have a question. (I've posted this at Lightfighter also, but I know a lot of high speed medics drop in here on a regular basis, so this seems like a good pond to fish in).

I'm taking a physiology course at university, and we're doing a fairly in depth (for me at least) section on cardiac physiology. Part of this includes tracking and matching ECG, left ventricular volume, atrial/ventricular/aortic pressures, and so on through the cardiac cycle, as well as the corresponding cardiac sounds and landmarks for auscultaing each sound (S1-S4).

Needless to say, this was never covered in my EMR (a Canadian BLS level cert) training, and in fact, auscultation of cardiac sounds was never covered - just deep airway/lung sounds.

This raised a few Qs for me:

Are any more advanced providers (more advanced than me anyway) auscultating cardiac sounds in the prehospital environment?

Is this covered in ACLS or other prehospital applicable certifications?

If performed, what specifically are you lookking for, and what provisional diagnosis can be made in part through cardiac auscultation?

Any other related information is also of course appreciated.

Cheers.

Firebeef · 06-15-2005, 07:36

hey Maple

well, I'm just getting off duty this morning as a Fireman/EMT-Intermediate. I worked 2 codes yesterday. I doubt that as a guy who used to carry a heavy commo ruck and now carries heavy hoses that I am more advanced than you, but in your question you hit on something that is a pet peeve of mine...you put the words "pre-hospital" and "diagnosis" in the same paragraph. We don't diagnose in the field, bro!

As an ALS provider, I know that the best care that I can give someone who is having a bad heart day is to get them to a hospital with a cardiac unit muy pronto and pain free. I can't imagine what someone in the field would do or do any differently if they were able to discern A-fib or WPW from auscultating a patients heart sounds.

I am not trying to discourage you, bud, but you have to be able to seperate the field environment from what is I'm sure is a very good tool to use in the confines of cardiac unit....once the patient is delivered there, and fast, with the proper and most thorough care that can be provided by a member of the pre-hospital team.

I'm not sure what ACLS has to say about auscultating cardiac sounds, but I don't remember that being covered in any ACLS or recert I've taken. Good luck in your Phys class.

**Eagle5US** · 06-15-2005, 09:42

Quote:

Originally Posted by Maple Flag

Needless to say, this was never covered in my EMR (a Canadian BLS level cert) training, and in fact, auscultation of cardiac sounds was never covered - just deep airway/lung sounds.

This raised a few Qs for me:

Are any more advanced providers (more advanced than me anyway) auscultating cardiac sounds in the prehospital environment?

Is this covered in ACLS or other prehospital applicable certifications?

If performed, what specifically are you lookking for, and what provisional diagnosis can be made in part through cardiac auscultation?

Any other related information is also of course appreciated.

Cheers.

These are hospital skills, not pre-hospital skills. The only real prehospital heart sounds you need are SOUNDS

your Q's:
1. No
2. No

In a hospital environment, you are listening for any number of different combinations and patterns of sounds that can show significant valvular anomolies and or pathology including regurgitation, stenosis, etc...

Good luck, get a good set of ears

Eagle

haztacmedic · 06-15-2005, 10:21

As an advanced life support provider, I see cardiac patients every shift period!
What is more important is providing bls and als interventions. There is nothing that listening to a heart sound will do to change what you do in the prehospital enviroment . If you really want to appear glamourous and use that sexy stethoscope Listen to lung sounds and take blood pressures....if you must listen to heart sounds...listent to an unresponsive, apneic and otherwise pulseless patient to see if he has no heart sounds at all as a way to confirm death.
Good Luck!
somedic

Maple Flag · 06-15-2005, 11:34

The answers are consistent, and they are what I suspected.

Firebeef, I use the word "diagnosis" with some caution, and only with "provisional" put in front. I'm well aware that diagnosis is not done in the field, at least by me. My question was more aimed at those who might be in a position to make a diagnosis, provisional or otherwise. I also agree that nothing I'm going to hear in a stethescope is going to change what I do (O2, CPR, AED, patient's ASA and nitro, depending on what's going on.). Lastly, your ALS cert trumps my lowly BLS cert, so I would consider you more advanced. Further, I only go out on infrequent calls, as I am a full time security manager. I (try to) make up for my experience gap with tons of reading, courses, and studying while I'm still wrestling with a career transition to EMS.

Eagle5US, thanks for the feedback. As for ears, almost everyone I've spoken to steered me toward the Littmann Master Cardio, so I've got one on order. I declined on the electronic steths (too much money to be banging about in the field, and I generally prefer things that don't require batteries).

Somedic, thanks for the feedback, and I agree (as above) that auscultating heart sounds would not change what I do at my level of cert. I'm just trying to improve my knowledge and skills always (which is why I'm taking this course to begin with). As for looking glamorous, I'll leave that to buff folks in their 20's who do beer commercial ads in their spare time. I'm just trying to have the best understanding of the work as I can.

