ACLS

Question 1

Interruptions in compressions should be limited to critical interventions (rhythm analysis, shock delivery, intubation, etc), and even then, these should be minimized to ____ seconds or less.

Answer 1

10

Question 2

In recent studies, nearly ___% of hospitalized patients with cardiorespiratory arrest had abnormal vital signs documented for up to ___ hours before the actual arrest.

Answer 2

80%
8 hours

Question 3

TTM interventions should be administered to comatose adult patients with ROSC after cardiac arrest, by selecting and maintaining a constant temperature between _____ and ________ for at least _____ hours.

Answer 3

32°C and 36°C (89.6°F and 95.2°F)
24 hours

Question 4

Providers should titrate inspired oxygen during the post–cardiac arrest phase to ______________.

Answer 4

the lowest level required to achieve an arterial oxygen saturation of 94% or greater, when feasible.

Question 5

Healthcare providers may start ventilation rates at _____/min.

Answer 5

10/min

Question 6

Normocarbia (partial pressure of end-tidal carbon dioxide [PETCO2] of _____to____mm Hg or PaCO2 of ___to ____ mm Hg) may be a reasonable goal unless patient factors prompt more individualized treatment.

Answer 6

PETCO2-30 to 40mm Hg

PaCO2-35 to 45mm Hg

Question 7

Providers should note that when a patient’s temperature is _________, laboratory values reported for PaCO2 might be higher than the actual values.

Answer 7

Below normal

Question 8

The optimal post–cardiac arrest blood pressure remains unknown; however, a mean arterial pressure of ______________ is a reasonable goal.

Answer 8

65mm Hg or greater

Question 9

In patients treated with TTM, prognostication using clinical examination should be delayed until at least________hours after return to normothermia. For those not treated with TTM, the earliest time is ______hours after cardiac arrest and potentially longer if the residual effect of sedation or paralysis confounds the clinical examination.

Answer 9

at least 72 hours
72 hours

Question 10

Mortality from IHCA remains high. The average survival rate is approximately ______%, despite significant advances in treatments. Survival rates are particularly poor for arrest associated with rhythms other than _________. _________rhythms are present in more than ___% of arrests in the hospital.

Answer 10

24%
VF/pVT
Non-VF/pVT
82%

Question 11

Cardiac arrest teams(in hospital) are unlikely to prevent arrests because their focus has traditionally been to respond only after the arrest has occurred. Unfortunately, the mortality rate is more than ___% once the arrest occurs.

Answer 11

75%

Question 12

The majority of published before-and-after studies of METs or rapid response systems have reported a ____% to____% drop in the rate of cardiac arrests after the intervention.

Answer 12

17% to 65%

Question 13

_________ is the No. 1 cause of death in the world—with more than __________ deaths per year.

Answer 13

Heart disease
17 million

Question 14

After determination of ______, the systematic approach first requires ACLS providers to determine the patient’s __________.

Answer 14

Scene safety
Level of consciousness

Question 15

As you approach the patient,
If the patient appears unconscious
– Use the _______Assessment for the initial evaluation

Answer 15

BLS

Question 16

As you approach the patient,
If the patient appears conscious
– Use the ________Assessment for your initial evaluation

Answer 16

Primary

Question 17

BLS Assessment

Check for absent or abnormal breathing (no breathing or only gasping) by looking at or scanning the chest for movement for about __to ___seconds

Answer 17

5 to 10 seconds

Question 18

BLS Assessment

Check pulse for __to ___ seconds
If no pulse within ___seconds, start CPR, beginning with chest compressions
If there is a pulse, start rescue breathing at 1 breath every __ to __seconds. Check pulse about every ___ minutes

Answer 18

5 to 10 seconds
10 seconds
5 to 6 seconds
2 minutes

Question 19

Coronary perfusion pressure (CPP) is_______ relaxation (“diastolic”) pressure minus__________ relaxation (“diastolic”) pressure. During CPR, CPP correlates with both myocardial blood flow and ROSC. In 1 human study, ROSC did not occur unless a CPP of ____mm Hg or greater was achieved during CPR.

Answer 19

aortic
right atrial
15 mm Hg or greater

Question 20

Quality Compressions
Compress the chest at least __inches (__cm).
Compress the chest at a rate of ___ to __/min.
Allow complete chest recoil after each compression.

Answer 20

at least 2 inches (5 cm)
100 to 120/min

Question 21

Chest compression depth

Chest compressions are more often too________ than too _______. However, research suggests that compression depth greater than _____inches (__cm) in adults may not be optimal for survival from cardiac arrest and may cause injuries. If you have a CPR quality feedback device, it is optimal to target your compression depth from ____to___inches (__to__cm).

Answer 21

Too shallow than too deep

greater than 2.4 inches (6 cm)

2 to 2.4 inches (5 to 6 cm)

Question 22

A single rescuer should_______________, get___________, return to the_______to________, and then__________.

On the other hand, if hypoxia is the presumed cause of the cardiac arrest (such as in a drowning patient), the healthcare provider may give approximately ___minutes of CPR before activating the emergency response system.

Answer 22

call for help (activate the emergency response system)
get an AED (if nearby)
return to the patient to attach the AED
provide CPR
2 minutes

Question 23

Switch compressor about every ___minutes or earlier if fatigued.*
*Switch should take ___seconds or less.

Answer 23

2 minutes
5 seconds or less

Question 24

Monitor CPR quality
– Quantitative waveform capnography (if PETCO2 is less than ____ mm Hg, attempt to improve CPR quality)
– Intra-arterial pressure (if relaxation phase [diastolic] pressure is less than ____mm Hg, attempt to improve CPR quality)

Answer 24

Less than 10 mm Hg
Less than 20 mm Hg

Question 25

SAMPLE:

Answer 25

Signs and symptoms
Allergies
Medications (including the last dose taken)
Past medical history (especially relating to the current illness)
Last meal consumed
Events

Question 26

H’s and T’s

Answer 26

Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/hyperkalemia
Hypothermia

Tension pneumothorax
Tamponade (cardiac)
Toxins
Thrombosis (pulmonary)

Question 27

__________and__________ are the 2 most common underlying and potentially reversible causes of PEA

Answer 27

Hypovolemia and Hypoxia

Question 28

Hypovolemia, a common cause of PEA, initially produces the classic physiologic response of a _________________(Rhythm) and typically produces_______ diastolic and __________ systolic pressures.

Answer 28

Rapid, narrow-complex tachycardia (sinus tachycardia)
Increased
Decreased

Question 29

Pericardial tamponade may be a reversible condition. In the periarrest period, ___________in this condition may help while definitive therapy is initiated.

Answer 29

Volume infusion

Question 30

The average respiratory rate for an adult is about ____ to____/min. Normal tidal volume of ____to___ mL/kg maintains normal oxygenation and elimination of CO2

Answer 30

12 to 16/min
8 to 10 mL/kg

Question 31

Tachypnea is a respiratory rate above ___/min and bradypnea is a respiratory rate below ___/min. A respiratory rate below __/min (hypoventilation) requires assisted ventilation with a bag-mask device or advanced airway with 100% oxygen

Answer 31

Above 20/min
Below 12/min
Below 6/min

Question 32

Respiratory distress is a clinical state characterized by abnormal respiratory _____ or_____. The respiratory effort may be____________ or_____________.
Respiratory distress can range from_____to_________. For example, a patient with mild tachypnea and a mild increase in respiratory effort with changes in airway sounds is in ________ respiratory distress. A patient with marked tachypnea, significantly increased respiratory effort, deterioration in skin color, and changes in mental status is in________ respiratory distress. Severe respiratory distress can be an indication of___________.

Answer 32

Rate or effort
increased (eg, nasal flaring, retractions, and use of accessory muscles)
inadequate (eg, hypoventilation or bradypnea)
mild to severe
mild
severe
respiratory failure

Question 33

A patient with marked tachypnea, significantly increased respiratory effort, deterioration in skin color, and changes in mental status is in _______respiratory __________.

Answer 33

Severe Respiratory Distress

Question 34

_______________is a clinical state of inadequate oxygenation, ventilation, or both.

Answer 34

Respiratory failure

Question 35

When____________ is inadequate, respiratory failure can occur without typical signs of respiratory distress.

Answer 35

Respiratory effort

Question 36

Respiratory arrest is the ___________of breathing Respiratory arrest is usually caused by an event such as______or_________. For an adult in respiratory arrest, providing a tidal volume of approximately ______to_____mL should suffice. This is consistent with a tidal volume that produces visible chest rise.

Answer 36

cessation (absence)
Drowning or head injury
500 to 600 mL (6 to 7 mL/kg)

Question 37

In the case of a patient in respiratory arrest with a pulse, deliver ventilations once every ____to____ seconds with a bag-mask device or any advanced airway device. Recheck the pulse about every ______ minutes. Take at least ___ seconds but no more than _____ seconds for a pulse check.

Answer 37

5 to 6 seconds
2 minutes
5 seconds but no more than 10 seconds

Question 38

______________may cause cerebral vasoconstriction, reducing blood flow to the brain.

Answer 38

hyperventilation

Question 39

If you find an unconscious/unresponsive patient who was known to be choking and is now unresponsive and in respiratory arrest, open the mouth wide and look for a foreign object. If you see one, remove it with _____________. If you do not see a foreign object,_________. Each time you__________ to give breaths, open the mouth wide and look for a foreign object. ——————- if present. If there is no foreign object, —————.

