Emergency medicine 3rd year 2nd semester Flashcards
Why is emergency preparedness essential in healthcare settings?
A) It ensures that the healthcare provider can avoid legal issues.
B) It helps to mitigate the risk of medical errors.
C) It leads to decreased patient safety and satisfaction.
D) It reduces the risk of morbidity and mortality in emergencies
✅ Correct Answer: D) It reduces the risk of morbidity and mortality in emergencies.
Explanation:
Emergency preparedness is crucial because it ensures that medical professionals are ready to act swiftly and effectively in an emergency, minimizing morbidity and mortality.
❌ A) It ensures that the healthcare provider can avoid legal issues – While preparedness can help mitigate legal risk, the primary goal is improving patient outcomes in emergencies.
❌ B) It helps to mitigate the risk of medical errors – Emergency preparedness reduces errors, but its primary function is ensuring quick and correct response during emergencies.
❌ C) It leads to decreased patient safety and satisfaction – This is incorrect. Proper emergency preparedness actually increases patient safety and satisfaction.
REGULATORY REQUIREMENTS IN ONTARIO
* The College of Naturopaths of Ontario (CONO) mandates:
◦ A written emergency response plan
◦ Access to emergency medications and equipment
◦ Basic Life Support (BLS) certification for all practitioners
* The Canadian College of Naturopathic Medicine (CCNM) requires:
◦ Detailed protocols for emergency response
◦ Evacuation and safety procedures
What is required by the College of Naturopaths of Ontario (CONO) for emergency preparedness in naturopathic clinics?
A) An evacuation and safety protocol only.
B) A written emergency response plan, access to emergency medications, and Basic Life Support (BLS) certification for all practitioners.
C) Only a list of medications required for emergencies.
D) Certification in Pediatric Advanced Life Support (PALS).
✅ Correct Answer: B) A written emergency response plan, access to emergency medications, and Basic Life Support (BLS) certification for all practitioners.
Explanation:
CONO requires written emergency response plans, access to emergency medications and equipment, and Basic Life Support (BLS) certification for all practitioners.
❌ A) An evacuation and safety protocol only – Although important, this alone is not the full requirement from CONO.
❌ C) Only a list of medications required for emergencies – Medications are a part of the plan but do not cover the entire regulatory requirement.
❌ D) Certification in Pediatric Advanced Life Support (PALS) – While advanced training may be recommended, it is not mandatory for all practitioners.
Which of the following is NOT typically required on the emergency equipment checklist for a naturopathic clinic?
A) Oxygen tank and mask
B) Pulse oximeter
C) Glucose meter
D) Stethoscope for diagnostic use only
✅ Correct Answer: D) Stethoscope for diagnostic use only
Explanation:
Stethoscopes are typically used for diagnostic purposes, but are not required as emergency equipment in the same way items like an oxygen tank, pulse oximeter, and glucose meter are.
❌ A) Oxygen tank and mask – Required in case of respiratory distress or anaphylaxis.
❌ B) Pulse oximeter – Essential for assessing oxygen saturation in emergencies.
❌ C) Glucose meter – Necessary for managing hypoglycemia, especially in diabetic patients.
EMERGENCY EQUIPMENT CHECKLIST
Essential equipment may clinic include:
* Oxygen tank and mask
* Automated External Defibrillator (AED)
* Pulse oximeter
* Blood pressure cuff and stethoscope
* Glucose meter
Under what circumstances can a naturopathic doctor legally provide treatment without explicit patient consent during an emergency?
A) If the patient is unable to provide consent due to unconsciousness or incapacity.
B) If the doctor feels the treatment is necessary but the patient refuses.
C) If the doctor has a family history of the condition being treated.
D) If the treatment is required for cosmetic purposes.
✅ Correct Answer: A) If the patient is unable to provide consent due to unconsciousness or incapacity.
Explanation:
Emergency care can be provided without explicit consent if the patient is unable to consent due to unconsciousness or incapacity, as this is covered under the Good Samaritan Act or other relevant legal frameworks.
❌ B) If the doctor feels the treatment is necessary but the patient refuses – Explicit consent is still required unless the patient is incapacitated.
❌ C) If the doctor has a family history of the condition being treated – Family history does not justify overriding patient consent in emergencies.
❌ D) If the treatment is required for cosmetic purposes – Cosmetic treatments require explicit consent and are not valid in emergency situations.
In which province is healthcare professionals’ legal obligation to respond in emergencies most clearly defined?
A) Ontario
B) Quebec
C) British Columbia
D) Alberta
✅ Correct Answer: B) Quebec
Explanation:
Quebec has a legal duty to respond in emergencies, requiring healthcare professionals to assist, whereas in other provinces, this is generally considered an ethical duty.
❌ A) Ontario – The duty is ethical, not legal, like in Quebec.
❌ C) British Columbia – The Good Samaritan Act protects individuals from liability when responding to emergencies but does not legally require them to act.
❌ D) Alberta – Similar to Ontario, healthcare professionals have an ethical duty to respond, not a legal one.
What is the primary purpose of having a written emergency response plan in a naturopathic clinic?
A) To ensure the clinic follows local regulations.
B) To ensure that emergency care is provided in a standardized and efficient manner.
C) To improve the clinic’s financial performance.
D) To reduce the number of insurance claims.
✅ Correct Answer: B) To ensure that emergency care is provided in a standardized and efficient manner.
Explanation:
The primary purpose of a written emergency response plan is to ensure that staff can respond to emergencies in a coordinated and effective manner, improving patient outcomes.
❌ A) To ensure the clinic follows local regulations – While regulatory compliance is necessary, the plan’s main goal is patient care.
❌ C) To improve the clinic’s financial performance – The focus is on patient safety, not financial performance.
❌ D) To reduce the number of insurance claims – The goal is improving care and patient safety, not reducing insurance claims.
Which of the following medications is typically used for the immediate management of anaphylaxis in a naturopathic clinic?
A) Diphenhydramine
B) Epinephrine
C) Nitroglycerin
D) Glucose tablets
Correct Answer: B) Epinephrine
Explanation:
B) Epinephrine is the first-line treatment for anaphylaxis as it quickly reverses the symptoms by constricting blood vessels and relaxing the muscles around the airways.
