Cardiology Introduction Use of Stethoscope

Introduction of Proper use of Stethoscope for cardiology

1. Can You Hear Me Now?? Bill Hathaway, BS, NRP

2. Objectives Stethoscope basics Stethoscope usage in physical exams:

3. History Of Auscultation The word stethoscope is derived from the two Greek words, stethos (chest) and scopos (examination). 400 BC. Basic concept of auscultation by Hippocrates Physicians would often perform physical examinations using techniques such as percussion and immediate auscultation. In immediate auscultation, physicians placed their ear directly on the patient to observe internal sounds.

4. Stethoscope Basics: Littmann Cardiology III Two tunable diaphragms which allow the user to alternate between low- and high-frequency sounds without turning over the chest piece. The large side can be used for adult patients, while the small side is useful for pediatric or thin patients, around bandages, and for carotid assessment. The pediatric side converts to a traditional bell by replacing the diaphragm with the non-chill bell sleeve included with each stethoscope.

5. How Is It Used? There is a right and wrong way to wear your stethoscope The earpieces are angled – they should point anteriorly when in your ears Most stethoscopes have adjustable tension in the headset – read your manual for guidance

6. Correct Use Place chestpiece directly against patient’s skin Diaphragm chestpiece should be applied with enough pressure to leave a slight depression when removed Excessive pressure may obstruct vessel blood flow (loss of sound, false bruits) Fingers holding chestpiece should remain straight still (movement may cause extraneous noise) Avoid stretching the tube

7. Chest Piece Applied to chest with firm pressure Detecting high-frequency (high-pitched sounds and murmurs Filters out the lower frequency sounds Sounds/murmurs best heart 1 st & 2 nd heart sounds Their splitting, ejection sounds, systolic clicks, the opening snaps of mitral or tricuspid stenosis Diastolic murmurs of aortic or pulmonic valve regurgitation Systolic murmur of Ventricular Septal Defect

8. Chest Piece cont.. Applied gently to the skin with as light a pressure as possible so as to barely make an air seal Detecting the faintest low-pitched and medium-pitched sounds and murmurs Diastolic rumbles of mitral and tricuspid stenosis 3 rd & 4 th heart sounds 1 st & 2 nd heart sounds

9. Finally: Using the Stethoscope! What are we listening for? Heart rate and rhythm Heart sounds Physiologic and pathologic Breath sounds Physiologic and pathologic Bowel sounds Bruits

10. Physical Characteristics of Sound Three physical properties: Frequency Loudness Harmonics 

11. Frequency A measure of the number of vibrations (cycles / second) or Hertz (Hz) The greater the number of vibrations the higher frequency the sound High frequency = high pitch Low frequency = low pitch

12. Intensity Determined by: The amplitude of the vibrations Source generating the energy Travel distance of the vibrations Medium through which they travel

13. Harmonics Relates to quality, mixture of frequencies, and duration of vibrations Short vibrations are classified as clicks or snaps Longer vibrations are classified as murmurs

14. Heart exam Auscultation

15. The Examination Optimize your environment for auscultation Obtain a quiet room for assessment Close doors, turn any radio / TV off Ask politely to abstain from conversation while auscultating Focus on one characteristic at a time Actual components (S1, S2, etc.)

16. Cardiac Exam Landmarks Aortic area Right 2 nd intercostal space Pulmonic area Left 2 nd intercostal space Tricuspid area 4 th -5 th intercostal space, just left of the sternum Mitral area 5 th intercostal space left mid-clavicular line

17. Cardiac Exam Landmarks Don’t forget! Listen on skin!

18. Sequence of Auscultation • Aortic area - Second right intercostals space close to the sternum of the chest. Characteristic heart sound S2 heard louder than S1 aortic closure heard loudest. • Pulmonic area - Second left intercostals space close to sternum. Its characteristic heart sound is splitting of S2 heard best, normally widens on inspiration; pulmonic closure heard best. • Erb's Point - Second and third left intercostals space close to the sternum of the chest. Its characteristic heart sound is frequent site of innocent murmurs and those of aortic or pulmonic origin. • Tricuspid area - Fifth right and left intercostals space close to the sternum of the chest. Its characteristic heart sound is a frequent site of innocent murmurs and those of aortic or pulmonic origin.