Answer 39

Your fingers
begin CPR
open the airway

Question 40

Always check ________________immediately after insertion of either an OPA or an NPA.

Answer 40

Spontaneous respirations

Question 41

Portable suction devices are easy to transport but may not provide adequate suction power. A suction force of ______to____ mm Hg is generally necessary.

Answer 41

-80 to -120 mm Hg

Question 42

Wall-mounted suction units should be capable of providing an airflow of greater than ____L/min at the end of the delivery tube and a vacuum of more than ______ mm Hg when the tube is clamped at full suction.

Answer 42

Greater than 40L/min
More than -300mm Hg

Question 43

Suction attempts should not exceed _____seconds.

Answer 43

10 seconds

Question 44

Approximately ____% of patients with blunt trauma serious enough to require spinal imaging in the ED have a spinal injury. This risk is _____ if the patient has a head or facial injury.

Answer 44

2%
Tripled

Question 45

______of the patients who die of ACS do so before reaching the hospital. ______or _________is the precipitating rhythm in most of these deaths. VF is most likely to develop during the first ___hours after onset of symptoms

Answer 45

Half
VF or pVT
4 hours

Question 46

ACS algorithm

The goal is to analyze the 12-lead ECG as soon as possible within ___minutes of the patient’s arrival in the ED

Answer 46

10 minutes

Question 47

Advanced Cardiovascular Life Support

High survival rates in studies are associated with several common elements:

Training of knowledgeable healthcare providers
Planned and practiced response
Rapid recognition of sudden cardiac arrest
Prompt provision of CPR
Defibrillation as early as possible and within ___ to ___ minutes of collapse
Organized post–cardiac arrest care

Answer 47

within 3 to 5 minutes of collapse

Question 48

A_________ is a group of regularly interacting and interdependent components.

Answer 48

system

Question 49

Successful resuscitation after cardiac arrest requires an integrated set of coordinated actions represented by the links in the system-specific__________

Effective resuscitation requires an integrated response known as a__________.

Answer 49

Chains of Survival
system of care

Question 50

Continual efforts to improve resuscitation outcomes are impossible without____________.

Answer 50

data capture

Question 51

The_________ Guidelines provide guidance for core performance measures, including

– Rate of________ CPR
– Time to_______
– Time to___________ management
– Time to first administration of resuscitation____________
– Survival to hospital___________

Answer 51

Utstein
bystander
defibrillation
advanced airway
medication
discharge

Question 52

Early ________ and ________ are crucial for survival from cardiac arrest.

Answer 52

recognition and CPR

Question 53

The primary goals of therapy for patients with acute coronary syndromes (ACS) are to

1. ___________ the amount of myocardial necrosis that occurs in patients with acute myocardial infarction, thus preserving left ventricular function, preventing heart failure, and limiting other cardiovascular complications
2. _________ major adverse cardiac events: death, nonfatal myocardial infarction, and the need for urgent revascularization
3. _________ acute, life-threatening complications of ACS, such as ventricular fibrillation (VF), pulseless VT (pVT), unstable tachycardias, symptomatic bradycardias, pulmonary edema, cardiogenic shock, and mechanical complications of acute myocardial infarction

Answer 53

Reduce
Prevent
Treat

Question 54

The goal of post–cardiac arrest management is to return patients to their__________ functional level.

Answer 54

prearrest

Question 55

The best way to improve a patient’s chance of survival from a cardiorespiratory arrest is to___________ it from happening

Answer 55

prevent

Question 56

The_____________ is a metaphor used to organize and describe the integrated set of time-sensitive coordinated actions necessary to maximize survival from cardiac arrest.

Answer 56

Chain of Survival

Question 57

Poor-quality CPR should be considered a____________.

Answer 57

preventable harm

Question 58

_____________of cardiac arrests in the hospital are the result of respiratory_________ or__________ shock, and the majority of these events are foreshadowed by changes in________, such as tachypnea, tachycardia, and hypotension.

Answer 58

More than half
failure
hypovolemic
physiology

Question 59

Team leaders may become trapped in a specific treatment or diagnostic approach; this common human error is called a___________.

Answer 59

fixation error

Question 60

An essential role of the team leader is monitoring and reevaluating

The patient’s__________
____________that have been performed
___________findings

Answer 60

status
Interventions
Assessment

Question 61

Healthcare providers use a _________ approach to assess and treat arrest and acutely ill or injured patients for optimal care. The goal of the high-performance team’s interventions for a patient in respiratory or cardiac arrest is to support and restore effective _______, ________, and _____________ with return of intact neurologic function. An intermediate goal of resuscitation is_____________

Answer 61

Systematic approach
Oxygenation, ventilation, and circulation
return of spontaneous circulation (ROSC).

Question 62

Unnecessary compressions are______ harmful than failing to provide compressions when needed.

Answer 62

less

Question 63

The BLS Assessment is a systematic approach to BLS that ____ trained healthcare provider can perform. This approach stresses early _______ and early __________.

Answer 63

Any
CPR
Defibrillation

Question 64

Agonal gasps are_________ breathing. Agonal gasps may be present in the first_______ after sudden cardiac arrest.
A patient who gasps usually looks like he is drawing air in very quickly. The mouth may be open and the jaw, head, or neck may move with gasps. Gasps may appear forceful or weak. Some time may pass between gasps because they usually happen at a slow rate. The gasp may sound like a snort, snore, or groan. Gasping is not normal breathing. It is a sign of____________

Answer 64

not normal
minutes
cardiac arrest

Question 65

Before approaching the patient, ensure______ safety. A rapid_________ should be performed to determine if any reason exists not to initiate CPR, such as a threat to safety of the provider.

Answer 65

scene
scene survey

Question 66

BLS Assessment
Defibrillation

If no pulse, check for a shockable rhythm with an AED/defibrillator as soon as_________

Answer 66

it arrives

Question 67

The identification of the_________ is of paramount importance in cases of PEA and asystole.

Answer 67

underlying cause

Question 68

You should consider___________ as a cause of hypotension, which can deteriorate to PEA. Providing prompt treatment can reverse the pulseless state by rapidly correcting the hypovolemia. Common nontraumatic causes of hypovolemia include occult internal____________ and severe__________. Consider ___________for PEA associated with a narrow-complex tachycardia.

Answer 68

hypovolemia
hemorrhage
dehydration
volume infusion

Question 69

Cardiac and Pulmonary Conditions

Massive or saddle PE obstructs flow to the pulmonary vasculature and causes acute right heart failure. In patients with cardiac arrest due to presumed or known PE, it is reasonable to administer____________.

Treatment for cardiac tamponade may require__________.

Answer 69

fibrinolytics
pericardiocentesis

Question 70

Clinical signs of respiratory DISTRESS typically include some or all of the following:

Tachypnea
Increased respiratory effort (eg, nasal flaring, retractions)
Inadequate respiratory effort (eg, hypoventilation or bradypnea)
Abnormal airway________
Tachycardia
________, cool skin (note that some causes of respiratory distress, like sepsis, may cause the skin to get warm, red, and diaphoretic)
Changes in level of_________/agitation
Use of________ muscles to assist in breathing

These indicators may vary in severity.

Answer 70

sounds (eg, stridor, wheezing, grunting)
Pale
consciousness
abdominal

Question 71

Suspect probable respiratory failure if some of the following signs are present:

________tachypnea
Bradypnea,______(late)
Increased, decreased, or______ respiratory effort
Poor to________ distal air movement
Tachycardia (early)
________(late)
Cyanosis
Stupor,________ (late)

Answer 71

Marked
apnea
no
absent
Bradycardia
coma

Question 72

Excessive ventilation can be harmful because it increases______ pressure, decreases_______ return to the heart, and diminishes cardiac______ and survival.

Answer 72

intrathoracic pressure
venous
output

Question 73

The systematic approach is __________, then ___________, for each step in the sequence

Answer 73

assessment, then action,

Question 74

Healthcare providers should make the decision to place an advanced airway during the________ Assessment.

Answer 74

Primary

Question 75

In this case, the patient is in respiratory arrest but continues to have a pulse. You should ventilate the patient once every______ seconds. Each breath should take______ and achieve visible chest rise.

Answer 75

5 to 6
1 second

Question 76

The AHA recommends continuous_________ in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an ET tube.

Answer 76

waveform capnography

Question 77

The most common cause of upper airway obstruction in the unconscious/unresponsive patient is______ in the________. In this case, the tongue falls back and occludes the airway at the level of the________

Answer 77

loss of tone in the throat muscles
pharynx

Question 78

_______________are the most common method of providing positive-pressure ventilation. When using a bag-mask device, deliver approximately____ mL tidal volume sufficient to produce chest rise over ___ second. Bag-mask ventilation is not the recommended method of ventilation for a_______ healthcare provider during CPR. (A single healthcare provider should use a________ to give ventilation, if available.)

Answer 78

Bag-mask devices
600
1
single
pocket mask

Question 79

Technique of OPA Insertion

1.______ the mouth and pharynx of secretions, blood, or vomit by using a______ pharyngeal suction tip if possible.

