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Heart Sounds ? Are they in your arsenal ?

Heart Sounds ? Are they in your arsenal ?

Ready to up your cardiac assessment game?

Time to pick up the stethoscope and listen to the ticker!

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Heart sounds are from my experience, not a daily nursing task. Should they be? We think so.

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By listening to the heart we can obtain a lot of extra information, to fill our patient assessment.

The best place to start is – Can you hear a sound or not? If you listen to 100 “normal” heart sounds – Lub Dub, Lub Dub - when you listen and you cannot really hear anything at all (muffled heart sounds), Your patient could have a a pericardial Effusion (+/- Tamponde). One of the Four H’s and Four T’s from ALS!! This is a Critical finding. All it takes is 1 minute to listen 😉 Probably a great place to start. The reason is that the sound becomes muffled due to the pericardium being filled with water/blood and hence the vibrational waves of the sound do not travel through the chest wall to your little ears and the sound is reduced and muffled in nature!

Hot Heart Sounds Tip = Is there clear sound – “Lub Dub” or is it muffled and quiet?

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GCS - What we know Vs what we don't know

GCS - What we know Vs what we don't know

Do you undertake a Glasgow Coma Scale on your patients?

Doing a Glasgow Coma Scale (GCS) and understanding a GCS are two different things…

 

BUT what are we really assessing?

The first component of the assessment provides a score for the “eyes”. Providing a score between 0-4. What does that actually mean?

 

The truth is, we are assessing the RETICULAR ACTIVATING SYSTEM.

 

Ok..?

So, What the hell, is the Reticular Activating System!

I would describe it as one of the most interesting parts of the human body. It is the system that helps link the sensory network to the conscious mind. Essentially, we are assessing their level of consciousness or how their wakefulness and sleep-wake transitions. We are NOT assessing how their eyes work.. !

Giuseppe Moruzzi. Giuseppe Moruzzi (July 30, 1910 – March 11, 1986) was an Italina Neurophysiologist and helped link wakefulness to the RAS. The GCS as a collective was invented in 1974 by Graham Teasdale and Bryan J. Jennett, professors of neurosurgery and you would never guess where they worked…..University og Glasgow! An amazing campus if you are ever in Glasgow, you should visit. You should also get a curry there!! Tasty!

The Best tips we have for assessing eyes within GCS

  • Always score the patient, the best score you can give them
  • Always be aware of whatever drugs they may have onboard that could effect that score i.e.
    • Propofol or Fentanyl, if they are intubated and ventilated or alcohol if it is in ED late on a Saturday night and they are cooked on alcohol or meth!
  • Do they have any significant sub-cutaneous emphysema that is impacting their mechanical ability to open their eyes or swelling etc…
  • BIG TIP: Whenever you deliver a painful stimulus when assessing eyes, this must be done as a peripheral stimulus. If you provide a central stimulus they are likely to grimace and intrinsically close their eyes. This is counter intuitive to your assessment. ALWAYS PERIPHERAL ASSESSMENT FOR Pain stimulus in The E score of the GCS

What do you find challenging about doing a GCS?

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Aortic Dissection

Aortic Dissection

Aortic Dissection is a mimic! - Acute dissection requires a tear in the aortic intima with blood passing through the tear separating the intima from the media or adventitia, creating a false lumen or channel. As blood is diverted into this channel, circulatory volume decreases, and the channel expands and creates either an expanding mass or a heamatoma from coagulating blood. Propagation of the dissection can proceed in anterograde or retrograde fashion from the initial tear involving side branches and causing complications such as malperfusion syndromes (cardiac, spinal, cerebral, renal, coeliac, mesenteric, iliac, or femoral arteries), tamponade, or aortic valve regurgitation. As circulatory volume decreases, cardiac output also decreases, resulting in end - organ failure.

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There are 2 main classification – DeBakey and Stanford, the latter more commonly used in Australia.

The Stanford classification system classifies dissections into two groups,

# Type A, which affects the ascending aorta- (62%) , and

# Type B, which affects only the descending aorta, beginning distal to the left subclavian artery (38%).

De Bakey has 3 stratified categories Type I, Type II and Type III.

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What about checking of differences in Blood Pressure between both arms?

Often we can see that > 10mmHg differences are abnormal but studies have shown that it is common for normotensive, hypertensive and in those with peripheral vascular disease to have significant systolic and diastolic differences between both arms. One review quoted studies showing a systolic difference of > 20 in 25-34%, 18-60% and 10-20% of the above groups respectively, whilst they had diastolic differences of > 10 in 15-30% and 15-40% of the first 2 groups.

That is blood pressure difference has no role unless significant enough to cause a pulse deficit. Pulse deficits (as defined by a weak or absent brachial, carotid or femoral pulse) described in 19- 30% of patients with an acute type A dissection compared with 9- 21% with a type B dissection.

However, if absent this does not rule out dissection: one meta-analysis found a pooled sensitivity of pulse deficits is 31%. Remember also to consider checking BPs in arms and legs if there is hypotension in both arms as there may be occlusion of the vessels supplying the arms without femoral involvement in type A (known as pseudohypotension).

Just like intussuseption in paediatric surgery, Aortic dissection can present as a spectrum of pain descriptions, locations and severities, and dissection may mimic other disorders such as stroke, myocardial infarction , vascular embolisation and abdominal pathology. Common misdiagnoses included acute coronary syndrome (19%), musculoskeletal pain (20%), pneumonia/pulmonary embolism (20%), pericarditis (12%), gastrointestinal (GI) pain (9%), and other causes (20%).

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Reference

Clark CE, Taylor RS, Shore AC, Campbell JL. The difference in blood pressure readings between arms and survival: primary care cohort study. BMJ. 2012;344:e1327. Published 2012 Mar 20. doi:10.1136/bmj.e1327

Merck Manual - https://www.merckmanuals.com/professional/cardiovascular-disorders/diseases-of-the-aorta-and-its-branches/aortic-dissection

Woods, S. L., Froelicher, E. S. S., & Motzer, S. A. (2000). Cardiac nursing. Philadelphia: Lippincott Williams & Wilkins.