A) Diphenhydramine (an antihistamine) is often used for allergic reactions but is not fast-acting enough for anaphylaxis.
C) Nitroglycerin is used for chest pain and myocardial infarctions, not for anaphylaxis.
D) Glucose tablets are used to treat hypoglycemia (low blood sugar), not anaphylaxis.
EMERGENCY MEDICATIONS CHECKLIST
Medications required may include:
* Epinephrine (auto-injector or ampoule)
* Diphenhydramine (oral and injectable)
* Nitroglycerin (sublingual spray or tablets)
* Glucose tablets or gel – for hypoglycemia
* Salbutamol (metered-dose inhaler with spacer)
Additional medications may be required for clinics with prescriptive authority, such
as corticosteroids and intravenous fluids
Under what circumstances is a naturopathic doctor legally required to report a case of child abuse in Ontario?
A) Only if the abuse is witnessed firsthand
B) Only if the child is a patient of the naturopathic doctor
C) If there is a reasonable suspicion of abuse, even if the child is not a patient
D) If the child is a patient, regardless of suspicion
Correct Answer: C) If there is a reasonable suspicion of abuse, even if the child is not a patient.
LEGAL AND ETHICAL CONSIDERATIONS
Duty to Report:
* Understanding jurisdiction-specific regulations.
* Recognizing reportable conditions (e.g., child abuse, public
health concerns).
Patient Confidentiality:
* Ensuring privacy in documentation and communication.
* Disclosing information only when legally mandated.
DUTY OF CARE AND DUTY TO REPORT
Duty of Care: The legal obligation to provide appropriate treatment to
a patient.
Duty to Report: Mandatory reporting for:
* Child abuse
* Elder abuse
* Communicable diseases
* Reportable deaths
If a naturopathic doctor decides to stop treatment for a patient and does not arrange for continuity of care, what legal concept does this constitute?
A) Negligence
B) Abandonment
C) Duty of care
D) Duty to report
**Correct Answer: B) Abandonment
occurs when a practitioner stops treating a patient without ensuring that the patient is appropriately referred to another healthcare provider or that care is continued in some way.
Explanation:
A) Negligence refers to failing to meet the standard of care, leading to harm, but abandonment specifically focuses on failing to provide continuity of care.
C) Duty of care refers to the professional responsibility to provide care but does not specifically refer to stopping care without ensuring continuation.
D) Duty to report refers to the legal requirement to report specific incidents (like abuse) and is unrelated to abandoning a patient.
NEGLIGENCE IN EMERGENCIES
Legal Definition of Negligence
1. Duty of Care – A professional responsibility to provide care.
2. Breach of Duty – Failing to meet professional standards.
3. Causation – The breach directly caused harm.
4. Harm – The patient suffered physical, emotional, or financial damage. Example:
* A patient in an anaphylactic reaction arrives at a naturopathic clinic. The naturopathic doctor delays treatment, causing the patient’s condition to worsen. This delay could be considered negligence.
ABANDONMENT, REASONABLE SKILL AND CARE
Abandonment
* Occurs when a practitioner stops treatment without ensuring continuity of care.
* If a naturopathic doctor cannot continue care, they must refer the patient appropriately.
Reasonable Skill and Care
* The level of competency expected in medical practice.
* In emergencies, a naturopathic doctor must act within their scope of training.
A naturopathic doctor fails to properly assess and treat a patient in respiratory distress, leading to further complications. What legal concept might apply in this situation?
A) Duty of care
B) Gross negligence
C) Abandonment
D) Good Samaritan Act
Correct Answer: B) Gross negligence
Explanation:
B) Gross negligence applies here because the naturopathic doctor’s failure to properly assess and treat the patient constitutes a severe departure from the standard of care, leading to significant harm.
A) Duty of care refers to the general obligation to provide appropriate care but does not specifically address failures that lead to harm.
C) Abandonment would apply if the doctor stopped providing care without ensuring the patient was handed over to appropriate care.
D) Good Samaritan Act provides protection to those helping in emergencies outside a clinical setting but does not apply when a healthcare professional is acting within their professional scope.
Which of the following is a key legal principle under the Good Samaritan Act in Ontario and British Columbia regarding emergency care?
A) Protection from all forms of liability
B) Protection only if the actions are performed in good faith
C) Protection against gross negligence
D) Protection only for healthcare professionals
Correct Answer: B) Protection only if the actions are performed in good faith
Explanation:
B) Protection only if the actions are performed in good faith is correct. The Good Samaritan Act protects individuals providing emergency care, but only if their actions are made in good faith and not due to recklessness or gross negligence.
A) Protection from all forms of liability is incorrect because the act does not protect from all liability, especially in cases of gross negligence.
C) Protection against gross negligence is incorrect because the Good Samaritan Act does not protect individuals from gross negligence.
D) Protection only for healthcare professionals is incorrect. The Good Samaritan Act applies to anyone who provides emergency assistance, not just healthcare professionals.
What is the minimum training requirement for all clinical staff to effectively handle emergencies in a naturopathic clinic?
A) Advanced Cardiovascular Life Support (ACLS)
B) Pediatric Advanced Life Support (PALS)
C) Basic Life Support (BLS) certification
D) First Aid certification
Correct Answer: C) Basic Life Support (BLS) certification
Explanation:
C) Basic Life Support (BLS) certification is the minimum training required for all clinical staff to handle emergencies, ensuring they can provide CPR and other basic emergency care.
A) Advanced Cardiovascular Life Support (ACLS) is recommended for practitioners treating high-risk patients but is not the minimum requirement for all clinical staff.
B) Pediatric Advanced Life Support (PALS) is advanced training for handling pediatric emergencies, which is not required for all clinical staff.
D) First Aid certification is useful but is not the minimum required for handling life-threatening emergencies, where BLS is essential.
THE GOOD SAMARITAN ACT (BC/ON)
What It Does
* Protects individuals who voluntarily provide emergency assistance.
* Prevents liability if actions are performed in good faith.
* Does not protect against gross negligence.
What It Means for Naturopathic Doctors
* If a naturopathic doctor stops to help someone experiencing a medical emergency, they are legally protected.
* However, they must not act beyond their training.