2. Select the_______ OPA. Place the OPA against the side of the face (Figure 17B). When the flange of the OPA is at the__________, the tip is at the________. A properly sized and inserted OPA results in proper alignment with the______ opening.

3.____ the OPA so that it curves______ toward the hard palate as it enters the mouth.

4. As the OPA passes through the oral cavity and approaches the posterior wall of the pharynx, rotate it_____ into the proper position

Answer 79

Clear
rigid
proper size
corner of the mouth
angle of the mandible
glottic
Insert
upward
180°

Question 80

Technique of NPA Insertion

1. Select the_______ NPA.
   The length of the NPA should be the same as the distance from the__________________ to the________

2._________ the airway with a water-soluble lubricant or anesthetic jelly.

3. Insert the airway through the nostril in a________ direction, _________ to the plane of the face. Pass it gently along the floor of the nasopharynx (Figure 18C).

If you encounter resistance:

Slightly rotate the tube to facilitate insertion at the angle of the nasal passage and nasopharynx. Attempt placement through the other nostril because patients have different-sized nasal passages.

Answer 80

proper size
tip of the patient’s nose
earlobe
Lubricate
posterior
perpendicular

Question 81

Suctioning

Adjust the amount of suction force for use in______and ______ patients.

Answer 81

children and intubated

Question 82

____________catheters may be used in the mouth or nose. —————catheters are available in sterile wrappers and can also be used for ET tube deep suctioning.

________catheters (eg, Yankauer) are used to suction the oropharynx. These are better for suctioning thick secretions and particulate matter.

Answer 82

Soft flexible
Rigid

Question 83

Oropharyngeal Suctioning Procedure

1.__________ the catheter before suctioning and do not insert it any further than the distance from the_________to the _______. Gently insert the suction catheter or device into the oropharynx beyond the tongue.

2. Apply suction by occluding the_______ opening of the catheter while withdrawing with a______or______ motion.

Answer 83

tip of the nose to the earlobe
side
rotating or twisting

Question 84

Endotracheal Tube Suctioning Procedure

1. Use_______ technique to reduce the likelihood of airway contamination.
2. Gently_______ the catheter into the ET tube. Be sure the side opening is not_______ during insertion. Insertion of the catheter beyond the tip of the ET tube is not recommended because it may injure the ET mucosa or stimulate coughing or bronchospasm.
3. Apply suction by_______ the side opening only while withdrawing the catheter with a rotating or twisting motion. Suction attempts should not exceed 10 seconds. To avoid hypoxemia, precede and follow suctioning attempts with a short period of administration of 100% oxygen.

Monitor the patient’s heart rate, pulse, oxygen saturation, and clinical appearance during suctioning. If bradycardia develops, oxygen saturation drops, or clinical appearance deteriorates,_________ suctioning at once. Administer_______ until the heart rate returns to normal and the clinical condition improves. Assist ventilation as needed.

Answer 84

sterile
insert
occluded
occluding
interrupt
high-flow oxygen

Question 85

Airway Devices
Any advanced airway

Ventilation During Cardiac Arrest
Once every____ seconds

Ventilation During Respiratory Arrest
Once every _____seconds

Answer 85

6

5 to 6

Question 86

The____________ is an advanced airway alternative to ET intubation and provides comparable ventilation. It is acceptable to use the —————— as an alternative to an ET tube for airway management in cardiac arrest.

Answer 86

laryngeal mask airway

Question 87

The advantages of the____________ are similar to those of the esophageal-tracheal tube; however, the —————- is more compact and less complicated to insert.
Healthcare professionals trained in the use of the —————— may consider it as an alternative to bag-mask ventilation or ET intubation for airway management in cardiac arrest.

Answer 87

laryngeal tube

Question 88

The__________ is an advanced airway alternative to ET intubation. This device provides adequate ventilation comparable to an ET tube. It is acceptable to use the —————— as an alternative to an ET tube for airway management in cardiac arrest.

Answer 88

esophageal-tracheal tube

Question 89

The_________ use of cricoid pressure in cardiac arrest is not recommended.

Cricoid pressure in nonarrest patients may offer some measure of_______ to the airway from aspiration and gastric insufflation during bag-mask ventilation. However, it also may_______ ventilation and interfere with placement of a supraglottic airway or intubation.

Answer 89

routine
protection
impede

Question 90

Precautions for Trauma Patients

Have another team member stabilize the head in a neutral position during airway manipulation. Use ______spinal motion restriction rather than_______ devices. ______spinal immobilization is safer.__________ may complicate airway management and may even interfere with airway patency.

Spinal immobilization devices are helpful during___________.

Answer 90

manual
immobilization
Manual
Cervical collars
transport

Question 91

The___________ is used in all ACS cases to classify patients into 1 of 3 ECG categories, each with different strategies of care and management needs. These 3 ECG categories are ST-segment________ suggesting ongoing acute_______, ST-segment_______ suggesting________, and nondiagnostic or_______ ECG.

Answer 91

initial 12-lead ECG
elevation
injury
depression
ischemia
normal

Question 92

Sudden cardiac death and hypotensive bradyarrhythmias may occur with acute_________. Providers will understand to anticipate these rhythms and be prepared for immediate attempts at_________ and administration of _____or________therapy for symptomatic bradyarrhythmias.

Answer 92

ischemia
defibrillation
drug or electrical

Question 93

When used as the initial reperfusion strategy for STEMI, PCI is called_________.

Treatment of ACS involves the initial use of_____ to relieve ischemic discomfort, dissolve clots, and inhibit thrombin and platelets

Answer 93

primary PCI
drugs

Question 94

Goals for ACS Patients

The primary goals are

-________of patients with STEMI and triage for early reperfusion therapy

-_______of ischemic chest discomfort

-__________of MACE, such as death, nonfatal MI, and the need for urgent postinfarction revascularization

-____________of acute, life-threatening complications of ACS, such as VF/pulseless VT, symptomatic bradycardias, and unstable tachycardias

Reperfusion therapy opens an occluded coronary artery with either________ means or_______. PCI, performed in the heart catheterization suite after coronary angiography, allows________ dilation and/or_______ placement for an occluded coronary artery. “Clot-buster” drugs are called__________, a more accurate term than__________.

Answer 94

Identification
Relief
Prevention
Treatment
mechanical
drugs
balloon
stent
fibrinolytics
thrombolytics

Question 95

Two important points for STEMI need emphasis:

The______ is central to the initial risk and treatment stratification process.

Healthcare personnel do not need evidence of__________ cardiac markers to make a decision to administer fibrinolytic therapy or perform diagnostic coronary angiography with coronary intervention (angioplasty/stenting) in STEMI patients.

Answer 95

ECG
elevated

Question 96

Application of the ACS Algorithm

The steps in the algorithm guide assessment and treatment:

___________of chest discomfort suggestive of ischemia (Step ___)
EMS__________, care, transport, and hospital prearrival notification (Step___)
Immediate ED assessment and___________ (Step ___)
____________of patients according to ST-segment analysis (Steps__,___, and___)
________(Steps __ through ___)

Answer 96

Identification Step 1
assessment Step 2
treatment Step 3
Classification Steps 5, 9, and 11
STEMI Steps 5 through 8

Question 97

Identification of Chest Discomfort Suggestive of Ischemia

The most common symptom of myocardial ischemia and infarction is_________chest_________. The patient may perceive this discomfort more as_________or________ than actual pain.

Symptoms suggestive of ACS may also include

Uncomfortable_______, fullness, squeezing, or pain in the_______ of the chest lasting several minutes (usually more than a few minutes)

Chest discomfort spreading to the_________, neck, one or both_______, or jaw

Chest discomfort spreading into the________ or between the shoulder blades

Chest discomfort with____________, dizziness, fainting, sweating, nausea, or vomiting

Unexplained, sudden______________, which may occur with or without chest discomfort

Consider the likelihood that the presenting condition is ACS or one of its potentially lethal mimics. Other life-threatening conditions that may cause acute chest__________ are aortic dissection, acute pulmonary embolism (PE), acute pericardial effusion with tamponade, and tension pneumothorax

Answer 97

retrosternal chest discomfort
pressure or tightness
pressure
center
shoulders
arms
back
light-headedness
shortness of breath
discomfort

Question 98

STEMI Chain of Survival

These links are:

Rapid _________ and __________ to STEMI warning signs

Rapid EMS_______ and rapid EMS system__________ and pre-arrival_____ to the receiving hospital

Rapid ________ and __________ in the ED (or cath lab)

Rapid___________

Answer 98

recognition and reaction
dispatch
transport
notification
assessment and diagnosis
treatment

Question 99

Chain of Survival

IHCA
1. Primary _______
2. _____team
3. ____Lab
4. _____

OHCA
1. ___rescuers
2. ____
3. ____
4. ____lab
5. ______

Answer 99

Primary providers
Code team
Cath lab
ICU

Lay rescuers
EMS
ED
Cath lab
ICU

Question 100

ACS

EMS Assessment, Care, and Hospital Preparation

EMS responders may perform the following assessments and actions during the stabilization, triage, and transport of the patient to an appropriate facility:

Monitor and support airway, breathing, and circulation (ABCs).
Administer______ and consider oxygen if O2 saturation is less than_______, nitroglycerin, and________ if discomfort is unresponsive to nitrates.
Obtain a 12-lead ECG; interpret or transmit for interpretation.
Complete a fibrinolytic checklist if indicated.
Provide prearrival notification to the receiving facility if ST elevation.

