Chest pain and EKG

Question 1

EKG should be completed within __ minutes

EKG should be read by physician within __ minutes

Answer 1

6

10

Question 2

Door to biomarker less than __ minutes or TAT (Troponin turnaround time)
Door to device less than __ minutes
Serial Troponin strategy will be __, __, and __ hours.

Answer 2

60
70
0, 3, 6

Question 3

The hallmark of the Third Universal Definition of MI is the detection of a rise and fall of cardiac biomarker values, with at least one of the values being elevated. In addition to the highly sensitive and specific cardiac biomarker of necrosis, Troponin, at least one of the following five diagnostic criteria should be met. What are they?

Answer 3

Symptoms of ischemia
New significant ST/T wave changes or left BBB
Development of pathological Q waves on ECG
Imaging evidence of new loss of viable myocardium or regional wall motion abnormality
Identification of intracoronary thrombus by angiography or autopsy

Question 4

If a patient cannot tolerate a treadmill stress test then a pharmacological test using ______, _______ or ______ infusion can be used.

Answer 4

Adenosine
dobutamine
persantine

Question 5

Telemetry is “______” quality; determine the rate and rhythm only
- 12 lead ECG is “_______” quality; determination of disease, infarction, infection

Answer 5

monitor

diagnostic

Question 6

ST segment elevation or depression are significant if greater than __mm (__ small block)

Answer 6

1

one

Question 7

The goal is to have any patient who meets EKG guidelines to have a door to EKG time of less than __ minutes

Answer 7

5

Question 8

Each individual EKG must have its own order, even if they are for the same patient
true or false

Answer 8

True

Question 9

Anything outside the guidelines requires an order from the physician before completing the EKG, what are the guidelines (symptoms)? (7)

Answer 9

Pt with CP ESI level less than 3 
Rapid heart rate >100 
Slow heart rate; bradycardia 
Syncope (LOC not dizziness) 
Palpitations 
Drug overdoses 
SOB

Question 10

Inferior Wall MI
The inferior wall is supplied by the ____ ____ ____ or ___.
ST elevations can be seen in leads __, __, and ___
Also be aware of possible right ventricular infarct, can be determined with a right sided 12- lead

Answer 10

right coronary artery
RCA
II, III, and aVF

Question 11

The anterior wall MI (slide saved)
The anterior wall is supplied by the ____ ____ ____ or ___
This is known as the ____ ____

Answer 11

left coronary artery
LCA
widow maker

Question 12

Septal Wall MI
Supplied by the left ____ ____ ____ or ___
Look for the lack of an _ wave in __

Answer 12

anterior descending artery
LAD
R wave in V2

Question 13

Lateral wall MI
The lateral wall is supplied mostly by the ____ ____ ____ or ___
__% of the population has their inferior wall supplied by the ___

Answer 13

left circumflex artery
LCX
10
LCX

Question 14

Posterior wall MI
The lateral wall is supplied by either the ___ or the ___
ST depression will be seen in leads V_, V_, V_, and V_
Reposition leads and obtain a posterior 12 lead containing leads V7, V8, and V9 for the ST elevations

Answer 14

LCA or the RCA

V1, V2, V3, and V4

Question 15

Right sided infarction / Right sided EKG

A mirror image right sided ECG may be helpful in detecting STE associated with what?

Answer 15

right ventricular infarction.

Question 16

Right sided EKG can be done using only the right side V_ lead in the right mid axillary line

Answer 16

4

Question 17

Remember when doing a right sided EKG to label it a what?

Answer 17

right sided EKG

Duuuuh!

Question 18

Posterior EKG
Posterior leads are used to evaluate for posterior wall MI. In a traditional EKG, posterior MI is demonstrated in leads V_-V_
Posterior leads V_, V_, V_ are placed below the left ____

Answer 18

V1-V4
7, 8, 9
scapula

Question 19

Sinus arrest; arrest with slow heart rates is the same as ____ ____ ____
Management of prolonged sinus arrest where junctional or ventricular escape does not take over (ventricular asystole occurs) requires immediate attention
what are 9 possible causes?

Answer 19

symptomatic sinus bradycardia
Etiology; hypoxia, hyperkalemia, excessive digitalis or propranolol, quinidine toxicity, damage to SA node from AMI, acute myocarditis, degenerative fibrosis

Question 20

Some clinical signs of atrial fibrillation are (5)

Answer 20

SOB and pulmonary edema, drop in cardiac output and decreased cardiac output, irregular rhythm may be perceived as palpitations

Question 21

Etiology of atrial fibrillation include what? (7)

Answer 21

acute coronary syndromes, CAD, CHF, disease at mitral or tricuspid valve, hypoxia, acute pulmonary embolism

Question 22

1st Degree AV Block; Clinical signs; usually ___

Etiologies; (3)

Answer 22

asymptomatic
; AV nodal blockers
Condition that stimulates the parasympathetic nervous system
AMI that affects circulation to the AV node (right coronary artery), most often inferior AMI

Question 23

Which cardiac condition is nicknamed Wenckebach?