* Example: Providing cardiopulmonary resuscitation (CPR) is acceptable, but attempting an advanced medical procedure without proper training could be considered negligence.
Which of the following is an example of implied consent in an emergency situation?
A) A patient verbally agrees to receive treatment for an allergic reaction.
B) A patient signs a written consent form before receiving treatment for chest pain.
C) A patient is unconscious and cannot communicate but requires immediate life-saving treatment.
D) A patient refuses life-saving treatment despite understanding the risks.
Correct Answer: C) A patient is unconscious and cannot communicate but requires immediate life-saving treatment.
Explanation: Implied consent is assumed in situations where a patient is unconscious or incapacitated and immediate treatment is necessary to preserve life. In this case, the unconscious patient is unable to give verbal or written consent, but implied consent is assumed to prevent harm.
A) Wrong: This is an example of expressed consent, where the patient gives verbal consent.
B) Wrong: This is also expressed consent, as it involves a written agreement.
D) Wrong: This involves a patient refusing consent, so the situation does not involve implied consent.
CONSENT IN EMERGENCIES
* Implied Consent: Assumed in life-threatening situations.
* Expressed Consent: Verbal or written agreement.
When Can You Provide Care Without Consent?
* If the patient is unconscious or incapacitated.
* If delaying treatment would cause serious harm.
Under what circumstance can a naturopathic doctor provide care without explicit consent?
A) When the patient is conscious and verbally refuses treatment.
B) When the patient is unconscious or incapacitated, and delaying treatment could cause harm.
C) When the patient signs a waiver releasing the doctor from liability.
D) When the patient is under the age of 18 and requires treatment for a minor injury.
Correct Answer: B) When the patient is unconscious or incapacitated, and delaying treatment could cause harm.
Explanation: In an emergency situation where a patient is unconscious or incapacitated, and delaying treatment could lead to serious harm or death, care can be provided without explicit consent. This is a legal exception.
A) Wrong: If the patient is conscious and refuses treatment, consent must be obtained, unless the patient is incapacitated.
C) Wrong: A waiver does not negate the need for consent. Explicit consent (either verbal or written) is required, except in emergency cases.
D) Wrong: In this case, explicit consent would still be required unless the situation is life-threatening.
Which of the following components is part of the Rapid Primary Survey in emergency management?
A) History taking
B) Scene survey
C) Exposure
D) Re-assessment
Correct Answer: C) Exposure
Explanation: Exposure is part of the Rapid Primary Survey where you look for hidden injuries, environmental injuries, and assess for medical alert tags. This is done after assessing airway, breathing, circulation, and disability.
A) Wrong: History taking is part of the secondary assessment and not the primary survey.
B) Wrong: The scene survey occurs before the primary survey and is focused on ensuring safety and assessing potential hazards.
D) Wrong: Re-assessment is performed after the primary and secondary surveys to track changes in the patient’s condition.
Which of the following components is part of the Rapid Primary Survey in emergency management?
A) History taking
B) Scene survey
C) Exposure
D) Re-assessment
**Correct Answer: C) Exposure
Explanation: Exposure is part of the Rapid Primary Survey where you look for hidden injuries, environmental injuries, and assess for medical alert tags. This is done after assessing airway, breathing, circulation, and disability.**
RAPID PRIMARY SURVEY
Objective: Identify and manage immediate life threats.
Key Actions: (ABCDE Approach)
* Airway: Check for obstructions, assess need for airway support, stabilize cervical spine if
trauma suspected.
* Breathing: Observe respiratory rate, depth, and symmetry; provide oxygen if necessary.
* Circulation: Assess pulse, blood pressure, skin color, and capillary refill; control major bleeding.
* Disability: Perform rapid neurological assessment (AVPU scale, GCS).
* Exposure: Identify hidden injuries, environmental injuries, medical alert tags
In which scenario is a naturopathic doctor required to report under the Duty to Report?
A) A patient with a routine cold that lasts for several days.
B) A patient who has disclosed they are dealing with a mental health issue but refuses to seek help.
C) A patient with suspected child abuse injuries.
D) A patient who has a prescription for an opioid and is using it responsibly.
**Correct Answer: C) A patient with suspected child abuse injuries.
Explanation: The Duty to Report includes the obligation to report suspected child abuse. This is a mandatory legal requirement to protect the safety of vulnerable individuals.**
A) Wrong: A routine cold does not require mandatory reporting, as it is not a reportable condition.
B) Wrong: While mental health concerns may require attention, they do not automatically trigger mandatory reporting unless the patient is at risk of harming themselves or others.
D) Wrong: Responsible opioid use does not require reporting unless there are concerns about misuse, overdose, or addiction, which would be addressed through appropriate channels.
Which of the following is an example of gross negligence?
A) A doctor forgets to check a patient’s blood pressure during an examination but takes corrective action immediately after noticing.
B) A doctor intentionally ignores a patient’s allergy history, resulting in an allergic reaction.
C) A nurse mistakenly administers the wrong dosage of medication but it doesn’t result in harm.
D) A healthcare professional fails to sterilize equipment but no infection results from the procedure
Correct Answer: B) A doctor intentionally ignores a patient’s allergy history, resulting in an allergic reaction.
Explanation: Gross negligence involves a severe disregard for the safety of others, such as deliberately ignoring a known risk (like an allergy) that leads to harm.
A) Wrong: This would be considered negligence, but it’s not as extreme as gross negligence, especially if corrective action is taken promptly.
C) Wrong: This is also negligence, but without significant harm, it’s not classified as gross negligence.
D) Wrong: While sterilization is crucial, this would also be considered negligence unless an infection occurs, in which case it could be considered gross negligence.
Why is it important to use Personal Protective Equipment (PPE) during the Scene Survey in an emergency?
A) PPE protects the healthcare provider from exposure to infectious agents.
B) PPE prevents cross-contamination between patients.
C) PPE ensures that the healthcare provider can safely handle hazardous materials or substances.
Correct Answer: D) All of the above
Explanation: PPE is essential in emergencies to protect both the healthcare provider and the patient from potential infection or hazardous materials. It serves multiple purposes: safeguarding the healthcare provider from exposure to infectious diseases (A), preventing the spread of infectious agents between patients (B), and allowing the provider to interact safely with hazardous substances (C). Hence, D is the correct choice.