Answer 100

aspirin
less than 90%
morphine

Question 101

ACS

EMS providers should administer oxygen if the patient is dyspneic, is hypoxemic, has obvious signs of heart failure, has an arterial oxygen saturation less than ___%, or the oxygen saturation is unknown. Providers should titrate oxygen therapy to a noninvasively monitored oxyhemoglobin saturation ___% or greater. Because its usefulness has not been established in normoxic patients with suspected or confirmed ACS, providers may consider_________ supplementary oxygen therapy in these patients

Answer 101

less than 90%
90% or greater
withholding

Question 102

ACS

Aspirin (Acetylsalicylic Acid)

A dose of ___ to ____ mg of non–enteric-coated aspirin causes immediate and near-total inhibition of thromboxane A2 production by inhibiting platelet cyclooxygenase (COX-1).________ are one of the principal and earliest participants in thrombus formation. This rapid inhibition also reduces coronary reocclusion and other recurrent events independently and after fibrinolytic therapy.
If the patient has not taken aspirin and has no history of true aspirin allergy and no evidence of recent GI bleeding, give the patient________to chew. In the initial hours of an ACS, aspirin is absorbed better when chewed than when swallowed, particularly if______ has been given. Use________________ for patients with nausea, vomiting, active peptic ulcer disease, or other disorders of the upper GI tract.

Answer 102

160 to 325 mg
Platelets
aspirin (160 to 325 mg) to chew
morphine
rectal aspirin suppositories (300 mg)

Question 103

ACS

Nitroglycerin (Glyceryl Trinitrate)

Give the patient __________ nitroglycerin tablet (or spray “dose”) every __to __ minutes for ongoing symptoms if it is permitted by medical control and no contraindications exist. Healthcare providers may repeat the dose_________. Administer nitroglycerin only if the patient remains hemodynamically stable: SBP is greater than ___ mm Hg or no lower than ____ mm Hg below baseline (if known) and the heart rate is ___ to ____/min.

Nitroglycerin is a__________ and needs to be used cautiously or not at all in patients with inadequate ventricular preload. These situations include

________wall MI and RV infarction.

Hypotension, bradycardia, or tachycardia. Avoid use of nitroglycerin in patients with hypotension (SBP less than ___ mm Hg), marked bradycardia (less than ___/min), or tachycardia.

Recent phosphodiesterase inhibitor use. Avoid the use of nitroglycerin if it is suspected or known that the patient has taken sildenafil or vardenafil within the previous___ hours or tadalafil within 48 hours. These agents are generally used for erectile dysfunction or in cases of pulmonary hypertension and in combination with nitrates may cause severe hypotension refractory to vasopressor agents.

Answer 103

1 sublingual nitroglycerin tablet (or spray “dose”) every 3 to 5 minutes
twice (total of 3 doses)
greater than 90 mm Hg or no lower than 30 mm Hg below baseline (if known) and the heart rate is 50 to 100/min
venodilator
Inferior
SBP less than 90 mm Hg, marked bradycardia (less than 50/min), or tachycardia
24 hours

Question 104

ACS

Opiates (eg, Morphine)

Give an opiate (eg, morphine) for chest discomfort_________ to sublingual or spray nitroglycerin if authorized by protocol or medical control. Use morphine with caution in_________ because of an association with increased mortality.

Morphine may be utilized in the management of ACS because it

Produces central nervous system________, which reduces the adverse effects of neurohumoral activation, catecholamine release, and heightened myocardial oxygen demand

Produces___________, which reduces LV preload and oxygen requirements

Decreases systemic vascular__________, thereby reducing LV afterload

Helps redistribute blood_______ in patients with acute pulmonary edema

Remember, morphine is a_________. Like nitroglycerin, use smaller doses and carefully monitor physiologic response before administering additional doses in patients who may be preload dependent. If hypotension develops,________ as a first line of therapy.

Answer 104

unresponsive
NSTE-ACS
analgesia
venodilation
resistance
volume
venodilator
administer fluids

Question 105

Pain Relief With Nitroglycerin

GI etiologies as well as other causes of chest discomfort can “respond” to nitroglycerin administration. Therefore, the response to nitrate therapy is not________ of ACS

Answer 105

Diagnostic

Question 106

Use of Nonsteroidal Anti-inflammatory Drugs

Use of__________________ is contraindicated (except for_____) and should be discontinued. Both nonselective as well as COX-2 selective drugs should not be administered during hospitalization for STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use.

Answer 106

nonsteroidal anti-inflammatory drugs (NSAIDs)
aspirin

Question 107

ACS

EMS providers should obtain a 12-lead ECG. The AHA recommends out-of-hospital 12-lead ECG_________ programs in urban and suburban EMS systems.

Prearrival notification of the ED shortens the time to treatment (__to___minutes has been achieved in clinical studies) and speeds reperfusion therapy with fibrinolytics or PCI or both, which may reduce mortality and minimize myocardial injury.

Answer 107

diagnostic
10 to 60

Question 108

ACS

Immediate ED Assessment and Treatment

The high-performance team should quickly evaluate the patient with potential ACS on the patient’s arrival in the ED. Within the first___ minutes, obtain a 12-lead ECG (if not already performed before arrival) and assess the patient.

The _________is at the center of the decision pathway in the management of ischemic chest discomfort and is the only means of identifying STEMI.

A targeted evaluation should be performed and focus on chest discomfort, signs and symptoms of heart failure, cardiac history, risk factors for ACS, and historical features that may preclude the use of fibrinolytics. For the patient with STEMI, the goals of reperfusion are to give fibrinolytics within___ minutes of arrival or perform PCI within___ minutes of arrival.

Answer 108

Within the first 10 minutes
12-lead ECG
Within 30 minutes
Within 90 minutes

Question 109

ACS

The First 10 Minutes

Assessment and stabilization of the patient in the first____ minutes should include the following:

Check vital signs and evaluate oxygen saturation.

Establish IV access.

Take a brief focused history and perform a physical examination.

Complete the fibrinolytic checklist and check for contraindications, if indicated.

Obtain a blood sample to evaluate initial cardiac marker levels, electrolytes, and coagulation.

Obtain and review portable chest x-ray (less than _______ minutes after the patient’s arrival in the ED). This
should not delay fibrinolytic therapy for STEMI or activation of the PCI team for STEMI.

Note: The results of cardiac markers, chest x-ray, and laboratory studies should not delay reperfusion therapy unless clinically necessary, eg, suspected aortic dissection or coagulopathy.

Answer 109

First 10 minutes

less than 30 minutes after the patient’s arrival in the ED

Question 110

ACS

Patient General Treatment

Unless allergies or contraindications exist, ___ agents may be considered in patients with ischemic-type chest discomfort:

Oxygen if hypoxemic (O2 % less than ___%) or signs of heart failure
-______
________
________ (eg, morphine if ongoing discomfort or no response to nitrates)

Answer 110

4

Oxygen if hypoxemic (O2 % less than 90%) or signs of heart failure
Aspirin
Nitroglycerin
Opiate (eg, morphine if ongoing discomfort or no response to nitrates)

Question 111

ACS

The major contraindication to nitroglycerin and morphine is__________, including hypotension from an RV infarction. The major contraindications to aspirin are true __________ and active or recent __________.

Answer 111

hypotension

true aspirin allergy and active or recent GI bleeding

Question 112

ACS

STEMI is characterized by ST-segment elevation in ____ or more contiguous leads or new ______. Threshold values for ST-segment elevation consistent with STEMI are _____-point elevation greater than _____ mm (____ mV) in leads ____ and ____* and ___ mm or more in all other leads or by new or presumed new ______.
*______ mm in men younger than 40 years; _____ mm in all women.

NSTE-ACS is characterized by ischemic ST-segment depression ____ mm (_____ mV) or greater or dynamic T-wave ______ with pain or discomfort. Nonpersistent or transient ST elevation ______ mm or greater for less than ____ minutes is also included in this category.

Low-/intermediate-risk ACS is characterized by normal or nondiagnostic changes in the ST segment or T wave that are inconclusive and require further risk stratification. This classification includes patients with normal ECGs and those with ST-segment deviation in either direction of less than ____ mm (____ mV) or T-wave inversion ____ mm or ____ mV. Serial cardiac studies and functional testing are appropriate. Note that additional information (troponin) may place the patient into a higher risk classification after initial classification.

A small percentage of patients with _______ ECGs may be found to have MI, for example. If the initial ECG is nondiagnostic and clinical circumstances indicate (eg, ongoing chest discomfort), ____ the ECG.

Answer 112

STEMI is characterized by ST-segment elevation in 2 or more contiguous leads or new LBBB. Threshold values for ST-segment elevation consistent with STEMI are J-point elevation greater than 2 mm (0.2 mV) in leads V2 and V3* and 1 mm or more in all other leads or by new or presumed new LBBB.
*2.5 mm in men younger than 40 years; 1.5 mm in all women.