19. Sequence of Auscultation • Tricuspid area - Located at the fifth right and left intercostals space close to the sternum of the chest. Its characteristic heart sound is S1 heard as louder sound preceding S2 (S1 synchronous with carotid pulse). • Mitrial or apical area - Located at the fifth intercostals space, left mid-clavicular line (third to fourth intercostals space and lateral to left mid-clavicular line in infants. Its characteristic heart sound is S1 heard loudest; splitting of S1 may be audible because mitrial closure is louder than tricuspid closure. S3 heard at beginning of expiration with child in recumbent or left side-lying position, occurs immediately after S2, sounds like word "Ken- tuc - ky " (S1-S2-S3). S4 heard best during expiration with child in recumbent position (left side-lying position decreases sound), occurs immediately before S1 sounds like word "Ten- nes -see" (S4-S1-S2).

20. Normal Heart Sounds S1 : Mitral and tricuspid valve closure S2 : Aortic and pulmonary valve closure (Mitral)

21. The Cardiac Cycle Systole : Between the first heart sound (S1) and the second (S2) Diastole : Between the (S2) and (S1) Lasts longer than systole

22. Physiologic Splitting of S2 Valves on the left side of the heart close slightly before those on the right Aortic valve (A2) closes first Pulmonic valve (P2) closes second Splitting is accentuated by deep inspiration

23. Abnormal* Heart Sounds S3 : Created by blood from the left atrium entering into an already overfilled ventricle during diastole S4 : Created by blood trying to enter a stiff ventricle during atrial contraction Both are low-pitched “extra sounds” heard best with the bell of your stethoscope Normal for comparison. *Can be normal in athletes; S3 can be normal in pediatric patients

24. Heart Murmurs May be “innocent” or indicative of underlying pathology Stenosis Regurgitation/insufficiency Longer duration than heart sounds Use chest wall location, intensity, pitch, duration, and direction of radiation to help identify

25. Assessing Murmurs Grading of Murmurs: Grade 1 - only a paramedic can hear (LOL) Grade 2 - audible to an EMT Grade 3 - audible to a EMT student Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed-side

26. Characteristics of a “functional” murmur Short and soft SEM Normal S1 and S2 Normal cardiac impulse No evidence for any hemodynamic abnormality

27. Common Murmurs and Timing (click on murmur to play) Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1

28. Auscultation “Aortic area” 2nd left intercostal space (URSB) compare S1 to S2-S1 should be softer. If the same, think Mitral Stenosis identify ejection murmur-time the peak intensity in relation to systole identify ejection click if present

29. Auscultation “Pulmonary Area” 2nd right intercostal space (ULSB) listen for split S2 (A2/P2) identify the intensities of A2 and P2 time split S2 with respiration normally widens with inspiration, closes with expiration wide split S2-RBBB, RV volume overload, PS, RV failure wide fixed split = ASD paradoxical split = LBBB, severe AS, severe LV dysfunction, pacemaker

30. Auscultation “Left Sternal Border” Listen for early diastolic murmurs Press firmly with diaphragm Listen upright with forced expiration Listen on hands and knees

31. Auscultation “Mitral Area” Listen for intensity of S1 Soft-LV dysfunction, first degree heart block, pre-closure with sudden severe AR/MR Loud-MS, sympathetic stimulation Variable- Complete heart block with AV dissociation, Wenkebach Identify splitting of S1

32. Auscultation “Mitral Area” Identify quality, timing and intensity of systolic murmurs ejection quality vs regurgitant quality pansystolic vs early or mid to late systolic murmur

33. Auscultation Apex Listen for S3 and S4 Consider differential diagnosis of S3 A2-wide P2, A2-OS, A2-PK, A2-S3 Identify diastolic rumble Determine radiation of murmur e.g.. MR to axilla

34. Clinical Signs of LV Dysfunction Hypotension Pulsus alternans Reduced volume carotid LV apical enlargement / displacement Sustained apex - to S2 Soft S1 Paradoxically split S2 S3 gallop (not S4 = impaired LV compliance) Mitral regurgitation Pulmonary congestion rales

35. Clinical Signs of RV Dysfunction With Pulmonary HPT Loud P2/palpable PR murmur Common findings Without Pulmonary HPT Soft P2 No PR RV S4 Edema RV S3 Murmur + Kussmaul’s

36. Carotid Arteries