Infection Control and PPE Use:
Question: Why is it important to initiate infection control procedures (PPE use, hand hygiene) during the Scene Survey of an emergency?
A) It protects the healthcare provider from exposure to infectious diseases.
B) It reduces the likelihood of cross-contamination between patients.
C) It ensures that the healthcare provider can safely interact with hazardous substances.
D) All of the above.
D) All of the above.
Explanation: The correct answer would be D) All of the above, as PPE and hand hygiene protect both the healthcare provider and the patient from potential infection.
Understanding GCS:
Question: What does a Glasgow Coma Scale (GCS) score of 6 indicate?
A) The patient is fully alert and responsive.
B) The patient has severe impairment of neurological function.
C) The patient is unresponsive to verbal or painful stimuli.
D) The patient is conscious but has impaired verbal and motor responses.
Explanation: The correct answer would be D) The patient is conscious but has impaired verbal and motor responses. A score of 6 on the GCS indicates moderate impairment.
How does scoring work in the Glasgow Coma Scale (GCS) of How does scoring work for GCS-P
Total GCS Score
The total GCS score is the sum of the eye, verbal, and motor responses, with a maximum score of 15 (fully awake and alert) and a minimum score of 3 (deep coma or no response).
GCS 15: Fully alert and oriented.
GCS 13-14: Mild impairment of consciousness.
GCS 9-12: Moderate impairment of consciousness.
GCS 3-8: Severe impairment, coma or unresponsive.
**Eyes **
4 - You can open your eyes and keep them open on your own.
3 - You only open your eyes when someone tells you to do so. Your eyes stay closed otherwise.
2 -Your eyes only open in response to feeling pressure.
1 - Your eyes don’t open for any reason.
Motor (movement) response score
6 - You follow instructions on how and when to move.
5 - Score meaning
You intentionally move away from something that presses on you.
4 - You only move away from something pressing on you as a reflex.
3 - You flex muscles (pull inward) in response to pressure.
2 - You extend muscles (stretch outward) in response to pressure.
1 - You don’t move in response to pressure.
Verbal response score
5 - You’re oriented. You can correctly answer questions about who you are, where you’re at, the day or year, etc.
4 - You’re confused. You can answer questions, but your answers show you’re not fully aware of what’s happening.
3 - You can talk and others can understand words you say, but your responses to questions don’t make sense.
2 - You can’t talk and can only make sounds or noises.
1 - You can’t speak or make sounds.
Pupil reaction is important because it’s an indicator of your brain function. When your pupils don’t react to light, it’s a sign that a serious problem or injury is affecting your brain. The pupil score ranges from 0 to 2.
The pupil scores mean:
2: Neither pupil reacts to light.
1: One pupil doesn’t react to light.
0: Both pupils react to light.
Subtracting the pupil reaction score from the GCS score means that the GCS-P score can range from 1 to 15. The GCS-P score still uses a score of 8 or fewer to mean a coma.
A GCS score of 3 and a pupil score of 2 is a GCS-P score of 1. That means a very deep coma and no pupil reaction in both eyes.
When assessing the Glasgow Coma Scale (GCS), the motor response is a key component used to gauge the level of consciousness and neurological function in a patient. One of the motor responses observed is “posturing” in response to painful stimuli, which can be either flexion (decorticate posturing) or extension (decerebrate posturing). The type of posturing provides valuable information about the severity of brain injury.
Here’s why extending the arms outward (decerebrate posturing) in response to pressure is considered worse than flexing the arms (decorticate posturing):
- Decorticate Posturing (Flexion)
Response: In this posture, the arms are flexed (bent) toward the body, the hands are clenched into fists, and the legs may be extended or rigid.
Indication: This type of posturing generally suggests damage above the brainstem (i.e., in the cerebral cortex or diencephalon), but still within the brain’s higher functions. The brain is showing some signs of function, but it may be impaired or disoriented.
GCS Score: Typically a motor response of 3 on the GCS (which indicates purposeful movement or flexion in response to pain).
- Decerebrate Posturing (Extension)
Response: In this posture, the arms extend outward and the hands are rotated and open, the legs may be rigid or extended as well.
Indication: This response typically indicates more severe brain damage, often involving damage to the brainstem (specifically to areas like the midbrain or pons). It suggests a loss of higher brain functions, including motor control and response, and is typically a worse sign of neurological impairment than decorticate posturing.
GCS Score: This is a motor response of 2 on the GCS, which indicates a more severe impairment of brain function.
Why Is Decerebrate Posturing Worse?
Brainstem Involvement: The brainstem controls essential functions such as breathing, heart rate, and basic motor functions. Damage to the brainstem (which often leads to decerebrate posturing) is more serious and suggests that the injury affects vital life-support systems.
Loss of Higher Function: Decerebrate posturing suggests widespread and severe damage to both the higher centers of the brain and the brainstem, leading to a poorer prognosis. In contrast, decorticate posturing typically indicates that the brainstem is still intact, and there may still be some brain function left, even though it is compromised.
Using the HEART Score:
Question: A patient presents with crushing substernal chest pain, diaphoresis, and a risk factor of smoking. The HEART Score for this patient is 6. What does this indicate?
A) The patient is at low risk for acute coronary syndrome (ACS).
B) The patient is at high risk for a myocardial infarction (MI).
C) The patient does not require immediate referral to the hospital.
D) The patient should be managed in an outpatient setting.
B) The patient is at high risk for a myocardial infarction (MI).
Explanation: The correct answer would be B) The patient is at high risk for a myocardial infarction (MI). A HEART Score of 6 indicates a high risk for MI and warrants urgent referral to the emergency department.
Glasgow Coma Scale (GCS)
Question 3:
A patient with a Glasgow Coma Scale (GCS) score of 10 has the following responses:
GCS meanings
GCS 15: Fully alert and oriented.
GCS 13-14: Mild impairment of consciousness.
GCS 9-12: Moderate impairment of consciousness.
GCS 3-8: Severe impairment, coma or unresponsive.
Eye Opening: 3
Verbal Response: 3
Motor Response: 4 What is the level of consciousness of this patient?