NSTE-ACS is characterized by ischemic ST-segment depression 0.5 mm (0.05 mV) or greater or dynamic T-wave inversion with pain or discomfort. Nonpersistent or transient ST elevation 0.5 mm or greater for less than 20 minutes is also included in this category.

Low-/intermediate-risk ACS is characterized by normal or nondiagnostic changes in the ST segment or T wave that are inconclusive and require further risk stratification. This classification includes patients with normal ECGs and those with ST-segment deviation in either direction of less than 0.5 mm (0.05 mV) or T-wave inversion ≤2 mm or 0.2 mV. Serial cardiac studies and functional testing are appropriate. Note that additional information (troponin) may place the patient into a higher risk classification after initial classification.

The ECG classification of ischemic syndromes is not meant to be exclusive. A small percentage of patients with normal ECGs may be found to have MI, for example. If the initial ECG is nondiagnostic and clinical circumstances indicate (eg, ongoing chest discomfort), repeat the ECG.

Question 113

ACS

STEMI

Patients with STEMI usually have _________ occlusion of an ________ _________ artery.

The mainstay of treatment for STEMI is early _________ therapy achieved with _________or_________

______________ therapy for STEMI is perhaps the most important advancement in treatment of cardiovascular disease in recent years.

Early __________ therapy or direct catheter-based reperfusion has been established as a standard of care for patients with STEMI who present within ______ hours of onset of symptoms with no contraindications. Reperfusion therapy reduces mortality and saves heart muscle; the shorter the time to reperfusion, the greater the benefit. A ______% reduction in mortality was noted when fibrinolytic therapy was provided in the first ______ after onset of symptoms.

Answer 113

ACS

STEMI

Patients with STEMI usually have complete occlusion of an epicardial coronary artery.

The mainstay of treatment for STEMI is early reperfusion therapy achieved with primary PCI or fibrinolytics.

Reperfusion therapy for STEMI is perhaps the most important advancement in treatment of cardiovascular disease in recent years. Early fibrinolytic therapy or direct catheter-based reperfusion has been established as a standard of care for patients with STEMI who present within 12 hours of onset of symptoms with no contraindications. Reperfusion therapy reduces mortality and saves heart muscle; the shorter the time to reperfusion, the greater the benefit. A 47% reduction in mortality was noted when fibrinolytic therapy was provided in the first hour after onset of symptoms.

Question 114

STEMI

Delay of Therapy

Potential delay during the in-hospital evaluation period may occur from ______ to ______ (ECG), from ______ to ________, and from _________ to _______ (or PCI). These 4 major points of in-hospital therapy are commonly referred to as the “4 D’s.”

All providers must focus on minimizing delays at each of these points. Out-of-hospital transport time constitutes only _____% of delay to treatment time; ED evaluation constitutes ______% to _____% of this delay.

Answer 114

STEMI

Delay of Therapy

Routine consultation with a cardiologist or another physician should not delay diagnosis and treatment except in equivocal or uncertain cases. Consultation delays therapy and is associated with increased hospital mortality rates.

Potential delay during the in-hospital evaluation period may occur from door to data (ECG), from data to decision, and from decision to drug (or PCI). These 4 major points of in-hospital therapy are commonly referred to as the “4 D’s.”

All providers must focus on minimizing delays at each of these points. Out-of-hospital transport time constitutes only 5% of delay to treatment time; ED evaluation constitutes 25% to 33% of this delay.

Question 115

STEMI

Early Reperfusion Therapy

Early activation of PCI may occur with established protocols. The following time frames are recommended:

For PCI, this goal for ED door–to–balloon inflation time is ____ minutes. In patients presenting to a non–PCI-capable hospital, time from first medical contact to device should be less than _____ minutes when primary PCI is considered.

If fibrinolysis is the intended reperfusion, an ED door-to-needle time (needle time is the beginning of infusion of a fibrinolytic agent) of ____ minutes is the medical system goal that is considered the longest time acceptable. Systems should strive to achieve the shortest time possible.

Patients who are ineligible for fibrinolytic therapy should be considered for transfer to a PCI facility regardless of ______. The system should prepare for a door-to-departure time of ____ minutes when a transfer decision is made.

Answer 115

STEMI

Early Reperfusion Therapy

Early activation of PCI may occur with established protocols. The following time frames are recommended:

For PCI, this goal for ED door–to–balloon inflation time is 90 minutes. In patients presenting to a non–PCI-capable hospital, time from first medical contact to device should be less than 120 minutes when primary PCI is considered.

If fibrinolysis is the intended reperfusion, an ED door-to-needle time (needle time is the beginning of infusion of a fibrinolytic agent) of 30 minutes is the medical system goal that is considered the longest time acceptable. Systems should strive to achieve the shortest time possible.

Patients who are ineligible for fibrinolytic therapy should be considered for transfer to a PCI facility regardless of delay. The system should prepare for a door-to-departure time of 30 minutes when a transfer decision is made.

Question 116

STEMI

Use of PCI

The most commonly used form of PCI is coronary intervention with ______ placement. Optimally performed ______ PCI is the preferred reperfusion strategy over fibrinolytic administration.

_________ PCI is used early after fibrinolytics in patients who may have persistent occlusion of the infarct artery (failure to reperfuse with fibrinolytics), although this term has been recently replaced and included by the term ___________ strategy.

PCI has been shown to be superior to fibrinolysis in the combined end points of death, stroke, and reinfarction in many studies for patients presenting between ____ and ____ hours after onset. However, these results have been achieved in experienced medical settings with skilled providers (performing more than _____ PCIs per year) at a skilled PCI facility (performing more than ______ PCIs for STEMI with cardiac surgery capabilities).

Considerations for the use of PCI include the following:

___ is the treatment of choice for the management of STEMI when it can be performed effectively with a door-to-balloon time of less than ____ minutes from first medical contact by a skilled provider at a skilled PCI facility.

Primary PCI may also be offered to patients presenting to non–PCI-capable centers if PCI can be initiated promptly within ____ minutes from first medical contact. The TRANSFER AMI (Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction) trial supports the transfer of high-risk patients who receive fibrinolysis in a non-PCI center within ___ hours of symptom onset to a PCI center within ___ hours of fibrinolytic administration to receive routine early coronary angiography and PCI if indicated.

For patients admitted to a hospital without PCI capabilities, there may be some benefit associated with transfer for PCI versus administration of on-site fibrinolytics in terms of reinfarction, stroke, and a trend to lower mortality when PCI can be performed within ____ minutes of first medical contact.

PCI is also preferred in patients with contraindications to fibrinolytics and is indicated in patients with cardiogenic shock or heart failure complicating MI.

Answer 116

STEMI

Use of PCI

The most commonly used form of PCI is coronary intervention with stent placement. Optimally performed primary PCI is the preferred reperfusion strategy over fibrinolytic administration.

Rescue PCI is used early after fibrinolytics in patients who may have persistent occlusion of the infarct artery (failure to reperfuse with fibrinolytics), although this term has been recently replaced and included by the term pharmacoinvasive strategy.

PCI has been shown to be superior to fibrinolysis in the combined end points of death, stroke, and reinfarction in many studies for patients presenting between 3 and 12 hours after onset. However, these results have been achieved in experienced medical settings with skilled providers (performing more than 75 PCIs per year) at a skilled PCI facility (performing more than 200 PCIs for STEMI with cardiac surgery capabilities).

Considerations for the use of PCI include the following:

PCI is the treatment of choice for the management of STEMI when it can be performed effectively with a door-to-balloon time of less than 90 minutes from first medical contact by a skilled provider at a skilled PCI facility.

Primary PCI may also be offered to patients presenting to non–PCI-capable centers if PCI can be initiated promptly within 120 minutes from first medical contact. The TRANSFER AMI (Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction) trial supports the transfer of high-risk patients who receive fibrinolysis in a non-PCI center within 12 hours of symptom onset to a PCI center within 6 hours of fibrinolytic administration to receive routine early coronary angiography and PCI if indicated.

For patients admitted to a hospital without PCI capabilities, there may be some benefit associated with transfer for PCI versus administration of on-site fibrinolytics in terms of reinfarction, stroke, and a trend to lower mortality when PCI can be performed within 120 minutes of first medical contact.

PCI is also preferred in patients with contraindications to fibrinolytics and is indicated in patients with cardiogenic shock or heart failure complicating MI.

Question 117

STEMI

Use of Fibrinolytic Therapy

A fibrinolytic agent or “clot-buster” is administered to patients with J-point ST-segment elevation greater than ___ mm (___ mV) in leads __ and ___ and ___ mm or more in all other leads or by new or presumed new LBBB (eg, leads III, aVF; leads V3, V4; leads I and aVL) without contraindications. Fibrin-specific agents are effective in achieving normal flow in about ___% of patients given these drugs. Examples of fibrin-specific drugs are rtPA, reteplase, and tenecteplase. ________ was the first fibrinolytic used widely, but it is not fibrin specific.

Considerations for the use of fibrinolytic therapy are as follows:

In the absence of contraindications and in the presence of a favorable risk-benefit ratio, fibrinolytic therapy is one option for reperfusion in patients with STEMI and onset of symptoms within ___ hours of presentation with qualifying ECG findings and if PCI is not available within ____ minutes of first medical contact.

