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A Blurb From Bruce

Do you listen to heart sounds?

 

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Here may be another reason why you should.

I’m not sure about you, but when I went to school to become a paramedic (and a nurse for that matter), one thing I never really understood was heart sounds, or heart tones, depending on who taught you.  My attempt at learning such resorted to scouring textbooks, journals, online editorials, watching clips on YouTube and listening…lots of listening to sound bits from the CD’s, you know the ones that come free with a new stethoscope. Instead of tuning into digital media, I should have been listening to the hearts of my many patients.  Needless to say, hindsight is 20/20, especially in this case.  All of my self-guided education yielded little result - kind of discouraging to say the least and because of such, I let it slip from my list of competent skillset – that is, until I took care of Henry.

Henry is a 68-year-old gentleman; (and I say “is” with bit of guarded breath)… only because for a short time, Henry was quickly falling off the cliff – you know that seemingly short height that separates life from death; but don’t worry, we’ll get him back by then end of this story.

I met Henry, after he summoned 911 EMS for some concerning symptoms – a near syncopal episode, shortness of breath and chest discomfort.  On arrival, a “standard” assessment revealed the following:

  • Objective Assessment and Vital signs:
    • Alert and Oriented, No jugular venous distention or pressure, Lung Sounds mid to base rales, palpable pulses, 2+ pitting lower extremity edema, skin is pink, warm and dry
    • Heart Rate / Rhythm: 90 beats per minute, correlating with ECG
    • Blood Pressure: 164/70 mmHg
    • Respirations: 24 breaths per minute
    • SpO2: 91% on room air
    • ECG: Sinus Rhythm, BBB pattern and (ECG criteria that met LVH)
  • Subjective Assessment:
    • “I was here in my chair, and got up to go to the bathroom and I felt like I was going to pass out”
    • “I didn’t really pass out, I just got kind of dizzy… but the pain in my chest and breathing hasn’t been real good for the last few weeks”.
    • “I can barely make it up the three steps outside the house without getting winded”
    • “my chest just hurts, I’m not sure if it’s my heart or my breathing”
    • “the pain seems to be in my chest, but sometimes I feel numb in my head”
    • “oh, if I had to give it a number, I would say its about a 5 or 6”
    • “the last time this happened my doctor told me to call 911, they did some tests in the hospital on my heart and told me that I should be around for a little while yet”
  • Allergies: None Known
  • Medications:
    • Aspirin 81 mg Daily
    • Lasix 20 mg Twice Daily
    • Potassium Supplement (20 mEq Daily)
    • Coreg 6.25 mg Twice Daily
    • Prevacid as needed
  • Medical History:
    • Heart Failure, last Ejection Fraction (two months prior) 35% - 40%
    • Hypertension
    • Aortic Stenosis (he says it’s pretty bad)
    • GERD

As a provider, I’m feeling somewhat prepared; I have some decent information and my partner and I form a game plan – place the patient on oxygen (nasal cannula), position of comfort, Aspirin 243 mg by mouth (since he already took his 81 mg this morning), 12 lead ECG, establish a peripheral IV (saline lock), Nitroglycerin spray (one dose – 0.4 mg sublingual), repeat 12 lead ECG, monitor five lead ECG and hopefully (fingers crossed) by then we’ll be at the hospital.

I preface the next part of this story with this; plans are great to have, but they very, very rarely (especially in EMS) are executed as initially desired.

Things were going really well, until that Nitro spray.  Shortly after administration, and by shortly I mean 20-30 seconds, Henry complained of worsening chest pain and when I looked over at him – he looked, uh, different…he appeared to have been sprayed with a can of grey paint.  Ever have that feeling…that gut sinking feeling that your Hippocratic obedience may have just gone out the window?!  A quick glance at the monitor confirms my worsening fear.  As if guided by an internal computer, the heart rate display is surrounded by a yellow box and I hear the distant sound of an alarm… treat the patient, not the monitor – the words are remote, but retrievable.  I look back at Henry – he looks the same, except this time, he has turned his head and is looking directly at me – almost staring right through me – as if he see’s something in the distance – like “the bright light”… or my shredded paramedic license.  A quick shake from my partner, and I’m back to reality.  Rhythm, I mutter to myself, slow rate, wide complex…CRAP; what just happened?  Recap time, I just gave Nitro and apparently, very apparently, it wasn’t tolerated well.  I ask my partner to check a pulse, while I cycle his blood pressure and simultaneously grabbing a bag of normal saline, spiking and hanging it.  I connect it to his IV and open it wide – ml’s/hr…who the heck knows; just get it into him STAT.  My partner gives me the first good news I’ve had in the last minute – “he has a pulse”…HORRAY!  Relief surrounds my personal space, and I audibly announce the blood pressure, “74/30”…hmmm; seems low, but lets watch what this IV fluid does.  My partner increases Henry’s oxygen, a nasal cannula gone from low flow to high flow with the turn of a knob.  I give Henry a sternal rub and those wandering eyes return to center, and he mumbles something incomprehensible.  His heart rate is coming up and his repeat blood pressure is better than before.  Finally, the magical moment when Henry asks the question that we all are craving to know – that beautiful moment when both patient and provider are on the same page…”what the heck happened?”.  I reassure Henry, telling him we are taking good care of him and that we will soon (sooner than before – lights and sirens please!) be at the hospital.  The rest remains routine; 200 ml’s of IV fluid in, hospital notified, a reduced flow of oxygen and Henry, dried out nostrils and all, arrive at the hospital, turn over care, and say a happy good bye to our friend.  And as every good EMS provider, I return to the truck and start writing - trust me, it was thoroughly documented that the receiving NURSE was aware of his “reaction” to Nitro.

