Cardiovascular emergencies

Question 1

Why must over-oxygenation be avoided during MIs?

Answer 1

High levels of oxygen can cause:
Vasoconstriction
Oxygen free radicals

Question 2

Which MIs can benefit from fluid therapy, why?

Answer 2

MIs with right ventricular involvement - fluids can increase pre-load and help the contractility

Question 3

Should you wait for an ECG to give asprin?

Answer 3

No - can be given on clinical suspicion

Question 4

What QRS width during VT would be considered narrow?

Answer 4

QRS<120ms (same as any other rythym)

Question 5

How should you treat pulsed broad complex tachycardia, what could it be?

Answer 5

If regular, treat as VT until proven otherwise

Could be SVT with bundle branch block

Question 6

What could irregular wide complex tachycardia be?

Answer 6

AF with bundle branch block
Pre-excited AF
Polymorphic VT (e.g. torsades)

Question 7

What is the general management of out of hospital pulsed VT?

Answer 7

-ABCDE approach
-Identify wide/narrow, irreulgar/regular
-Prepare for it to degenerate into pulseless VT or VF.
-Appropriate transport (PPCI/ arrhythmia centre/ local trust protocols)

-Consider RVP with advanced practitioner/ HEMS for synchronised cardioversion/ administration of amiodarone.

-Synchronising avoids the delivery of a shock during repolarisation which can induce VF (this is not within the standard scope of practice for paramedics).

Question 8

For what arrythmias are vagal manouevres indicated?

Answer 8

Regular narrow complex pulsed tachycardias

Question 9

What are irregular narrow complex pulsed tachycardias likely to be?

Answer 9

Atrial fibrilation

Question 10

What is the difference between AVRT and AVNRT?

Answer 10

Atrioventricular reentrant tachycardia (AVRT) is a rhythm problem that results from an extra connection between the atria and ventricles

Atrioventricular nodal reentrant tachycardia (AVNRT) is a type of paroxysmal supraventricular tachycardia that results due to the presence of a reentry circuit within or adjacent to the AV node. Usually caused by a miss-timed ectoptic.

Question 11

How does adenosine work?

Answer 11

Causes a block within the AV node
Inhibits adenylyl cyclase, reduces cAMP and therefore, causing hyperpolarisation by increasing Potassium efflux.

Question 12

What are some examples of bradyarrythmia causes?

Answer 12

3rd degree/ complete heart block (or high grade AVB)
AF with slow ventricular response
Ventricular escape rhythm
Sinus bradycardia/
SSS

Question 13

What is the algorithm for bradycardia management?

Answer 13

Question 14

What adverse features are you looking for with bradycardias?

Answer 14

Shock
-Organ/cerebral hypoperfusion
Syncope
Myocardial ischaemia
Heart failure

Question 15

How can MIs cause bradyarrythmias?

Answer 15

Inferior MIs specifically can cause reduced blood flow to the AV node and therefore bradycardias

Question 16

What is acute cardiogenic pulmonary oedema?

Answer 16

The cardiogenic form of pulmonary edema (pressure-induced) produces a non-inflammatory type of edema by the disturbance in Starling forces.

Question 17

What can cause acute cardiogenic pulmonary oedema?

Answer 17

Cardiomyopathy/Heart failure
Heart valve problems.
Hypertension.
Inflammation of the heart muscle (myocarditis)
Congenital heart defects
Arrhythmias

Question 18

How can heart valve problems cause acute cardiogenic pulmonary oedema?

Answer 18

Narrowing (stenosis) of the aortic or mitral heart valves or a valve that leaks or doesn’t close properly affects blood flow into the heart. A valve leak that develops suddenly might cause sudden and severe pulmonary edema.

Question 19

How can hypertension cause acute cardiogenic pulmonary oedema?

Answer 19

Untreated or uncontrolled high blood pressure can enlarge the heart, causing cardiomyopathy, reduced cardiac output and a build up of pulmonary vein pressure and therfore pulmonary oedema

Question 20

What is the paramedic management of acute cardiogenic pulmonary oedema?

Answer 20

Oxygen therapy
Nitrates (lower preload, lower vasoconstriction/ cause vasodilatation, reduce hydrostatic arterial pressure.)
Loop diuretics (Furosemide)
CPAP

Question 21

What are some adverse affects of furosemide?

Answer 21

Hyponatraemia
Hypokalaemia
Hypovolaemia
Hypotension
Dehydration

Question 22

Why would you want to turn off an ICD?

Answer 22

If it is mis-firing/firing inappropriately i.e. without sign of arrythmias on cardiac monitoring often 3x within 20 minutes.

Question 23

How do you turn off an ICD?

Answer 23

By placing a ring magnet over the top of the ICD – you will hear an alarm to let you know it is disabled. To re-enable simply remove the magnet.

Question 24

What are the STEMI ECG diagnosis criteria?

Answer 24

At least two contiguous leads with ST-segment elevation
≥ 2.5 mm in men < 40 years (V2 & V3),
≥2 mm in men ≥ 40 years (V2 & V3),
≥ 1.5 mm in women (V2 & V3)

or
≥ 1 mm in all other leads
(except V4/7/8/9 0.5mm)

Question 25

What adverse features are you looking for in pulsed tachycardic patients?

Answer 25

Shock
Syncope
Myocardial ischaemia
Heart failure