In the absence of contraindications, it is also reasonable to give fibrinolytics to patients with onset of symptoms within the prior ___ hours and ECG findings consistent with true posterior MI. Experienced providers will recognize this as a condition where ST-segment depression in the early precordial leads is equivalent to ST-segment elevation in others. When these changes are associated with other ECG findings, it is suggestive of a “STEMI” on the _________ wall of the heart.

Fibrinolytics are generally not recommended for patients presenting more than ____ hours after onset of symptoms. But they may be considered if ischemic chest discomfort continues with persistent ST-segment elevation.

Do not give fibrinolytics to patients who present more than _____ hours after the onset of symptoms or patients with ST-segment depression unless a true posterior MI is suspected.

Answer 117

STEMI

Use of Fibrinolytic Therapy

A fibrinolytic agent or “clot-buster” is administered to patients with J-point ST-segment elevation greater than 2 mm (0.2 mV) in leads V2 and V3 and 1 mm or more in all other leads or by new or presumed new LBBB (eg, leads III, aVF; leads V3, V4; leads I and aVL) without contraindications. Fibrin-specific agents are effective in achieving normal flow in about 50% of patients given these drugs. Examples of fibrin-specific drugs are rtPA, reteplase, and tenecteplase. Streptokinase was the first fibrinolytic used widely, but it is not fibrin specific.

Considerations for the use of fibrinolytic therapy are as follows:

In the absence of contraindications and in the presence of a favorable risk-benefit ratio, fibrinolytic therapy is one option for reperfusion in patients with STEMI and onset of symptoms within 12 hours of presentation with qualifying ECG findings and if PCI is not available within 90 minutes of first medical contact.

In the absence of contraindications, it is also reasonable to give fibrinolytics to patients with onset of symptoms within the prior 12 hours and ECG findings consistent with true posterior MI. Experienced providers will recognize this as a condition where ST-segment depression in the early precordial leads is equivalent to ST-segment elevation in others. When these changes are associated with other ECG findings, it is suggestive of a “STEMI” on the posterior wall of the heart.

Fibrinolytics are generally not recommended for patients presenting more than 12 hours after onset of symptoms. But they may be considered if ischemic chest discomfort continues with persistent ST-segment elevation.

Do not give fibrinolytics to patients who present more than 24 hours after the onset of symptoms or patients with ST-segment depression unless a true posterior MI is suspected.

Question 118

STEMI

Adjunctive Treatments

Heparin (Unfractionated or Low-Molecular-Weight)

The inappropriate dosing and monitoring of Heparin therapy has caused excess intracerebral bleeding and major hemorrhage in _____ patients.

IV Nitroglycerin

_____ use of IV nitroglycerin is not indicated and has not been shown to significantly reduce mortality in STEMI. IV nitroglycerin is indicated and used widely in ischemic syndromes. It is preferred over topical or long-acting forms because it can be titrated in a patient with potentially unstable hemodynamics and clinical condition. Indications for initiation of IV nitroglycerin in STEMI are

Recurrent or continuing chest discomfort unresponsive to sublingual or spray nitroglycerin
Pulmonary edema complicating STEMI
Hypertension complicating STEMI
Treatment goals using IV nitroglycerin are as follows:

Treatment Goal
Relief of ischemic chest discomfort-
Management
Titrate to effect
Keep SBP greater than ____ mm Hg
Limit drop in SBP to ____ mm Hg below baseline in hypertensive patients

Treatment Goal
Improvement in pulmonary edema and hypertension
Management
Titrate to effect
Limit drop in SBP to ____% of baseline in normotensive patients
Limit drop in SBP to ____ mm Hg below baseline in hypertensive patients

Answer 118

STEMI

Adjunctive Treatments

Heparin (Unfractionated or Low-Molecular-Weight)

The inappropriate dosing and monitoring of heparin therapy has caused excess intracerebral bleeding and major hemorrhage in STEMI patients. Providers using heparin need to know the indications, dosing, and use in the specific ACS categories.

IV Nitroglycerin

Routine use of IV nitroglycerin is not indicated and has not been shown to significantly reduce mortality in STEMI. IV nitroglycerin is indicated and used widely in ischemic syndromes. It is preferred over topical or long-acting forms because it can be titrated in a patient with potentially unstable hemodynamics and clinical condition. Indications for initiation of IV nitroglycerin in STEMI are

Recurrent or continuing chest discomfort unresponsive to sublingual or spray nitroglycerin
Pulmonary edema complicating STEMI
Hypertension complicating STEMI
Treatment goals using IV nitroglycerin are as follows:

Treatment Goal
Relief of ischemic chest discomfort-
Management
Titrate to effect
Keep SBP greater than 90 mm Hg
Limit drop in SBP to 30 mm Hg below baseline in hypertensive patients

Treatment Goal
Improvement in pulmonary edema and hypertension
Management
Titrate to effect
Limit drop in SBP to 10% of baseline in normotensive patients
Limit drop in SBP to 30 mm Hg below baseline in hypertensive patients

Question 119

Stroke

The target times and goals are recommended by the NINDS, which has recommended measurable goals for the evaluation of stroke patients. These targets or goals should be achieved for at least ______% of patients with acute stroke.

Answer 119

The target times and goals are recommended by the NINDS, which has recommended measurable goals for the evaluation of stroke patients. These targets or goals should be achieved for at least 80% of patients with acute stroke.

Question 120

Stroke

Potential Arrhythmias With Stroke

The _____ does not take priority over obtaining a computed tomography (CT) scan. No arrhythmias are specific for stroke, but the ECG may identify evidence of a recent AMI or arrhythmias such as atrial fibrillation as a cause of an embolic stroke. There is general agreement to recommend cardiac monitoring during the first ___ hours of evaluation in patients with acute ischemic stroke to detect atrial fibrillation and potentially life-threatening arrhythmias.

Answer 120

Stroke

Potential Arrhythmias With Stroke

The ECG does not take priority over obtaining a computed tomography (CT) scan. No arrhythmias are specific for stroke, but the ECG may identify evidence of a recent AMI or arrhythmias such as atrial fibrillation as a cause of an embolic stroke. Many patients with stroke may demonstrate arrhythmias, but if the patient is hemodynamically stable, most arrhythmias will not require treatment. There is general agreement to recommend cardiac monitoring during the first 24 hours of evaluation in patients with acute ischemic stroke to detect atrial fibrillation and potentially life-threatening arrhythmias.

Question 121

Stroke

Major Types of Stroke

The major types of stroke are

Hemorrhagic stroke: Accounts for ___% of all strokes and occurs when a blood vessel in the brain suddenly ruptures into the surrounding tissue. Fibrinolytic therapy is contraindicated in this type of stroke. Avoid anticoagulants.

Types of stroke. ________percent of strokes are ischemic and potentially eligible for fibrinolytic therapy if patients otherwise qualify. ______ percent of strokes are hemorrhagic, and the majority of these are intracerebral.. Blacks have almost _______ the risk of first-ever stroke compared with whites.

Answer 121

Stroke

Major Types of Stroke

Stroke is a general term. It refers to acute neurologic impairment that follows interruption in blood supply to a specific area of the brain. Although expeditious stroke care is important for all patients, this case emphasizes reperfusion therapy for acute ischemic stroke.

The major types of stroke are

Hemorrhagic stroke: Accounts for 13% of all strokes and occurs when a blood vessel in the brain suddenly ruptures into the surrounding tissue. Fibrinolytic therapy is contraindicated in this type of stroke. Avoid anticoagulants.

Types of stroke. Eighty-seven percent of strokes are ischemic and potentially eligible for fibrinolytic therapy if patients otherwise qualify. Thirteen percent of strokes are hemorrhagic, and the majority of these are intracerebral.. Blacks have almost twice the risk of first-ever stroke compared with whites.

Question 122

Stroke

Approach to Stroke Care

Introduction

Each year in the United States, about ________ people have a new or recurrent stroke. Stroke remains a leading cause of ______ in the United States.

Early recognition of acute ischemic stroke is important because IV fibrinolytic treatment should be provided as early as possible, generally within ___ hours of onset of symptoms, or within ___ hours of onset of symptoms for selected patients. Endovascular therapy may be given within ___ hours of onset of symptoms, but better outcomes are associated with shorter times to treatment. Most strokes occur at home, and only _____ of acute stroke patients use EMS for transport to the hospital. Stroke patients often deny or try to rationalize their symptoms.

Answer 122

Stroke

Approach to Stroke Care

Introduction

Each year in the United States, about 795 000 people have a new or recurrent stroke. Stroke remains a leading cause of death in the United States.

Early recognition of acute ischemic stroke is important because IV fibrinolytic treatment should be provided as early as possible, generally within 3 hours of onset of symptoms, or within 4.5 hours of onset of symptoms for selected patients. Endovascular therapy may be given within 6 hours of onset of symptoms, but better outcomes are associated with shorter times to treatment. Most strokes occur at home, and only half of acute stroke patients use EMS for transport to the hospital. Stroke patients often deny or try to rationalize their symptoms.