A) The patient is fully alert and responsive.
B) The patient is in a coma.
C) The patient has moderate impairment of consciousness.
D) The patient is unresponsive to stimuli.
GCS ranges for head injuries
When providers use the GCS in connection with a head injury, they tend to apply scoring ranges to describe how severe the injury is. The ranges are:
13 to 15: Mild traumatic brain injury (mTBI). Also known as a concussion.
9 to 12: Moderate TBI.
3 to 8: Severe TBI.
Generally, having a score of 8 or fewer means you’re in a coma. The lower the score, the deeper the coma is.
Which of the following tools is used to assess the likelihood of Pulmonary Embolism (PE) in a patient?
A) HEART Score
B) Wells Criteria
C) PERC (Pulmonary Embolism Rule-Out Criteria)
D) Glasgow Coma Scale (GCS)
Correct Answer: B) Wells Criteria
Clinical decision tools for risk Stratification
Explanation: B) Wells Criteria is specifically designed to assess the likelihood of Pulmonary Embolism (PE). It considers factors like clinical signs, risk factors, and history.
A) is incorrect because the HEART Score is used for risk assessment of acute coronary syndrome (ACS),
C) PERC (Pulmonary Embolism Rule-Out Criteria) is used to rule out PE in low-risk cases
D) (GCS) is unrelated to chest pain and PE.
D-dimer Test – Used in low to moderate PE risk cases
What does the “A” in the AVPU scale stand for?
A) Alert
B) Agitated
C) Awake
D) Anxious
AVPU – LEVEL OF CONSCIOUSNESS
A – Alert: The patient is awake and responsive.
V – Verbal: The patient responds to verbal stimuli.
P – Pain: The patient responds only to painful stimuli.
U – Unresponsive: The patient does not respond to any stimuli.
In the DOTS secondary survey, what does the “T” stand for?
Hint: DOTS is used during a secondary survey to assess injuries or abnormalities in a patient after the primary survey.
A) Trauma
B) Temperature
C) Tenderness
D) Tension
Answer: C) Tenderness
Explanation: The “T” in DOTS stands for Tenderness, which refers to any painful or sensitive areas found during the physical exam.
DOTS – SECONDARY SURVEY
D – Deformities
O – Open wounds
T – Tenderness
S – Swelling
Which of the following is included in the DCAP-BTLS head-to-toe trauma survey?
Hint: DCAP-BTLS mnemonic is used for a head-to-toe trauma assessment. It’s specifically for detecting injuries related to trauma, including skin issues, but it goes beyond just the skin to assess the underlying structure and damage.
A) Tension
B) Burns
C) Temperature
D) Throbbing
DCAP-BTLS – HEAD-TO-TOE TRAUMA SURVEY
* D – Deformities
* C – Contusions
* A – Abrasions
* P – Punctures/Penetrations
* B – Burns
* T – Tenderness
* L – Lacerations
* S – Swelling
The SAMPLE mnemonic is used for which aspect of patient care?
A) Pain assessment
B) History taking
C) Trauma survey
D) Wound care
Answer: B) History taking
Explanation: SAMPLE is a mnemonic used for gathering important patient history during an emergency assessment
SAMPLE – HISTORY TAKING
S – Signs & Symptoms
A – Allergies
M – Medications
P – Past medical history
L – Last oral intake
E – Events leading to injury/illness
What does the “I” in the MIST handover to EMS stand for?
A) Injuries identified
B) Information gathered
C) Immediate treatment
D) Illness detected
Answer: A) Injuries identified
MIST – HANDOVER TO EMS
M – Mechanism of injury
I – Injuries or illness identified
S – Signs & symptoms
T – Treatment given
Acute Coronary Syndrome (ACS)
A 60-year-old male presents with severe chest pain that started 45 minutes ago. The pain is described as crushing and radiates to his left arm. He is sweating heavily and has a history of hypertension, diabetes, and smoking. His blood pressure is elevated, and his heart rate is tachycardic. What is the most likely diagnosis?
A) Pulmonary Embolism (PE)
B) Acute Coronary Syndrome (ACS)
C) Tension Pneumothorax
D) Esophageal Rupture (Boerhaave’s Syndrome)
Correct Answer: B) Acute Coronary Syndrome (ACS)
Explanation: The patient’s presentation, including crushing chest pain, radiation to the left arm, diaphoresis, and risk factors such as smoking and hypertension, is most consistent with ACS. Immediate evaluation with an ECG and troponins is necessary for diagnosis.
** Pulmonary Embolism (PE)**
A 50-year-old female presents with sudden pleuritic chest pain and shortness of breath after a long flight. Her heart rate is elevated, and her oxygen saturation is low. She has no significant medical history. What is the most likely diagnosis?
Correct Answer: B) Pulmonary Embolism (PE)
Explanation: The patient’s pleuritic chest pain, tachycardia, and recent history of a long flight suggest pulmonary embolism. A D-dimer and CT pulmonary angiography would be helpful to confirm the diagnosis.
Aortic Dissection
A 65-year-old male presents with sudden, severe, “tearing” chest pain that radiates to his back. He is hypertensive and has a history of smoking. His blood pressure is unequal between arms. What is the most likely diagnosis?
A) Aortic Dissection
B) Tension Pneumothorax
C) Acute Coronary Syndrome (ACS)
D) Esophageal Rupture (Boerhaave’s Syndrome)
Correct Answer: A) Aortic Dissection
Explanation: Aortic dissection presents with severe, tearing chest pain that radiates to the back. The unequal blood pressure in the arms is a classic finding. Immediate imaging (e.g., CT angiography) and surgical consultation are required.
Tension Pneumothorax
A 25-year-old male presents with sudden sharp chest pain after a motorcycle accident. His blood pressure is low, and his heart rate is elevated. On examination, there are absent breath sounds on the left side of his chest. What is the most likely diagnosis?
A) Tension Pneumothorax
B) Pulmonary Embolism (PE)
C) Acute Coronary Syndrome (ACS)
D) Musculoskeletal Pain
Correct Answer: A) Tension Pneumothorax
Explanation: Tension pneumothorax is a life-threatening condition that presents with absent breath sounds on one side of the chest, hypotension, and tachycardia. Immediate needle decompression and chest tube insertion are required.