Now for the debrief; which I’ll keep short and sweet, because I enjoy when articles, like this, provide some information, but allow me to be a knowledge constructivist; assembling my own knowledge with that which I have just learned.

Most healthcare providers are aware of the effect that Nitro has on the human physiology.  Through relaxation of the muscle layer surrounding the blood vessels, the patient may experience hypotension.  Essentially this increases the space with in the vessel, meaning the vessel diameter becomes greater.  With a patient who is euvolemic, this can create less tension on the vascular wall, hence hypotension.  But again, what does any of this have to do with heart sounds?  This peripheral vasodilation, when experienced systemically, can be reasonably tolerated in a patient with normal cardiac valvular function; and if not, easily treated by changes in position, volume repletion, etc.  The valve can support and compensate for the change in systemic tension or pressure.  However, in a patient, like the one above (Henry), who has aortic stenosis, in conjunction with heart failure, the valve is not able to do this.  The calcified and stenotic aortic valve relies very heavily on peripheral vascular impedance or resistance, in order to maintain a fixed forward flow.  The fixed forward flow is directly derived from the failing valve; as the valve becomes more calcified the jet stream evacuating from the left ventricle is essentially fixed and is not tolerant to changes in systemic circulation.  In a way the systemic vascular network is assuring an adequate cardiac output, specifically the stroke volume.  Any changes within the peripheral circulation and its associated pressure is going to dramatically tank the patient’s afterload, thereby directly impacting the patient’s preload and hence the downward spiral of the blood pressure and the patient’s condition.  It is imperative to remember that patients with aortic valvular stenosis are significantly dependent on preload.  In order to maintain preload in the prehospital and critical care transport setting, fluid is one of the better and more prudent options.  This can be akin to treating a low flow state in a ventricular assist device.  Low flow states in these devices cause the ventricular outflow mechanism to pull against the endocardium and myocardium resulting in ventricular irritation or ectopy.  Rather than chasing blind alleys it may be worth several boluses of a balanced intra-venous solution; you just may be surprised by the result – a calm ventricle and a better functioning ventricular assist device.  Contrasting this aortic valve stenosis, the similarities become understandable and the rationale plausible.  I guess the short of the long is this - patients with aortic stenosis are particularly sensitive to drugs that affect the vascular network and are significantly reliant on optimal preload – which can make them and their diagnosis tricky to treat.

One might wonder how competence in assessing heart tones may have had an impact on this case.  Well, as you may have guessed, you can hear the dysfunction of the valve.  This is accomplished by placing a stethoscope (preferably a clean one and using the diaphragm) on the patient’s chest and listening – very, very carefully.  The turbulent blood flow through the faulty valve is heard and recognized as a systolic murmur.  In a normal patient you will hear the traditional “lub dub”.  However, in a patient with aortic stenosis you will often hear lub-swish-dub”, meaning it starts after the first heart sound, and ends (usually) before the second heart sound.  This is best heard by placing the patient in an upright / seated position and listening over the upper right sternal border, also known as the aortic area (pretty handy, right?).

As mentioned earlier, this case was an impactful learning experience for me and thankfully the outcome was favorable for both patient and provider.  If I might offer some advice – listen to heart tones – a lot!!  Do you hear what I hear?

Until the next time…Be well and stay safe.

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Bruce Hoffman is a critical care nurse, paramedic and current graduate student.  He works as both a clinician and educator in Connecticut, Massachusetts and Maryland, with background in the division of critical care (ICU, ER, Cardiology, and Flight).  He enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.  He is a frequent and national lecturer for a host of Emergency Medical Services and Critical Care continuing education programs. He remains a member of his hometown ambulance service where he has served in a variety of administrative and operational roles. In his spare time, Bruce enjoys spending time with his wife Stephanie as well as traveling, hiking and biking.

 

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