My purpose here was to see if these skills discussed in the course were worth practicing if I'm to move up in the area of pre-hospital care. Sounds like they may be useful, but not in the pre-hospital care environment.

Thanks for the commentary folks. It was helpful.

Thursday · 06-19-2005, 22:13

There is one thing that you need to remember more than anything else.

TREAT THE PATIENT, NOT THE MONITOR

It doesn't matter what the monitor says, it matters what s/s your patient is showing. I have seen a patient that has been in a 3rd degree heart block that have been almost totally fine except for being bradycardic. He didn't need to get any adenosine, just some atropine. It's all about how your patient is feeling and what you see in him that will determine what your treatment is. Reading what monitor a monitor says or hearing muffeled heart tones with a tension pneumothorax are associated symptoms or pertinant negatives that help out making your differential field diagnosis.

Quote:

Originally Posted by Maple Flag

Firebeef, I use the word "diagnosis" with some caution, and only with "provisional" put in front. I'm well aware that diagnosis is not done in the field, at least by me.

As for your statement above, I don't agree with it. You NEED to make a diagnosis, otherwise, how would you treat your patient? While doing your initial assessment and general impression you start to form your differential diagnosis. If you are called to a scene with a patient with trouble breathing you should be thinking: OK, what could it be? Astham attack, end stage COPD pt, O2 deficient environment, thorasic trauma? You have to make a dx. And don't listen to the doctors and nurses ( especially ) when they say that you can't diagnose in the field. If that were the case, then we may as well throw away our licenses and go back to having the funeral home hearse drivers picking up all 911 callers.

**Eagle5US** · 06-19-2005, 22:39

Greetings Thursday,
Welcome to the medical section of PS.com.
Thank you for filling out your profile, please reflect a bit on your guidance to others-and remember you are a student of emergency medicine with limited knowledge and experience (if your profile is correct). We are ALL in fact students of medicine-just at different stages of knowledge. And there is a WEALTH of knowledge here.

Advising others to not listen to physicians is poor advice, MOST physicians have a good bit of schooling, knowledge, and experience....your operational orders and protocols are all coming from a physician.
Understand also-you do not get / obtain / earn a liscense. You become certified.

Enjoy your stay here...

Eagle

Thursday · 06-20-2005, 00:36

Hi Eagle,

I didn't intend on sounding like a jerk above, but it may have come off as though I did, I appologise. But as for what I said, it still stick behind it. First of all, in Illinois, we do recieve licenses, not certifications ( link ), I have one in my wallet that says EMT-Basic License, and will soon say Paramedic.

And as for the statement that I said don't listen to the doctors or the nurses, I think you mis-read it. I said don't listen to them when they say that we can't daignose in the field. Saying we can't and shouldn't diagnose in the field is like telling someone to go put out a fire but not giving them any water to do it with; it doesn't make any sence. Sure, my diagnosis might be just increased intracranial pressure when its actually a subdural hematoma, but what is the difference in the field? They both get treated the same way on my side of things, and the hospital will still come to their own diagnosis.

Again, I don't want to get into a pissing match with you about this, it's stupid to do so. Also, I am having a good time here. I mainly stick to the medical forums and sometimes venture into the weapons forum. There is a lot of good info and pictures as well, and I enjoy throwing my 2 cents in here and there.

Sacamuelas · 06-20-2005, 10:07

Thursday-
EVERYONE in this thread is more experienced and better trained than you are as a young EMT-B. According to your state's law on EMT-B, you are only minimally qualified and not professionaly trained to do much more than inject someone with an epi-pen, provide basic life support measures, assist and follow the directions of an onsite EMT-P, and drive a bus.

You can NOT make a medical diagnosis... what you described above is simply making a semi-educated guess as to what "might" be the etiology of the symptoms you are observing. You are not licensed to diagnose and definitively treat anything, and you are only allowed to perform supportive procedures that fall within guidelines and policies previously written by a MD. ...

Find somewhere else to put your .02 in if you are going to make recommendations and give advice outside your own experience or training level.

Firebeef · 06-20-2005, 22:23

Diagnosis...schmyignosis. You ASESS the patient...then you TREAT the patient. The reason it is a pet-peeve of mine is because I have witnessed well meaning PMs and other field personell obsessing over what the correct "diagnosis " might be, and meantime eat up another 5-6 minutes on scene. You have every right to disagree with me, it is a semantic fine line between "asessment" and "diagnosis" after all, but the question was asked about cardiac auscultation in the field. I rest my case.

towheadedmule · 09-15-2007, 17:55

Sorry to open a dead thread Admin edit-Eagle

Are heart tones important? To a certain degree, yes. However, they are a tool just like a blood pressure or breath sounds. If you are an EMT, you should be listening to all your patients. Heart tones and breath sounds, to learn what is normal, and when something is abnormal it will stand out.

Sorry for any wasted bandwidth.

PM Sent