Question 123

Stroke

Stroke Chain of Survival

The goal of stroke care is to minimize brain injury and maximize the patient’s recovery. It links actions to be taken by patients, family members, and healthcare providers to maximize stroke recovery. These links are

Rapid __________ and ________ to stroke warning signs

Rapid _____ _______

Rapid _______ system _________ and prearrival __________ to the receiving hospital

Rapid ________ and ________ in the hospital

Answer 123

Stroke

Stroke Chain of Survival

The goal of stroke care is to minimize brain injury and maximize the patient’s recovery. The Stroke Chain of Survival (Figure 25) described by the AHA and the American Stroke Association is similar to the Chain of Survival for sudden cardiac arrest. It links actions to be taken by patients, family members, and healthcare providers to maximize stroke recovery. These links are

Rapid recognition and reaction to stroke warning signs

Rapid EMS dispatch

Rapid EMS system transport and prearrival notification to the receiving hospital

Rapid diagnosis and treatment in the hospital

Question 124

Stroke

The 8 D’s of Stroke Care

The 8 D’s of Stroke Care highlight the major steps in diagnosis and treatment of stroke and key points at which delays can occur:

__________: Rapid recognition of stroke symptoms
_________: Early activation and dispatch of EMS by 9-1-1
_________: Rapid EMS identification, management, and transport
___________: Appropriate triage to stroke center
__________: Rapid triage, evaluation, and management within the ED
__________: Stroke expertise and therapy selection
__________: Fibrinolytic or endovascular therapy
___________: Rapid admission to the stroke unit or critical care unit

Answer 124

Stroke

The 8 D’s of Stroke Care

The 8 D’s of Stroke Care highlight the major steps in diagnosis and treatment of stroke and key points at which delays can occur:

Detection: Rapid recognition of stroke symptoms
Dispatch: Early activation and dispatch of EMS by 9-1-1
Delivery: Rapid EMS identification, management, and transport
Door: Appropriate triage to stroke center
Data: Rapid triage, evaluation, and management within the ED
Decision: Stroke expertise and therapy selection
Drug/Device: Fibrinolytic or endovascular therapy
Disposition: Rapid admission to the stroke unit or critical care unit

Question 125

Stroke

Goals of Stroke Care

The NINDS has established critical in-hospital time goals for assessment and management of patients with suspected stroke. This algorithm reviews the critical in-hospital time periods for patient assessment and treatment:

Immediate general assessment by the stroke team, emergency physician, or another expert within ____ minutes of arrival; order urgent noncontrast CT scan

Neurologic assessment by the stroke team or designee and CT scan performed within ___ minutes of hospital arrival

Interpretation of the CT scan within ____ minutes of ED arrival

Initiation of fibrinolytic therapy in appropriate patients (those without contraindications) within ___ hour of hospital arrival and ___ hours from symptom onset

Door-to-admission time of ____ hours

Answer 125

Stroke

Goals of Stroke Care

The NINDS has established critical in-hospital time goals for assessment and management of patients with suspected stroke. This algorithm reviews the critical in-hospital time periods for patient assessment and treatment:

Immediate general assessment by the stroke team, emergency physician, or another expert within 10 minutes of arrival; order urgent noncontrast CT scan

Neurologic assessment by the stroke team or designee and CT scan performed within 25 minutes of hospital arrival

Interpretation of the CT scan within 45 minutes of ED arrival

Initiation of fibrinolytic therapy in appropriate patients (those without contraindications) within 1 hour of hospital arrival and 3 hours from symptom onset

Door-to-admission time of 3 hours

Question 126

Stroke

Administration of endovascular therapy, timed from onset of symptoms
___ hours in selected patients

Answer 126

Stroke

Administration of endovascular therapy, timed from onset of symptoms
6 hours in selected patients

Question 127

Stroke

Application of the Suspected Stroke Algorithm
We will now discuss the steps in the algorithm, as well as other related topics:

Identification of signs and symptoms of possible stroke and activation of emergency response (Step __)
Critical EMS assessments and actions (Step ___)
Immediate general assessment and stabilization (Step ___)
Immediate neurologic assessment by the stroke team or designee (Step __)
CT scan: hemorrhage or no hemorrhage (Step ___)
Fibrinolytic therapy risk stratification if candidate (Steps __, __, and ___)
General stroke care (Steps __ and ___)

Answer 127

Stroke

Application of the Suspected Stroke Algorithm
We will now discuss the steps in the algorithm, as well as other related topics:

Identification of signs and symptoms of possible stroke and activation of emergency response (Step 1)
Critical EMS assessments and actions (Step 2)
Immediate general assessment and stabilization (Step 3)
Immediate neurologic assessment by the stroke team or designee (Step 4)
CT scan: hemorrhage or no hemorrhage (Step 5)
Fibrinolytic therapy risk stratification if candidate (Steps 6, 8, and 10)
General stroke care (Steps 11 and 12)

Question 128

Stroke
Cincinnati Prehospital Stroke Scale

By using the CPSS, medical personnel can evaluate the patient in less than __ minute. The presence of 1 finding on the CPSS has a sensitivity of ___% and a specificity of ___% when scored by prehospital providers.

With standard training in stroke recognition, paramedics demonstrated a sensitivity of __% to __% for identifying patients with stroke. After receiving training in use of a stroke assessment tool, paramedic sensitivity for identifying patients with stroke increased to __% to ___%.

Interpretation: If any 1 of these 3 signs is abnormal, the probability of a stroke is __%. The presence of all 3 findings indicates that the probability of stroke is greater than ___%.

Answer 128

Stroke
Cincinnati Prehospital Stroke Scale

The CPSS identifies stroke on the basis of 3 physical findings:

Facial droop (have the patient smile or try to show teeth)
Arm drift (have the patient close eyes and hold both arms out, with palms up)
Abnormal speech (have the patient say, “You can’t teach an old dog new tricks”)

By using the CPSS, medical personnel can evaluate the patient in less than 1 minute. The presence of 1 finding on the CPSS has a sensitivity of 59% and a specificity of 89% when scored by prehospital providers.

With standard training in stroke recognition, paramedics demonstrated a sensitivity of 61% to 66% for identifying patients with stroke. After receiving training in use of a stroke assessment tool, paramedic sensitivity for identifying patients with stroke increased to 86% to 97%.

Interpretation: If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%. The presence of all 3 findings indicates that the probability of stroke is greater than 85%.

Question 129

Stroke

Both out-of-hospital and in-hospital medical personnel should provide supplementary _______ to hypoxemic (ie, oxygen saturation less than ___%) stroke patients or patients for whom oxygen saturation is unknown.

Assess the patient’s neurologic status by using one of the more advanced stroke scales. Following is an example:
National Institutes of Health Stroke Scale
The NIHSS uses ____ items to assess the responsive stroke patient.

The initial _______________ scan is the most important test for a patient with acute stroke.

Answer 129

Stroke

Both out-of-hospital and in-hospital medical personnel should provide supplementary oxygen to hypoxemic (ie, oxygen saturation less than 94%) stroke patients or patients for whom oxygen saturation is unknown.

Assess the patient’s neurologic status by using one of the more advanced stroke scales. Following is an example:
National Institutes of Health Stroke Scale
The NIHSS uses 15 items to assess the responsive stroke patient.

The initial noncontrast CT scan is the most important test for a patient with acute stroke.

Question 130

Stroke

Fibrinolytic Therapy

Several studies have shown a higher likelihood of good to excellent functional outcome when rtPA is given to adults with acute ischemic stroke within ___ hours of onset of symptoms, or within ____ hours of onset of symptoms for selected patients.

Evaluate for Fibrinolytic Therapy

Inclusion Criteria

Diagnosis of ischemic stroke causing measurable neurologic deficit
Onset of symptoms <___ hours before beginning treatment
Age ≥___ years

Exclusion Criteria
Significant head trauma or prior stroke in previous ___ months
Symptoms suggest subarachnoid hemorrhage
Arterial puncture at noncompressible site in previous ___ days
History of previous intracranial hemorrhage
– Intracranial neoplasm, arteriovenous malformation, or aneurysm
– Recent intracranial or intraspinal surgery
Elevated blood pressure (systolic >___ mm Hg or diastolic >______ mm Hg)
Active internal bleeding
Acute bleeding diathesis, including but not limited to
– Platelet count <______/mm3
– Heparin received within ___ hours, resulting in aPTT greater than the upper limit of normal
– Current use of anticoagulant with INR >1.7 or PT >15 seconds
– Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa activity assays)
Blood glucose concentration <___ mg/dL (2.7 mmol/L)
CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Relative Exclusion Criteria
Recent experience suggests that under some circumstances—with careful consideration and weighing of risk to benefit—patients may receive fibrinolytic therapy despite 1 or more relative contraindications. Consider risk to benefit of rtPA administration carefully if any one of these relative contraindications is present:
Only minor or rapidly improving stroke symptoms (clearing spontaneously)
Pregnancy
Seizure at onset with postictal residual neurologic impairments
Major surgery or serious trauma within previous ____ days
Recent gastrointestinal or urinary tract hemorrhage (within previous ____ days)
Recent acute myocardial infarction (within previous ___ months)

Answer 130

Stroke

Fibrinolytic Therapy

Several studies have shown a higher likelihood of good to excellent functional outcome when rtPA is given to adults with acute ischemic stroke within 3 hours of onset of symptoms, or within 4.5 hours of onset of symptoms for selected patients.

