Cardiac Emergencies I

Question 1

Per Dr. Hoffman, Thurston County Medical Director, generally-speaking, right-sided heart failure is fixed with ___, while left-sided failure is fixed with ___.

Answer 1

1. Volume;
2. Medicine;
   * -Dr. Hoffman, Thurston County Medical Director*

Question 2

Abnormal hardening of body tissues.

Answer 2

1. Sclerosis;

Question 3

An occassional condition caused by a fixed coronary stenosis that causes symptoms only when under stress.

Answer 3

1. Unstable Angina;

-EM Basic Podcast: MI and ACS

Question 4

What mnemonic can be used to recall the principle differentiating signs of Unstable Angina?

Answer 4

RND UA

Random Urinalysis

R - Rest

N - New

D - Different

UA - Unstable Angina

Note: If the patient’s chest pain occurs at rest, is occurring for the first time, or the intensity, character, or exertion level required to produce the chest pain are different than angina they have experienced in the past (and there is no evidence of a STEMI), the diagnosis is of unstable angina.

-EM Basic Podcast: MI and ACS​

Question 5

Which type of ACS does not feature a stenosis large enough to create a cardiac enzyme leak? Which do(es)?

Answer 5

1. Unstable angina;
2. NSTEMI and STEMI;
   * -EM Basic Podcast: MI and ACS*

Question 6

A Type ___ NSTEMI is an ACS in which the patient experiences chest pain and cardiac enzyme elevation without the presence of a non-cadiac stressor.

Answer 6

1. 1;

-EM Basic Podcast: MI and ACS​

Question 7

A Type ___ NSTEMI is an ACS in which the patient experiences chest pain and cardiac enzyme elevation in the setting of a non-cadiac stressor (such as sepsis, trauma, surgical abdomen, etc.), usually due to prolonged ___.

Answer 7

1. 2;
2. Tachycardia;
   * -EM Basic Podcast: MI and ACS​​*

Question 8

What mnemonic can be used to recall where to look on an ECG for reciprocal ST-segment changes?

Answer 8

PAILS

P - Posterior

A - Anterior

I - Inferior

L - Lateral

S - Septal

Note: ST elevations in these leads most commonly create reciprocal ST depressions in the corresponding leads of the next letter in the mnemonic. That is to say, posterior ST elevation will usually cause anterior lead ST depressions and anterior lead ST elevations will usually be seen with inferior lead depressions.

-EM Basic Podcast: MI and ACS​​

Question 9

What mnemonic is useful in recalling STEMI mimics?

Answer 9

ELEVATION

E - Electrolytes (Hyperkalemia)

L - Left Bundle Branch Block

E - Early Repolarization

V - Ventricular Hypertrophy (Left)

A - Aneurysm (Ventricular, Aortic Dissection, AAA)

T - Thailand (Brugada Syndrome)

I - Inflammation (Pericarditis) / Intracranial Hemorrhage

O - Osborne (J) Waves

N - Non-Ischemic Vasospasm

-wikem.org

Question 10

Cardioversions, which are primarily intended to terminate ___ arrhythmias, may benefit from different electrode placement than for defibrillations, which are primarily intended to terminate arrhythmias originating in the ___.

Answer 10

1. Atrial;
2. Ventricles;
   * -Physio-Control LIFEPAK 15 User Manual*

Question 11

Patients with atrial fibrillation are prone to blood clot formation in their ___. _(therapy)_ may knock loose one of these blood clots, causing a ___.

Answer 11

1. Left atrium;
2. Cardioversion;
3. Stroke;
   * -Physio-Control LIFEPAK 15 User Manual*

Question 12

Cardioversion electrodes can be placed either Anterior– Posterior (AP) or Anterior-Anterior (AA; aka Anterior Lateral [AL]), though ___ placement is preferable for maximum current flow through the ___.

Answer 12

1. AP;
2. Atria;
   * -Physio-Control LIFEPAK 15 User Manual*

Question 13

For what therapies is Anterior-Lateral defibrillation pad placement approved for?

Answer 13

1. Defibrillation;
2. Synchronized cardioversion;
3. Transcutaneous pacing;
   * -Physio-Control LIFEPAK 15 User Manual*

Question 14

To monitor an ECG using the LIFEPAK 15 therapy electrodes, how must they be arranged?