Esophageal Rupture (Boerhaave’s Syndrome)
A 45-year-old male presents with sudden severe chest pain after vomiting. He is having difficulty swallowing and is tachycardic. What is the most likely diagnosis?
A) Esophageal Rupture (Boerhaave’s Syndrome)
B) Acute Coronary Syndrome (ACS)
C) Tension Pneumothorax
D) Pneumonia
Correct Answer: A) Esophageal Rupture (Boerhaave’s Syndrome)
Explanation: Esophageal rupture causes sudden, severe chest pain after forceful vomiting and difficulty swallowing. This condition is life-threatening and requires immediate surgical intervention.
Esophageal Rupture (Boerhaave’s Syndrome):
What it is: An esophageal rupture, or Boerhaave’s Syndrome, is a rare and severe condition that occurs when there is a tear or rupture in the wall of the esophagus, typically due to severe vomiting or trauma. The tear can cause stomach contents and air to leak into the chest cavity.
Does the esophagus completely sever?: While the term “rupture” suggests that a tear occurs, it doesn’t always mean the esophagus is completely severed. The rupture can range from a small tear to a larger, more severe breach in the wall. The esophagus is muscular and flexible, so it’s more likely to tear or rupture in a specific area rather than “completely severing.” In severe cases, the tear can cause massive infection or peritonitis (infection of the abdominal cavity) if not treated quickly.
What happens: After the rupture, gastric contents (like food, acid, and air) can leak into the pleural space (around the lungs) or the mediastinum. This can lead to life-threatening complications such as sepsis, shock, and pneumothorax (air in the chest cavity). It is indeed a medical emergency and can be fatal if not addressed promptly. The sudden onset of severe chest pain after vomiting is the hallmark sign.
Musculoskeletal Chest Pain
A 30-year-old male presents with localized chest pain after lifting a heavy box. The pain is reproducible with palpation of the chest wall. What is the most likely diagnosis?
A) Musculoskeletal Chest Pain
B) Pulmonary Embolism (PE)
C) Acute Coronary Syndrome (ACS)
D) Tension Pneumothorax
Stepwise Approach to Chest Pain Evaluation
A 50-year-old male with a history of hypertension and smoking presents with chest pain. What is the first step in evaluating this patient?
A) Physical Exam
B) History
C) CT Angiography
D) Laboratory Tests
Correct Answer: B) History
Explanation: The first step in evaluating chest pain is obtaining a thorough history, including risk factors (e.g., hypertension, smoking) and details of the chest pain (e.g., onset, duration, character). This will guide further evaluation.
A 55-year-old male presents to the emergency department with severe, tearing chest pain that radiates to his back. He appears pale and diaphoretic. His blood pressure in the right arm is significantly different from the left arm.
Which of the following conditions is the most likely cause of his symptoms?
A) Gastroesophageal reflux disease (GERD)
B) Panic attack
C) Aortic dissection
D) Costochondritis
**C) Aortic dissection (Correct, Emergent) – The patient’s symptoms of tearing pain radiating to the back and blood pressure differences between arms strongly suggest an aortic dissection, a life-threatening emergency requiring immediate intervention.
**
Explanation of Answers:
A) GERD (Incorrect) – GERD can cause chest pain, but it is typically a burning pain, often related to meals, and does not cause significant hemodynamic instability or radiation to the back. This is a non-emergent condition.
B) Panic attack (Incorrect) – While anxiety can cause chest tightness and shortness of breath, it does not cause severe, tearing pain, blood pressure differences, or other signs of circulatory collapse. This is also non-emergent.
D) Costochondritis (Incorrect) – This is a benign musculoskeletal cause of chest pain that is localized and worsens with palpation. It does not cause tearing pain or blood pressure differences.
LIFE-THREATENING CAUSES OF CHEST PAIN (MUST
NOT MISS)
Acute Coronary Syndrome (ACS) – STEMI, NSTEMI, Unstable Angina
Pulmonary Embolism (PE) – Tachycardia, dyspnea, pleuritic pain
Aortic Dissection – “Tearing” pain, radiates to back, widened
mediastinum
Tension Pneumothorax – Unilateral absent breath sounds, hypotension
Esophageal Rupture (Boerhaave’s Syndrome) – Vomiting, sudden severe pain
NON-EMERGENT CAUSES OF CHEST PAIN (BENIGN
ETIOLOGIES)
* Musculoskeletal: Costochondritis, rib fractures
* Gastroesophageal: Gastroesophageal reflux disease
(GERD), esophageal spasm
* Pulmonary: Pneumonia, pleuritis
* Psychogenic: Panic attacks, anxiety
Identifying Acute Coronary Syndrome (ACS)
A 55-year-old male presents to the emergency department with crushing substernal chest pain that radiates to his left arm. He is diaphoretic and has a history of hypertension, smoking, and diabetes. His HEART Score is 6. What is the next best step in management?
A) Administer proton pump inhibitors and discharge home
B) Prescribe NSAIDs and schedule outpatient follow-up
C) Immediate transfer to the emergency department for ACS workup
D) Reassure the patient that his pain is due to anxiety
Correct Answer: C) Immediate transfer to the emergency department for ACS workup
✅ Explanation: The patient’s symptoms (crushing chest pain, radiation, and diaphoresis) are classic for Acute Coronary Syndrome (ACS). His HEART Score of 6 indicates high risk for myocardial infarction (MI), requiring urgent emergency evaluation and management.
❌ Why other choices are wrong:
A) GERD (Incorrect): GERD can cause chest pain, but it does not present with left arm radiation and diaphoresis.
B) NSAIDs (Incorrect): Costochondritis can cause chest pain, but this case strongly suggests ACS, not a musculoskeletal cause.
D) Anxiety (Incorrect): Although anxiety can cause chest tightness, ignoring red flags for ACS could be fatal.
Pulmonary Embolism (PE) Evaluation
A 40-year-old female presents with sudden pleuritic chest pain, dyspnea, and tachycardia. She recently took a long-haul flight. What is the most appropriate next step in diagnosis?