Evaluate for Fibrinolytic Therapy

Inclusion Criteria

Diagnosis of ischemic stroke causing measurable neurologic deficit
Onset of symptoms <3 hours before beginning treatment
Age ≥18 years

Exclusion Criteria
Significant head trauma or prior stroke in previous 3 months
Symptoms suggest subarachnoid hemorrhage
Arterial puncture at noncompressible site in previous 7 days
History of previous intracranial hemorrhage
– Intracranial neoplasm, arteriovenous malformation, or aneurysm
– Recent intracranial or intraspinal surgery
Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
Active internal bleeding
Acute bleeding diathesis, including but not limited to
– Platelet count <100 000/mm3
– Heparin received within 48 hours, resulting in aPTT greater than the upper limit of normal
– Current use of anticoagulant with INR >1.7 or PT >15 seconds
– Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa activity assays)
Blood glucose concentration <50 mg/dL (2.7 mmol/L)
CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Relative Exclusion Criteria
Recent experience suggests that under some circumstances—with careful consideration and weighing of risk to benefit—patients may receive fibrinolytic therapy despite 1 or more relative contraindications. Consider risk to benefit of rtPA administration carefully if any one of these relative contraindications is present:
Only minor or rapidly improving stroke symptoms (clearing spontaneously)
Pregnancy
Seizure at onset with postictal residual neurologic impairments
Major surgery or serious trauma within previous 14 days
Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
Recent acute myocardial infarction (within previous 3 months)

Question 131

Stroke

Patient Is a Candidate for Fibrinolytic Therapy
Begin your institution’s stroke rtPA protocol, often called a “_______ of care.”

Do not administer anticoagulants or antiplatelet treatment for ___ hours after administration of rtPA, typically until a follow-up CT scan at ____ hours shows no intracranial hemorrhage.

Extended IV rtPA Window 3 to 4.5 Hours

Treatment of carefully selected patients with acute ischemic stroke with IV rtPA between __ and _____ hours after onset of symptoms has also been shown to improve clinical outcome, although the degree of clinical benefit is smaller than that achieved with treatment within 3 hours.

Inclusion Criteria
Diagnosis of ischemic stroke causing measurable neurologic deficit
Onset of symptoms __ to ___ hours before beginning treatment

Exclusion Criteria
Age >___ years
Severe stroke (NIHSS score >___)
Taking an oral anticoagulant regardless of INR
History of both diabetes and prior ischemic stroke

Answer 131

Stroke

Patient Is a Candidate for Fibrinolytic Therapy
Begin your institution’s stroke rtPA protocol, often called a “pathway of care.”

Do not administer anticoagulants or antiplatelet treatment for 24 hours after administration of rtPA, typically until a follow-up CT scan at 24 hours shows no intracranial hemorrhage.

Extended IV rtPA Window 3 to 4.5 Hours

Treatment of carefully selected patients with acute ischemic stroke with IV rtPA between 3 and 4.5 hours after onset of symptoms has also been shown to improve clinical outcome, although the degree of clinical benefit is smaller than that achieved with treatment within 3 hours.

Inclusion Criteria
Diagnosis of ischemic stroke causing measurable neurologic deficit
Onset of symptoms 3 to 4.5 hours before beginning treatment

Exclusion Criteria
Age >80 years
Severe stroke (NIHSS score >25)
Taking an oral anticoagulant regardless of INR
History of both diabetes and prior ischemic stroke

Question 132

Stroke

Intra-arterial rtPA

For patients with acute ischemic stroke who are not candidates for standard IV fibrinolysis, consider intra-arterial fibrinolysis in centers with the resources and expertise to provide it within the first ___ hours after onset of symptoms. Intra-arterial administration of rtPA is not yet approved by the FDA.

Mechanical Clot Disruption/Stent Retrievers

Mechanical clot disruption or retrieval with a stent has been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke.

Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria:

Prestroke mRS score of 0 to ___
Acute ischemic stroke receiving intravenous rtPA within _____ hours of onset according to guidelines from professional medical societies
Causative occlusion of the internal carotid artery or proximal MCA (M1)
Age ___ years or older
NIHSS score of ___ or greater
ASPECTS of ___ or greater
Treatment can be initiated (groin puncture) within ___ hours of symptom onset

Answer 132

Stroke

Intra-arterial rtPA

Improved outcome from use of cerebral intra-arterial rtPA has been documented. For patients with acute ischemic stroke who are not candidates for standard IV fibrinolysis, consider intra-arterial fibrinolysis in centers with the resources and expertise to provide it within the first 6 hours after onset of symptoms. Intra-arterial administration of rtPA is not yet approved by the FDA.

Mechanical Clot Disruption/Stent Retrievers

Mechanical clot disruption or retrieval with a stent has been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke.

Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria:

Prestroke mRS score of 0 to 1
Acute ischemic stroke receiving intravenous rtPA within 4.5 hours of onset according to guidelines from professional medical societies
Causative occlusion of the internal carotid artery or proximal MCA (M1)
Age 18 years or older
NIHSS score of 6 or greater
ASPECTS of 6 or greater
Treatment can be initiated (groin puncture) within 6 hours of symptom onset

Question 133

Stroke

Begin Stroke Pathway

Additional stroke care includes support of the airway, oxygenation, ventilation, and nutrition. Provide normal saline to maintain intravascular volume (eg, approximately ____ to ____ mL/h) if needed.

Monitor Blood Glucose

________________ is associated with worse clinical outcome in patients with acute ischemic stroke. Consider giving IV or subcutaneous insulin to lower blood glucose in patients with acute ischemic stroke when the serum glucose level is greater than ______ mg/dL.

Answer 133

Stroke

Begin Stroke Pathway

Additional stroke care includes support of the airway, oxygenation, ventilation, and nutrition. Provide normal saline to maintain intravascular volume (eg, approximately 75 to 100 mL/h) if needed.

Monitor Blood Glucose

Hyperglycemia is associated with worse clinical outcome in patients with acute ischemic stroke. Consider giving IV or subcutaneous insulin to lower blood glucose in patients with acute ischemic stroke when the serum glucose level is greater than 185 mg/dL.

Question 134

Stroke

Hypertension Management in rtPA Candidates

If a patient is eligible for fibrinolytic therapy, blood pressure must be ___ mm Hg or less systolic and __ mm Hg or less diastolic to limit the risk of bleeding complications. Because the maximum interval from onset of stroke until effective treatment of stroke with rtPA is limited, most patients with sustained hypertension above these levels will not be eligible for IV rtPA.

Potential Approaches to Arterial Hypertension in Acute Ischemic Stroke Patients Who Are Potential Candidates for Acute Reperfusion Therapy:

***Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mm Hg:

-Labetalol ___-___ mg IV over __-__ minutes, may repeat × ___ time, or

-Nicardipine IV ___ mg/h, titrate up by ____ mg/h every __-__ minutes, maximum ____ mg/h; when desired blood pressure is reached, adjust to maintain proper blood pressure limits, or

-Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate

***If blood pressure is not maintained at or below 185/110 mm Hg, do not administer rtPA. Management of blood pressure during and after rtPA or other acute reperfusion therapy:

-Monitor blood pressure every ____ minutes for ___ hours from the start of rtPA therapy, then every ___ minutes for __ hours, and then every hour for ___ hours.

***If systolic blood pressure 180-230 mm Hg or diastolic blood pressure 105-120 mm Hg:

-Labetalol ____ mg IV followed by continuous IV infusion __-____ mg/min, or

-Nicardipine IV ___ mg/h, titrate up to desired effect by ____ mg/h every ___-___ minutes, maximum ___ mg/h

-If blood pressure not controlled or diastolic blood pressure >140 mm Hg, consider ______ nitroprusside.

Many patients have spontaneous declines in blood pressure during the first 24 hours after onset of stroke.

Answer 134

Stroke

Hypertension Management in rtPA Candidates

If a patient is eligible for fibrinolytic therapy, blood pressure must be 185 mm Hg or less systolic and 110 mm Hg or less diastolic to limit the risk of bleeding complications. Because the maximum interval from onset of stroke until effective treatment of stroke with rtPA is limited, most patients with sustained hypertension above these levels will not be eligible for IV rtPA.

Potential Approaches to Arterial Hypertension in Acute Ischemic Stroke Patients Who Are Potential Candidates for Acute Reperfusion Therapy:

***Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mm Hg:

-Labetalol 10-20 mg IV over 1-2 minutes, may repeat × 1 time, or

-Nicardipine IV 5 mg/h, titrate up by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h; when desired blood pressure is reached, adjust to maintain proper blood pressure limits, or

-Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate

***If blood pressure is not maintained at or below 185/110 mm Hg, do not administer rtPA. Management of blood pressure during and after rtPA or other acute reperfusion therapy:

-Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours.

***If systolic blood pressure 180-230 mm Hg or diastolic blood pressure 105-120 mm Hg:

-Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg/min, or

-Nicardipine IV 5 mg/h, titrate up to desired effect by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h

-If blood pressure not controlled or diastolic blood pressure >140 mm Hg, consider sodium nitroprusside.

Many patients have spontaneous declines in blood pressure during the first 24 hours after onset of stroke.

Question 135

VF/pVT

Question 136

VF/pVT