Take A Minute to Listen, It Could Save a Life

Submitted by Amy Roberts Huff PhD, APRN, FNP-BC, FAANP; Melinda Hermanns, PhD, RN, PMH-BC, CNE, ANEF

Tags: auscultation bruit carotid early recognition saving a life stroke

Take A Minute to Listen, It Could Save a Life

Share Article:

Dedicated in memory of Dr. Hermanns’ Father

Amy Roberts Huff PhD, APRN, FNP-BC, FAANP
Melinda Hermanns, PhD, RN, PMH-BC, CNE, ANEF (corresponding author)

Abstract

Listening for a carotid bruit might help save a life. Stroke cases are increasing and are debilitating to patients and their families. Listening to the carotids for one minute each time you listen to the heart since a 2mm carotid luminal narrowing can cause a bruit. If a bruit is detected, report this finding to the primary care provider to help curb the upward trend of strokes. 

In the United States (US), every 40 seconds, someone suffers a cerebrovascular disease (stroke) and every three minutes someone dies of a stroke. Each year more than 795,000 people in the US have a stroke and approximately 610,000 of these cases are new strokes. There are two main classifications of stroke based on etiology: (1) strokes caused by a ruptured vessel (bleeding out) or (2) strokes caused by occlusion (ischemic strokes). Eighty-seven percent of strokes are ischemic strokes (Centers for Disease Control and Prevention, 2023). Ischemic strokes are caused by a clot. Approximately 20–30% of ischemic strokes are caused by internal carotid artery stenosis. Stroke is the leading cause of disability and the second leading cause of death in the United States (Blears et al., 2022). Risk factors for strokes include elevated blood cholesterol and other lipids (high-density lipoprotein and non-high density lipoprotein cholesterol), obesity, advanced age, poor diet, diabetes, cigarette smoking, physical inactivity, and atrial fibrillation (Ntaios et al., 2019).

Strokes do not affect all races and ethnicities equally. The risk of having a first stroke is nearly twice for Black adults versus White adults. Black and Pacific Islander adults have the highest rates of death due to strokes. The National Center of Health Statistics (2023) discovered the death rate for strokes is on the rise increasing from 38.8 per 100,000 in 2020 to 41.1 per 100,000 in 2021. With this increase in strokes, it is imperative that nurses recognize the early signs of stroke. The American Heart Association (AHA) recommends learning the following acronym to detect stroke: F.A.S.T. - Face drooping, Arm weakness, Speech difficulty, Time to call 911 (AHA, 2020).

But nurses can do more than just recognize the signs of a stroke. We can listen for bruits in our patients. We were taught in school how to listen for a bruit but this is sadly not done much in practice. When listening to the heart, listen for a carotid bruit; this is important because 25% of people who recover from their first stroke will have another stroke within five years. It is estimated that 40% of the people with strokes have carotid plaque (Kamtchum-Tatuene et al., 2020).

Early detection of carotid disease is central to minimizing the incidence of stroke. In patients with a 2 mm carotid artery luminal narrowing, carotid bruit is present 70% to 89% of the time (Grotta, 2013). Atherosclotic lesions are commonly found in the arteries that arise from the aortic arch. About 80% are in the bifurcation of the carotid artery. The carotid artery is pictured below. >

Cartoid

Figure 1. Common carotid artery image (Source: Wikipedia)

To assess a carotid artery bruit, place your bell side of the stethoscope over the carotid artery. The carotid is located to the right of the upper end of the thyroid cartridge and just below the angle of the jaw. To auscultate with a bell on the stethoscope with two flat heads, lightly place the stethoscope over the carotid artery with only light pressure pushing on the head. If one side of the stethoscope is concave that is the bell side. Have the patient hold their breath so you can isolate the sound in the artery. If you hear a blowing sound, then this is a bruit. Listen on both sides to assess the possible limitation of oxygen to the brain as the artery has turbulent blood flow. This turbulent blood flow is usually due to partial occlusion by plaque. Since plaque accumulates with age, it is important to listen to the carotids particularly in the geriatric patients (Lucerna & Espinosa, 2023). Sadly, strokes are not just a disease of the aged as in 2014, 38% of the people hospitalized for stroke were less that 65 years old. Strokes in younger populations have a significant economic impact on them and their families as many are disabled in their peak earning years (Hathidara et al., 2019). Of note, cocaine consumption has increased and so has one major side effect of cocaine, ischemic strokes in younger patients (Rendon et al., 2023).