A) D-dimer testing and CT Pulmonary Angiography if positive
B) Administer nitroglycerin and monitor for improvement
C) Reassure the patient and recommend deep breathing exercises
D) Prescribe proton pump inhibitors for suspected GERD
Correct Answer: A) D-dimer testing and CT Pulmonary Angiography if positive
✅ Explanation: The patient has sudden pleuritic chest pain, dyspnea, tachycardia, and a major risk factor (long-haul flight). These findings are highly concerning for Pulmonary Embolism (PE). A D-dimer test is used for risk stratification—if positive, CT Pulmonary Angiography confirms the diagnosis.
❌ Why other choices are wrong:
B) Nitroglycerin (Incorrect): This is used for ACS, not PE. PE does not respond to nitroglycerin.
C) Deep breathing exercises (Incorrect): PE is life-threatening and requires urgent imaging and anticoagulation, not reassurance.
D) Proton pump inhibitors (Incorrect): GERD does not cause tachycardia or pleuritic pain.
Red Flags for Immediate Referral
Which of the following symptoms requires immediate emergency referral?
A) Chest pain that worsens with movement and is tender to palpation
B) Intermittent burning chest pain relieved with antacids
C) Sudden severe back pain with widened mediastinum on X-ray
D) Chest tightness triggered by stress and relieved with deep breathing
Correct Answer: C) Sudden severe back pain with widened mediastinum on X-ray
✅ Explanation: Widened mediastinum with severe back pain suggests Aortic Dissection, which is life-threatening and requires immediate intervention.
❌ Why other choices are wrong:
A) Musculoskeletal Pain (Incorrect): Localized tenderness suggests costochondritis, a non-emergent condition.
B) GERD (Incorrect): Burning pain relieved with antacids suggests GERD, which is not life-threatening.
D) Panic Attack (Incorrect): While distressing, anxiety-related chest pain does not indicate an immediate life threat.
FOR IMMEDIATE EMERGENCY REFERRAL
* Sudden, severe back pain with widened mediastinum →
Aortic Dissection
* Hypotension with absent breath sounds → Tension
Pneumothorax
* Syncope with chest pain → ACS, PE, or Aortic Dissection
* New neurologic symptoms with chest pain → Stroke due to
dissection
Why does syncope (fainting) with chest pain suggest ACS, PE, or aortic dissection?
Acute Coronary Syndrome (ACS): A heart attack (STEMI/NSTEMI) can cause sudden drops in blood pressure due to impaired cardiac output, leading to syncope.
Pulmonary Embolism (PE): A large clot in the lungs can obstruct blood flow, leading to decreased oxygen delivery and a sudden drop in blood pressure, causing fainting.
Aortic Dissection: If the dissection extends to the aortic arch, it can disrupt blood flow to the brain, leading to syncope. Additionally, if the tear compromises major arteries, it can cause shock and collapse.
Management of Cardiac Arrest
A patient collapses in your clinic. He is unresponsive, pulseless, and not breathing. What is the most appropriate first step?
A) Administer aspirin and place the patient in a comfortable position
B) Check for responsiveness, call 911, and initiate CPR
C) Perform a full neurologic exam before starting chest compressions
D) Administer beta-blockers and wait for EMS to arrive
Correct Answer: B) Check for responsiveness, call 911, and initiate CPR
✅ Explanation: The first step in cardiac arrest is immediate CPR and early defibrillation (if indicated). High-quality chest compressions improve survival outcomes.
❌ Why other choices are wrong:
A) Aspirin (Incorrect): Aspirin is useful in ACS, but not in cardiac arrest. The priority is CPR and defibrillation.
C) Neurologic exam (Incorrect): Do not delay CPR—time is critical in cardiac arrest.
D) Beta-blockers (Incorrect): These are used for long-term cardiac management, not cardiac arrest.
CARDIAC ARREST
Diagnostic Criteria:
* Clinical recognition of pulselessness and unresponsiveness.
* Confirmed via cardiac monitoring showing asystole, pulseless electrical activity (PEA), ventricular fibrillation (VF), or pulseless ventricular tachycardia (VT.)
CARDIAC ARREST
Management:
* Immediate initiation of cardiopulmonary resuscitation (CPR).
* Early defibrillation for shockable rhythms (VF, pulseless VT).
* Follow Advanced Cardiac Life Support (ACLS) protocols,
addressing reversible causes (the “H’s and T’s”):
◦ Hypoxia, Hypovolemia, Hyperkalemia, Hypothermia,
◦ Toxins, Cardiac Tamponade, Coronary Thrombosis, Pulmonary
Thrombosis, Tension Pneumothorax.
STEMI vs. NSTEMI
Which of the following is a key distinguishing feature of STEMI compared to NSTEMI?
A) ST-segment elevation on ECG
B) Chest pain relieved with nitroglycerin
C) Normal troponin levels
D) No need for immediate reperfusion therapy
Correct Answer: A) ST-segment elevation on ECG
✅ Explanation: STEMI is characterized by ST-segment elevation in two contiguous ECG leads, indicating a complete coronary artery blockage requiring immediate reperfusion therapy.
❌ Why other choices are wrong:
B) Nitroglycerin relief (Incorrect): Unstable angina and NSTEMI can also respond to nitroglycerin, making this not a distinguishing feature.
C) Normal troponin (Incorrect): NSTEMI has elevated troponins, but unstable angina has normal troponins.
D) No reperfusion therapy (Incorrect): STEMI requires immediate PCI or thrombolysis to restore blood flow.
ST-ELEVATION MYOCARDIAL INFARCTION (STEMI)
Diagnostic Criteria:
* Electrocardiogram (ECG): ST-segment elevation in two
contiguous leads.
* Elevated cardiac biomarkers, such as troponins.
Which of the following is the most appropriate first step in managing a patient in cardiac arrest?
A) Administer aspirin
B) Initiate high-quality CPR
C) Obtain an ECG
D) Give intravenous beta-blockers
CARDIAC ARREST
Management:
* Immediate initiation of cardiopulmonary resuscitation (CPR).
* Early defibrillation for shockable rhythms (VF, pulseless VT).