Answer 23

2nd Degree AV Block (Mobitz Type 1, Wenckebach)

Question 24

2nd Degree AV Block (Mobitz Type 1, Wenckebach)

what are the signs (symptoms on another card)

Answer 24

Signs; hypotension, shock, pulmonary congestion, CHF, angina

Question 25

2nd Degree AV Block (Mobitz Type 1, Wenckebach) | what are the symptoms (signs on another card)

Answer 25

chest pain, SOB, decreased level of consciousness

Question 26

2nd Degree AV Block (Mobitz Type 1, Wenckebach) | etiologies

Answer 26

AV nodal blocking agents; B-blockers, non-dihydropyridine calcium channel blockers, digoxin Conditions that stimulate the parasympathetic nervous system Acute coronary syndrome that involves right coronary artery

Question 27

2nd Degree AV Block (Mobitz Type II) | Clinical signs; (due to bradycardia)

Answer 27

Signs; hypotension, shock, pulmonary congestion, CHF, AMI

Question 28

2nd Degree AV Block (Mobitz Type II) | Clinical symptoms; (due to bradycardia)

Answer 28

Symptoms; chest pain, SOB, decreased level of consciousness

Question 29

2nd Degree AV Block (Mobitz Type II) | Etiologies

Answer 29

Acute coronary syndrome that involves branches of left coronary artery 3rd degree heart block- involved left anterior descending (LAD) artery and branches to interventricular septum which supplies the bundle branches

Question 30

3rd Degree AV Block (complete AV Block) clinical symptoms (due to bradycardia)

Answer 30

Symptoms; chest pain, SOB, decreased level of consciousness

Question 31

3rd Degree AV Block (complete AV Block) clinical signs (due to bradycardia)

Answer 31

Signs; hypotension, shock, pulmonary congestion, CHF, AMI

Question 32

3rd Degree AV Block (complete AV Block) etiologies

Answer 32

Acute coronary syndrome that involves branches of the left coronary artery Involved left anterior descending (LAD) artery and branches to interventricular septum which supplies the bundle branches

Question 33

What are some of the causes of Supraventricular Tachycardia

Answer 33

``` Normal exercise Hypoxemia Fever Hypovolemia Adrenergic stimulation, anxiety Hyperthyroidism Anemia Pain ```

Question 34

What are the clinical signs of Ventricular Tachycardia (Monomorphic)

Answer 34

Typical signs of decreased cardiac output (orthostasis, hypotension, syncope, exercise limitations, ect) do develop; can be asymptomatic; untreated and unsustained VT will deteriorate to unstable VT, often VF

Question 35

What are some of the signs of Ventricular Tachycardia (Monomorphic)

Answer 35

Ventricular irritability R on T phenomenon Drug induced prolonged QT interval Low ejection fraction due to chronic systolic heart failure

Question 36

What is R-on-T phenomenon

Answer 36

It is a ventricular extrasystole caused by a ventricular depolarization superimposing on the previous beat's repolarization. Although rare, this can result in ventricular arrhythmias, which can lead to cardiac arrest

Question 37

What is another name for Ventricular Tachycardia (Polymorphic)

Answer 37

“Torsade de Pointes”

Question 38

Ventricular Tachycardia (Polymorphic) “Torsade de Pointes”, what are the Clinical Signs

Answer 38

Typically will rapidly deteriorate to pulseless VT or VF | Symptoms of decreased cardiac output (orthostasis, hypotension, syncope) before pulseless arrest; seldom sustained VT

Question 39

What are the etiologies of Ventricular Tachycardia (Polymorphic) “Torsade de Pointes”

Answer 39

Ventricular irritability R on T phenomenon Hereditary long QT interval syndromes Prolonged QT interval due to tricyclic antidepressants, procainamide, sotalol, amiodarone, ibutilide, some antipsychotics, digoxin, some long-acting antihistamines Electrolytes and metabolic alterations (hypomagnesemia)

Question 40

What are the clinical signs of Ventricular Fibrillation / Pulseless V Tach?

Answer 40

Collapse; unresponsive; no pulse; agonal gasps or apnea; sudden death

Question 41

What are the etiologies of Ventricular Fibrillation / Pulseless V Tach?

Answer 41

``` Acute coronary syndromes Unstable VT untreated R-on-T phenomenon Drug, electrolyte, acid-base abnormalities QT prolongation Electrocution Hypoxia Amiodarone or Lidocaine Identification and treatment of the underlying causes (H’s and T’S) ```

Question 42

What are the clinical signs of Pulseless Electrical Activity (PEA)

Answer 42

Collapse, unresponsiveness, agonal gasps or apnea, no pulse detectable by palpation, the rhythm seen with PEA may assist in identifying PEA etiology

Question 43

What are the etiologies of Pulseless Electrical Activity (PEA)

Answer 43

``` Use the H’s and T’s mnemonic to recall possible causes of PEA H’s Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypothermia T’s Toxins (drug overdose, ingestion) Tamponade (cardiac) Tension pneumothorax Thrombosis, coronary ACS Thrombosis, pulmonary embolism ```

Question 44

As per the CPC chest pain center guidelines, what is the third universal definition of myocardial infarction?

Answer 44

Detection of a rise and/or fall of cardiac biomarker values, with at least one of the values being elevated.

Question 45

The Third universal definition of myocardial infarction Detection is a rise and/or fall of cardiac biomarker values, with at least one of the values being elevated. In addition, at least one of the five following criteria should be met. What are they?

Answer 45

Symptoms of ischemia New or presumably new significant ST/T wave changes, or LBBB Development of pathological Q waves on ECG Imaging evidence of new loss of viable regional wall abnormality Identification of intracoronary thrombus by angiography or autopsy

Question 46

Acute coronary syndrome is applied to patients in whom there is a suspicion or confirmation of acute MI ischemia or infarction. Three types of ACS are

Answer 46

NSTEMI 40% Unstable angina 40% STEMI 20%

Question 47

What are the times for arrival EKG? read by provider? Troponin turnaround time or first result? Troponin intervals? What should be done with each subsequent troponin?

Answer 47

arrival EKG? 6 minutes read by provider? 10 minutes Troponin turnaround time or first result? 60 minutes Troponin intervals? 3 and 6 hours What should be done with each subsequent troponin?