Answer 14

1. Anterior-Lateral (AL);

-Physio-Control LIFEPAK 15 User Manual

Question 15

Describe how to perform anterior-lateral placement of LIFEPAK 15 therapy electrodes.

Answer 15

1. Place the positive therapy electrode lateral to the patient’s left nipple in the midaxillary line, with the center of the electrode in the midaxillary line, if possible. Then place the other therapy electrode on the patient’s upper right torso, lateral to the sternum and below the clavicle.

-Physio-Control LIFEPAK 15 User Manual

Question 16

Describe the anterior-posterior placement of LIFEPAK 15 therapy electrodes.

Answer 16

1. Place the positive therapy electrode over the left precordium. The upper edge of the electrode should be below the nipple. Avoid placement over the nipple, the diaphragm, or the bony prominence of the sternum, if possible. Then place the other electrode behind the heart in the infrascapular area. For patient comfort, place the cable connection away from the spine. Do not place the electrode over the bony prominence of the spine or scapula.

-Physio-Control LIFEPAK 15 User Manual

Question 17

Anterior-posterior placement of LIFEPAK 15 therapy electrodes is an alternative position for noninvasive pacing, manual defibrillation, and synchronized cardioversion, but not for ___ monitoring.

Answer 17

1. ECG (it does not represent a standard lead);

-Physio-Control LIFEPAK 15 User Manual

Question 18

Describe an alternative to anterior-lateral and anterior-posterior therapy electrode placement when performing synchronized cardioversion of atrial fibrillation.

Answer 18

1. Either place the positive therapy electrode over the left precordium and the other electrode on the patient’s right posterior infrascapular area, or place the positive therapy electrode to the right of the sternum and the other electrode on the patient’s posterior left infrascapular area.

-Physio-Control LIFEPAK 15 User Manual

Question 19

Synchronized cardioversion uses a sensor to deliver a shock synchronized with the peak of the ___ complex, - the highest point of the ___ wave.

Answer 19

1. QRS;
2. R;
   * -Physio-Control LIFEPAK 15 User Manual*

Question 20

If a tachycardic, stable patient presents with a monomorphic wide-complex rhythm, the AHA recommends ___, because treatment has the potential for ___.015

Answer 20

1. Expert consultation;
2. Harm;
   * -2015 AHA ECC Handbook*

Question 21

Adenosine is said to terminate approximately ___% of reentry tachyarrhythmias within ___ minutes.

Answer 21

1. 90;
2. Two;
   * -2015 AHA ECC Handbook*

Question 22

If a tachycardic rhythm converts with adenosine, it was most likely ___.

Answer 22

1. Reentry SVT;

-2015 AHA ECC Handbook

Question 23

If a tachycardic rhythm that had been successfully treated with adenosine returns, consider using adenosine again, or consider treating with longer-lasting ___ or ___.

Answer 23

1. Beta-Blockers;
2. Calcium Channel Blockers (nondihydropyridine);
   * -2015 AHA ECC Handbook*

Question 24

Adenosine should not be given for unstable or for irregular or polymorphic wide-complex tachycardias, because it may cause degeneration of the arrhythmia to ___.

Answer 24

1. VF;

-2015 AHA ECC Handbook

Question 25

Management of chronic, stable atrial fibrillation may involve control of heart rate; however, cardioversion and drugs that may convert the rhythm to sinus rhythm are contraindicated if the patient is not ___ because of the risk of ___ complications.

Answer 25

1. Anticoagulated; 2. Embolic; * -2015 AHA ECC Handbook*

Question 26

The AHA recommends starting an ACS patient on oxygen if their SPO2 level is below \_\_\_%.

Answer 26

1. 90; ## Footnote *-2015 AHA ECC Handbook*

Question 27

Right ventricular MIs often present on a 12-Lead as ___ wall STEMIs.

Answer 27

1. Inferior; Note: Confirm with a right-sided 12-Lead ECG. *-2015 AHA ECC Handbook*

Question 28

What does PCI stand for, with regards to a cath lab?

