1. by Don Hudson, D.O., FACEP/ACOEP
HEART SOUNDS by
Don Hudson, D.O., FACEP/ACOEP

2. Everything You need to Know About Heart Sounds
We have all heard the heart make the usual sounds.
LUB DUB
Lub is the first sound or S1
Dub is the second heart sound or S2

3. So What is All of The Other Sounds
The best way to understand the individual sounds is to think about what is causing them
First you need to concentrate on the total sounds and then try to listen to the individual component sounds

4. Systole The time between the S1 and S2 sounds is: Lub------------Dub
The ventricles contracting
Blood flowing from the heart to the lungs and body
Blood flowing across the Pulmonic and Aortic valves

5. Diastole Dub----------Lub
The time between S2 and S1 is :
The blood is flowing from the atria to the ventricles.
The blood flowing across the bicuspid and tricuspid valves.
The atrial contraction also occurs now.

6. S1- What is it ? The “lub” in the lub – dub.
This sound is primarily because of the closing of the bicuspid and tricuspid valves.
Anatomically they are located between the atria and the ventricles
They close because the ventricles contract
The Pulmonic and Aortic valves are opening and blood is being forced into the arteries

7. S2- What is it ? This is the end of systole
S2 is the “dub” in the lub- dub
The sounds are because of the closing of the Pulmonic and Aortic valves as the pressure from the arteries is greater then the pressure in the ventricles.
This is the end of systole

8. What Kinds of Sounds Do You Hear?
Murmurs-usually indicate turbulence & they range from 1 to 5 in loudness.
Does it occur during diastole or systole?
Does it crescendo (get progressively louder)?
Does it decrescendo (get progressively quieter)?
Where do you hear it best? (Neck, Chest, Axilla)

9. Other Sounds Gallops- these are either S3 or S4 sounds.
Rubs- pericardial or plural friction rubs and usually indicated either pericarditis or possible pleurisy ( must be careful to listen to both heart and lung sounds)
Rubs- sounds “sandpapery”

10. Other Sounds
Clicks- only occur in systole and represent the loud valve closing
Diastolic Knock- occurs because of a abrupt arrest of ventricular filling by a non-compliant & constricting pericardium.
Continuous Murmurs- indicate a constant shunt flow throughout systole & diastole i.e. Coarctation, or patent ductus arteriosus.

11. LUB-- DUB-------------LUB--DUB
Anatomy of A Sound
LUB-- DUB LUB--DUB
S S2 S3 S4 S S2
Here is where you expect to hear the various sounds

12. Now that you Hear the Sounds (what does it mean?)
First Heart Sound (S1)
- Louder than usual - Mitral Stenosis
- Variable Atrial Fib./Complete Heart Block
-Diminished Mitral or Aortic Regurg.

13. Second Heart Sounds (S2) (what does it mean)
Wide split sounds or fixed ( not moving with respiration) may indicate:
Atrial Septal Defect
RBBB
Pulmonic Stenosis

14. Extra Heart Sounds (S3 & S4) (what do they mean to you)
Third Heart Sound (S3)  Markedly Diminished Left Ventricular Function
(Almost always present with Myocardial Ischemia or early after an AMI)
Fourth Heart Sound (S4) Modestly Diminished Left Ventricular Function

15. What Special Things Do You Need To Hear These Sounds
Stethoscope
As quite an environment as possible
Proper positioning of the patient
Stethoscope must touch the skin
Patient history
Ability to observe the chest, abdomen & neck

16. Where Do You Listen?
Left Ventricle Area- The apex of the heart is at the 4th or 5th intercostal space (ICS) along the midclavicular line (MCL).
Right Ventricular Area- the 3rd to 5th ICS along the left sternal border (LSB)
Pulmonic Area- 2end ICS along LSB
Aortic Area- 2end ICS along the right sternal border (RSB)

17. Stethoscope Use
The diaphragm of your stethoscope is most useful for picking up high-pitched sounds i.e. S1, S2, Aortic or Mitral Regurgitation Murmurs or Friction Rubs.
The Bell is most useful for picking up low-pitched sounds, S3, S4, or Mitral Stenosis.

18. The Most Important Things To Have In Order To Hear These Sounds
Quiet

19. Thank You For Your Patience
Practice, Practice, Practice
Patience to take time to listen
Time to listen to history
Expose the patient
Think
Reflect
Your patients will appreciate your efforts

20. Just For Fun!!!!!