If a bruit is heard it is important to assess mental cognition and any recent changes in cognition. When bruits are heard further work up is needed. Additional imaging studies such as a carotid duplex doppler scan of the carotid arteries might be ordered. Recent developments of duplex doppler ultrasound to assess plaque vulnerability to breakage and identify preembolic unstable carotid plaques (Cires-Drouet et al., 2017). This advancement in doppler imaging can help identify the approximate 20-30% of ischemic strokes caused by rupturing carotid plaque and internal carotid stenosis (Blears et al., 2022).

Most bruits will not need intervention; however, the most stenosed artery will require intervention. There are new developments in imaging with the three dimensional ultrasound transducers that reduce operator dependence and variability. The difference is a doppler ultrasound is used to estimate blood flow through your vessels. The duplex ultrasonography shows both anatomic structures of the carotid and blood flow through the carotid making it is easier to predict the plaque that will break off and cause embolism than it has been in the past (Cires-Drouet, 2017). There are also newer developments on how to treat a clogged carotid. The carotid endarterectomy is an option that has been available for a while. In this procedure, the carotid is cleaned out and a stent is often placed to keep the carotid artery open. Now doctors can use ENROUTE flow reversal technology which has been found to prevent embolic stroke during the stenting process. This flow reversal technology also reduced cranial nerve injury (Blears et al., 2022).

Nurses do a good job educating their patients about risk factors for stroke and caring for patients with strokes. It is now time that we do a simple noninvasive screening by listening for carotid bruits for one minute each time we assess a patient. We have the skill and recommend taking one minute to listen as it could save a life.

References

  1. American Heart Association [AHA]. (2020). https://www.stroke.org/en/about-stroke/stroke-symptoms?gclid=EAIaIQobChMIu96vqPLN7AIVx0XVCh1ZAAKYEAAYASAAEgJ--_D_BwE
  2. Blears, E., Patel, S., Doyle, M., Lombardi, N., & Muluk, S. (2022). Predicting transcarotid artery revascularization adverse outcomes by imaging characteristics. Annals of Vascular Surgery, 87, 388–401. https://doi.org/10.1016/j.avsg.2022.05.013
  3. Common carotid artery. In Wikipedia (2021, August 25). https://en.wikipedia.org/wiki/Common_carotid_artery
  4. Centers for Disease Control and Prevention (4 May 2023). Stroke facts. https://www.cdc.gov/stroke/facts.htm
  5. Cires-Drouet, R. S., Mozafarian, M., Ali, A., Sikdar, S., & Lal, B. K. (2017). Imaging of high-risk carotid plaques: Ultrasound. Seminars in Vascular Surgery, 30(1), 44–53. https://doi.org/10.1053/j.semvascsurg.2017.04.010
  6. Kamtchum-Tatuene, J., Wilman, A., Saqqur, M., Shuaib, A., & Jickling, G. C. (2020). Carotid plaque with high-risk features in embolic stroke of undetermined source: Systematic review and meta-analysis. Stroke, 51(1), 311–314. https://doi.org/10.1161/STROKEAHA.119.027272
  7. Hathidara, M. Y., Saini, V., & Malik, A. M. (2019). Stroke in the young: A global update. Current Neurology and Neuroscience Reports, 19(11), 91. https://doi.org/10.1007/s11910-019-1004-1
  8. Grotta, J. C. (2013). Carotid stenosis. The New England Journal of Medicine, 369(12), 1143–1150. https://doi.org/10.1056/NEJMcp1214999
  9. Lucerna, A., & Espinosa, J. (2023). Carotid bruit. In StatPearls. StatPearls Publishing.
  10. National Center for Health Statistics. (8 September 2023). Multiple cause of death 2018–2021 on CDC WONDER Database.
  11. Ntaios, G., Perlepe, K., Sirimarco, G., Strambo, D., Eskandari, A., Karagkiozi, E., Vemmou, A., Koroboki, E., Manios, E., Makaritsis, K., Michel, P., & Vemmos, K. (2019). Carotid plaques and detection of atrial fibrillation in embolic stroke of undetermined source. Neurology, 92(23), e2644–e2652. https://doi.org/10.1212/WNL.0000000000007611
  12. Rendon, L. F., Malta, S., Leung, J., Badenes, R., Nozari, A., & Bilotta, F. (2023). Cocaine and ischemic or hemorrhagic stroke: A systematic review and meta-analysis of clinical evidence. Journal of Clinical Medicine, 12(16), 5207. https://doi.org/10.3390/jcm12165207