Answer 28

1. Percutaneous Coronary Intervention; ## Footnote *-2015 AHA ECC Handbook*

Question 29

First-line therapy for unstable, wide-complex tachycardia is immediate \_\_\_.

Answer 29

1. Synchronized cardioversion; ## Footnote *-2015 AHA ECC Handbook*

Question 30

The AHA advises not to delay cardioversion to get a 12-lead ECG if the patient is \_\_\_.

Answer 30

1. Unstable; ## Footnote *-2015 AHA ECC Handbook*

Question 31

You should ___ immediately after delivering a shock, and continue for two minutes before doing a rhythm check.

Answer 31

1. Resume CPR; ## Footnote *-2015 AHA ECC Handbook*

Question 32

\_(medication)\_ stimulates spontaneous contractions when asystole is present.

Answer 32

1. Epinephrine; ## Footnote *-2015 AHA ECC Handbook*

Question 33

\_\_\_ to the face is a vagal maneuver that is safe to perform in infants and children of all ages. Children old enough to cooperate can perform a ___ maneuver by ___ through a narrow straw.

Answer 33

1. Ice (or cold application); 2. Valsalva; 3. Blowing; * -2015 AHA ECC Handbook*

Question 34

\_\_\_ is the most common cause of ___ in pediatric patients.

Answer 34

1. Hypoxemia; 2 Cardiac arrest; *-2015 AHA ECC Handbook*

Question 35

Complicatons of ACS include shock, pulmonary edema, and hypotension, with ___ being the leading cause of death in patients with acute myocardial infarction (AMI).

Answer 35

1. Cardiogenic shock; ## Footnote -*ACLS for Experienced Providers, 2013 Ed.*

Question 36

The text *ACLS for Experienced Providers* recommends using ECG interpretation to place chest discomfort patients into one of three possible acute ischemic symptom categories: \_\_\_.

Answer 36

1. STEMI (ST elevation in two or more contiguous leads or new/presumably new LBBB); 2. UA/NSTEMI (ST depression or dynamic T-wave inversion); 3. Low-/Intermediate-Risk ACS (normal or nondiagnostic changes in ST segment or T wave); * -ACLS for Experienced Providers, 2013 Ed.*

Question 37

What does IABP stand for with respect to ACS interventions?

Answer 37

1. Intra-aortic balloon pump; ## Footnote *-ACLS for Experienced Providers, 2013 Ed.*

Question 38

What does MACE stand for, with respect to ACS?

Answer 38

1. Major adverse cardiac event; ## Footnote *-ACLS for Experienced Providers, 2013 Ed.*

Question 39

Atherosclerosis is the formation and accumulation of ___ and ___ byproducts in an arterial wall.

Answer 39

1. Lipid; 2. Oxidative; * -ACLS for Experienced Providers, 2013 Ed.*

Question 40

ST elevation begins approximately \_\_\_-\_\_\_ hours after cardiac markers are detectable.

Answer 40

1. 4-6; ## Footnote *-ACLS for Experienced Providers, 2013 Ed.*

Question 41

\_\_\_ are ECG findings in ACS which are consistent with a scar.

Answer 41

1. Q waves; ## Footnote *-ACLS for Experienced Providers, 2013 Ed.*

Question 42

What should be used as the "baseline" when measuring ST-segment elevation?

Answer 42

1. The TP segment; Note: The TP segment is considered to be a more accurate baseline for evaluation of ST deviation that the PR segment. *-ACLS for Experienced Providers, 2013 Ed.*

Question 43

If the ___ cannot be identifies because of a rapid heart rate or artifact, use the ___ as the baseline reference point for evaluating ST-segment elevation.

Answer 43

1. TP segment; 2. PR junction; Note: The PR junction is the intersection of the PR segment with the QRS complex. *-ACLS for Experienced Providers, 2013 Ed.*

Question 44

From what point should ST-segment elevation be measured according to *ACLS for Experienced Providers*?

Answer 44

1. 1 mm after the J point; ## Footnote *-ACLS for Experienced Providers, 2013 Ed.*

Question 45

Coronary arteries are usually closed approximately \_\_\_% by angiography (\_\_\_% closed when viewed by a pathologist) before they cause symptoms and ar econsidered for stending or surgery.

