Heart Sounds and Percussion

[AnthonyM83]

Anyone want to write something up on how to take heart sounds and what you're listening for and what it can tell you?

And maybe something on how to percuss the chest/abdomen?

I know it probably won't tell me much in the prehospital setting, but on longish transports I hate just sitting around. Might as well be practicing something . . .

[mshow00]

In regards to the heart sounds it can assist you in your field diagnosis if it has extra sounds: normally it is a "lub" followed by a "dub" sound. I don't know what the 'extra" sounds translate out too, but that is the gist of that. It is done with both the flat and bell part of your ears. You can hear murmurs, mitral valve prolapse (supposedly) and things of that nature.

As far as percussion it is a lost art that when trained properly one can map out organs of the body etc. It can also tell you whether your pt has a hemo vs pneumothorax. Dull sounds mean a mass (blood, organ etc) It is a lost art according to my medical control doctor.

At least that is what my minimal training has told/showed me. Hope this helps a little.

[Ridryder 911]

Here is a great link to understanding heart tones as a Paramedic and reference in EMS.

http://www.co.gaston.nc.us/gemshp/training/HeartTones.htm

R/r 911

[itku2er]

Here is a great link to understanding heart tones as a Paramedic and reference in EMS.

http://www.co.gaston.nc.us/gemshp/training/HeartTones.htm

R/r 911

That is pretty good site rid one of the better ones I have seen.

[firedoc5]

Heart sounds can lead you to detect any kind of pericardial problems. One thing on listening for heart sounds/ tones is that you have to listen to many, many in a clinical setting. You have to learn from listening to them over and over again. I was very fortunate that I had an ER doc and a Pulmonologist take me under their wings. I'd say it took more than three months before I felt I knew them sufficiently enough to take it to the field. I hope everyone will take the time to learn them. It was very beneficial.

[mobey]

I am also very interested to expand my knowledge in this area.

About all I use either method for now is a comparison on trauma pt's.

I will percuss and listen to heart sounds with each set of vitals and listen for changes as the call progresses.

But there is no way I would say I know what "Normal heart sounds" are, I wonder if I even see enough patients to ever know what normal sounds like, not to mention abnormal.

[Doczilla]

I could tell you how to percuss, but you are probably better off having one of the docs at the hospital quickly show you the technique. Percussion allows you to hear the relative density of what is directly underneath the skin. It is most useful in the abdomen and chest. Percussion of the abdomen can tell you if there is dilation of the bowel or a large amount of free air. Percussion of the chest can detect large pneumothorax or pleural effusions or consolidation.

For different percussion densities, practice first on yourself.

Percuss your thigh. This gives you an idea of what a pleural effusion will sound like. If you percuss the right upper quadrant of the abdomen, you will get a similar sound over the liver. You can percuss down the anterior liver until the sound changes. This point is the liver edge, so it gives you an idea of the size of the liver. You can do the same with the spleen in the left flank. You can use this to detect hepatomegaly or splenomegaly.

Next percuss your upper chest. This sounds a little less dense, more of a "thump" than the "thwack" like you get percussing the thigh. This is normal lung tissue. You can do this on someone's back and measure the movement of the diaphragm as the patient breathes.

Next percuss the abdomen in the various quadrants. You should at some point run into a pocket of gas, which will sound like a tiny drum. This hollow sound is what a pneumothorax might sound like. Large pockets of gas, such as those with ileus or bowel obstruction, will sound even more pronounced and hollow.

Percussion can be used to elicit pain to diagnose certain conditions as well. Percussion tenderness is more sensitive and specific for peritoneal irritation than rebound tenderness. You can elicit rebound tenderness on just about everyone, whether they have peritonitis or not, but percussion will not generally hurt those who don't (granted, some emotional stuff plays in, and some patients will complain of tenderness with percussion anyway. For a good exam, watch their face as you do it). For the patient with suspected peritonitis from appendicitis, percussion tenderness may help give clues to who really has it and who might not. Percussion of the costovertebral angle can elicit pain from obstructive uropathies (like a kidney stone) or pyelonephritis. Percussion of the maxillary or frontal sinuses can indicate acute bacterial sinusitis.

'zilla

[Ridryder 911]

I do believe one of our major downfalls is the inadequacy of patient assessment skills. No matter what level we are discussing. Sorry, very few Paramedics actually know how and worse do not perform detailed neuro assessments when needed; most referring to the old PEARL. Which most know by now in comparison is really a farce. There are so much more that EMS personal can obtain by learning detailed assessment techniques and then applying them and using them appropriately.

Yes, one should be able to focus on the problem and perform a detailed assessment and history. So many are being taught.. " you don't need to know this or you don't use this or that in the field" Those that teach that is full of B.S. and should be considered poor instructors. One can master such assessment techniques and then develop related clinical understandings. After performing several; then one can modify and learn to "speed up" assessment techniques.

Yes, I listen for gallops and murmurs on cardiac patients .. (it takes < than aminute) .. yes, I check skin turgor, clubbing, even a brief overview of hair growth patterns (which can reveal circulatory problems). How many look at the conjuctiva on a hypotensive or GI bleed? .. All can be major indicators of related illnesses and injuries. Again, why not? Most of this is an automatic assessment, much occurs while approaching my patient.

I found it humerous a few months ago, while I had some EMS clinical students. I pointed out what what I could detect by just observing the feet alone. They were sticking out from the ED curtains at the time. The edema present, poor skin break down with the skin having an ash/flaky appearance, thick toe nails, ulcerations located in medial aspect of the legs/ankles and foot drop. Without even seeing the patient's chart or viewing above the ankles.. that I predicted that the patient was a long term care patient, a diabetic probably on Dyalisis and was septic. I have to admit the students were shocked to see that I was correct on all accounts; just by knowing disease process associated with observation of a patient....

My scene time is just as short in comparrision to others, but after practicing and developing my skill continously, one can master a thourough assessment in a brief period of time. It's not hard .. just have to study and practice repeatedly.

R/r 911

[spenac]

R/r 911 that would take effort and would be common sense. Those two things on here I have learned quickly are not allowed in EMS. I guess you and I are just rebels. We both like learning as much as we can about our patients.

I agree I hate that so many are taught the you don't need or won't use this in the field crap. Several people signed up for the intermediate program that I took online. They dropped out. Why? Because they were being required to go beyond what you have to know in the field. They now are completing an intermediate program that just focuses on the skills. That really scares me.

I am a firm believer that as a Pre Hospital Medical Professional I need to know the ins and outs of what and why I do everything. I need to know what to expect from my treatment and what to be ready to do next. I also think it is important that I identify any problem I can, even those that in the field I can do nothing about, so i can point it out to the doctor so they can address it. We as a profession must get away from the minimum and start digging deep.