Answer 45

1. 70%; 2. 90%; * -ACLS for Experienced Providers, 2013 Ed.*

Question 46

\_(procedure)\_ can cause strking ST-segment elevation, often \> 10 mm, but lasting only a minute or two immediately after intervention.

Answer 46

1. Synchronized cardioversion; ## Footnote *-ACLS for Experienced Providers, 2013 Ed.*

Question 47

The majority of myocardial infarction occurs by ___ hours after the onset of symptoms. After ___ hours the infarct is nearly complete.

Answer 47

1. 4; 2. 6; * -ACLS for Experienced Providers, 2013 Ed.*

Question 48

Guidelines recommend that healthcare providers instruct patients and family to activate EMS if chest discomfort symptoms persist or worsen ___ minutes after their \_(number)\_ nitroglycerin dose. These patients may have STEMI or prolonged ischemia and ar at risk for sudden cardiac death.

Answer 48

1. 5; 1. First; * -ACLS for Experienced Providers, 2013 Ed.*

Question 49

Relief of \_(symptom)\_ is an important early goal for patients with STEMI or another ACS. Surges of \_(substance)\_ have been implicated in plaque fissuring, thrombus propagation and reduction in VF threshold.

Answer 49

1. Discomfort; ## Footnote *-ACLS for Experienced Providers, 2013 Ed.*

Question 50

Congestive heart failure occurs when the heart is unable, for any reason, to pump ___ enough or ___ enough to empty its chambers; as a result, blood backs up into the ___ circuit, the ___ circuit, or both.

Answer 50

1. Powerfully; 2. Fast; 3. Systemic; 4. Pulmonary; * -Emergency Care in the Streets, 7th Ed.*

Question 51

Although CHF may develop in situations other than AMI, for example, in a patient with chronic \_\_\_, the basic principles of diagnosis and treatment are similar, whatever the precipitating factors.

Answer 51

1. Hypertension; ## Footnote *-Emergency Care in the Streets, 7th Ed.*

Question 52

The ___ ventricle is most commonly damaged duringan AMI.

Answer 52

1. Left; ## Footnote *-Emergency Care in the Streets, 7th Ed.*

Question 53

In chronic hypertension, the ___ ventricle tends to suffer the long-term effects of having to pump against an increased afterload (constricted peripheral arteries).

Answer 53

1. Left; ## Footnote *-Emergency Care in the Streets, 7th Ed.*

Question 54

As a result of left-sided heart failure, blood backs up behind the left ventricle, and the pressure in the left ___ and ___ veins increases. As the \_(same)\_ veins become engorged with blood, ___ is forced out of the pulmonary ___ and into the alveoli. The \_(same as #3)\_ mixes with air in the alveoli to produce ___ (pulmonary edema). This is left-sided heart failure.

Answer 54

1. Atrium; 2. Pulmonary; 3. Serum; 4. Capillaries; 5. Foam; * -Emergency Care in the Streets, 7th Ed.*

Question 55

During left-sided heart failure, in addition to fluid being forced into the alveoli, fluid also leaks into the ___ spaces in the lungs, and increasing \_(same)\_ pressure causes narrowing of the \_\_\_. Air passing through the narrowed \_(same)\_ creates ___ noises, wheareas air bubbling through fluid-filled alveoli produces \_\_\_.

Answer 55

1. Intersitial; 2. Bronchioles; 3. Wheezing; 4. Crackles; * -Emergency Care in the Streets, 7th Ed.*

Question 56

The ___ response to the feeling of hypoxemia-induced panic during left-sided heart failure produces peripheral vaso\_\_\_: Peripheral resistance (afterload) \_\_\_, and the weakened, hypoxic heart now has to push blood out into smaller and smaller vessels. Clinically, peripheral vasoconstriction is apparent as \_\_\_, ___ and ___ skin as well as ___ blood pressure;

Answer 56

1. Sympathetic nervous system; 2. Pale; 3. Cold; 4. Diaphoretic; 5. Elevated; * -Emergency Care in the Streets, 7th Ed.*

Question 57

Prehospital treatment of left-sided heart failure is aimed at improving oxygenation and ___ the workload of the heart, chiefly by reducing the ___ so that the ___ ventricle is less overburdened.

Answer 57

1. Decreasing; 2. Preload (volume of venous blood retun to the heart); 3. Left; * -Emergency Care in the Streets, 7th Ed.*

Question 58

In what position is it recommended to place a patient suffering from left-sided heart failure? How does this position positively affect the burden on the heart?

Answer 58

1. Sit the patient up, with the feet and/or legs dangling. 2. This position encourages venous pooling in the legs, thereby reducing venous return to the heart and hence reducing its workload. Note: The sitting position also makes breathing easier for a patient in respiratory distress. *-Emergency Care in the Streets, 7th Ed.*

Question 59

How can nitroglycerin positively affect a patient suffering from left-sided heart failure?

Answer 59

1. Nitroglycerin acts as a vasodilator to create venous pooling, reducing the volume of blood returned from the periphery to the heart, and hence its workload. ## Footnote *-Emergency Care in the Streets, 7th Ed.*

Question 60

Right-sided heart failure most commonly occurs as a result of \_\_\_. Name one (of two listed) additional precipitating condition.

Answer 60

1. Left-sided heart failure; 2. PE; 3. COPD; * -Emergency Care in the Streets, 7th Ed.*

Question 61

Edema resulting from right-sided heart failure is most likely to be visible in ___ parts of the body, such as the ___ in a person who is sitting or standing or the ___ in a bedridden patient.

Answer 61

1. (Gravity) Dependent; 2. Feet (pedal edema); 3. Lower back (presacral edema); * -Emergency Care in the Streets, 7th Ed.*

Question 62

\_\_\_ is a medical term used to describe the accumulation of fluid in the abdominal cavity.

Answer 62

1. Ascites; ## Footnote *-Emergency Care in the Streets, 7th Ed.*

Question 63

\_\_\_\_% of patients with an inferior wall myocardial infarction will also have a right ventricular infarction.

Answer 63

1. 30; ## Footnote *FireRescue1 Academy - Myocardial Infarction*

Question 64

It is said that only \_\_\_% of patients experiencing a myocardial infarction will exhibit diagnostic changes on their prehospital ECG.

Answer 64

1. 50; ## Footnote *FireRescue1 Academy - Myocardial Infarction*

Question 65

Myocardial infarction (MI) is typically the result of a blockage in one of the ___ arteries due to an ___ plaque.

Answer 65

1. Coronary; 2. Atherosclerotic; * FireRescue1 Academy - Myocardial Infarction*

Question 66

Name three (of six listed) varieties of fibrinolytic drugs used for dissolving coronary artery blood clots.

Answer 66

1. tPA; 2. rtPA; 3. Streptokinase; 4. Activase (Alteplase); 5. TNKase; 6. Retavase (Reteplase); * FireRescue1 Academy - Myocardial Infarction* * https://en.wikipedia.org/wiki/Thrombolysis*

Question 67

Name four (of seven listed) common "blood thinners" (anticogulants).

Answer 67

1. Warfarin (Coumadin); 2. Heparin; 3. Dabigatran; 4. Rivaroxaban; 5. Apixaban; 6. Edoxaban; 7. Betrixaban; * https://en.wikipedia.org/wiki/Anticoagulant*

Question 68

The abnormal narrowing of a passage in the body.

Answer 68

1. Stenosis; ## Footnote *Google Search, Oxford Dictionary*

Question 69

According to Poiseuille's Law, resistance to laminar fluid flow in a tube increases by a factor of ___ when the diameter of the tube is decreased by half.

Answer 69

1. 16; Note: Poiseuille's Law states that resistance to laminar fluid flow in a tube = (8 x Length x Viscosity) / (π x r⁴) *Kahn Academy: Resistance in a Tube*

Question 70

What is the formular for systemic vascular resistance (SVR)?

Answer 70

1. SVR = ([MAP - CVP] / CO) x 80; Note: Normal SVR is 700 - 1,500 dynes / seconds / cm^-5 *https://www.nursingcenter.com/ncblog/may-2017/systemic-vascular-resistance-and-pulmonary-vascula*