* Follow Advanced Cardiac Life Support (ACLS) protocols,
addressing reversible causes (the “H’s and T’s”):
◦ Hypoxia, Hypovolemia, Hyperkalemia, Hypothermia,
◦ Toxins, Cardiac Tamponade, Coronary Thrombosis, Pulmonary
Thrombosis, Tension Pneumothorax.
A 65-year-old man experiences syncope with tearing chest pain radiating to the back. What is the most likely diagnosis?
A) Acute pericarditis
B) Aortic dissection
C) Stable angina
D) NSTEMI
Answer: B) Aortic dissection
Correct: Sudden, severe, tearing pain with syncope suggests aortic dissection, especially if blood pressure asymmetry or pulse deficits are present.
Incorrect Choices:
Pericarditis (A): Causes sharp pleuritic pain but is not typically associated with syncope or back pain.
Stable angina (C): Predictable chest pain with exertion, relieved by rest, not associated with syncope.
NSTEMI (D): Can cause chest pain but not typically a tearing sensation or syncope.
Which of the following is NOT a reversible cause of cardiac arrest?
A) Hypoxia
B) Pulmonary embolism
C) Hyperkalemia
D) Pericarditis
Answer: D) Pericarditis
Correct: Acute pericarditis is not typically a direct cause of cardiac arrest.
Incorrect Choices (Reversible Causes - “H’s and T’s”):
Hypoxia (A): Lack of oxygen can lead to cardiac arrest.
Pulmonary embolism (B): A massive PE can cause cardiac arrest due to obstructed circulation.
Hyperkalemia (C): High potassium levels can cause lethal arrhythmias.
CARDIAC ARREST
Management:
* Immediate initiation of cardiopulmonary resuscitation (CPR).
* Early defibrillation for shockable rhythms (VF, pulseless VT).
* Follow Advanced Cardiac Life Support (ACLS) protocols,
addressing reversible causes (the “H’s and T’s”):
◦ Hypoxia, Hypovolemia, Hyperkalemia, Hypothermia,
◦ Toxins, Cardiac Tamponade, Coronary Thrombosis, Pulmonary
Thrombosis, Tension Pneumothorax.
What does “reversible cause” mean in the H’s and T’s of cardiac arrest?
Answer: A reversible cause is a condition that can be corrected or treated to restore cardiac function. The H’s and T’s list potentially correctable causes of cardiac arrest, such as hypoxia (which can be treated with oxygen) or tension pneumothorax (which can be treated with needle decompression).
What is the definitive diagnostic test for aortic dissection?
A) Chest X-ray
B) CT Angiography
C) Troponin test
D) Echocardiogram
Answer: B) CT Angiography
Correct: CT Angiography is the gold standard for diagnosing aortic dissection.
Incorrect Choices:
Chest X-ray (A): May show a widened mediastinum but is not definitive.
Troponin test (C): Used for myocardial infarction, not dissection.
Echocardiogram (D): Can help but is not the primary diagnostic tool.
AORTIC DISSECTION
Diagnostic Criteria:
* High clinical suspicion based on presentation.
* Confirmation with Computed Tomography (CT) Angiography.
* Chest X-ray (CXR) may show a widened mediastinum but is
not definitive.
Which of the following medications is NOT used in the initial management of STEMI?
A) Aspirin
B) Beta-blockers
C) Heparin
D) Corticosteroids
Answer: D) Corticosteroids
Correct: Corticosteroids are not used in STEMI and may worsen outcomes.
Incorrect Choices:
Aspirin (A): Reduces clot formation.
Beta-blockers (B): Reduce myocardial oxygen demand.
Heparin (C): Prevents further clot formation.
ST-ELEVATION MYOCARDIAL INFARCTION (STEMI)
Management:
* Immediate reperfusion therapy:
◦ Percutaneous Coronary Intervention (PCI) within 90 minutes if available.
◦ Fibrinolysis (thrombolytic therapy) if PCI is unavailable or delayed.
* Medications:
◦ Acetylsalicylic acid (aspirin).
◦ P2Y12 inhibitors (such as clopidogrel or ticagrelor).
◦ Anticoagulants (such as heparin).
◦ Beta-adrenergic blockers (beta-blockers).
◦ Hydroxymethylglutaryl-CoA reductase inhibitors (statins).
What is the first-line treatment for a Type A aortic dissection?
A) Intravenous beta-blockers
B) Emergency surgery
C) Fibrinolysis
D) High-dose aspirin
Answer: B) Emergency surgery
Correct: Type A dissections (ascending aorta) require urgent surgical repair.
Incorrect Choices:
Beta-blockers (A): Used for Type B dissections but do not replace surgery.
Fibrinolysis (C): Contraindicated, as it can worsen bleeding.
Aspirin (D): Not part of dissection management.
Do all types of aortic dissection require emergency surgery? What is the difference between the types?
Answer: No, not all types require emergency surgery.
Type A dissection (involves the ascending aorta): Requires immediate surgery because it can cause life-threatening complications like cardiac tamponade or aortic rupture.
Type B dissection (confined to the descending aorta): Usually managed medically with blood pressure control unless complications arise, such as organ ischemia or aneurysm rupture, in which case surgery may be needed.
Which finding is most characteristic of pericarditis?
A) ST-segment depression
B) ST-segment elevation in all leads
C) Widened mediastinum
D) Pulsus paradoxus
Answer: B) ST-segment elevation in all leads
Correct: Diffuse ST-segment elevation is the hallmark ECG finding in acute pericarditis.
Incorrect Choices:
ST depression (A): Seen in ischemia, not pericarditis.
Widened mediastinum (C): Suggests aortic dissection.
Pulsus paradoxus (D): Seen in cardiac tamponade, not isolated pericarditis.
Which symptom distinguishes unstable angina from stable angina?
A) Pain relieved by rest
B) Pain triggered by exertion
C) Pain occurring at rest
D) Pain radiating to the jaw
Answer: C) Pain occurring at rest
Correct: Unstable angina occurs at rest or with minimal exertion, unlike stable angina.
Incorrect Choices:
Pain relieved by rest (A): Characteristic of stable angina.
Pain triggered by exertion (B): Seen in stable angina.
Pain radiating to the jaw (D): Can occur in both stable and unstable angina.
1. Why Do These Symptoms Happen?
Crushing, Pressure-like Chest Pain Radiating to the Jaw/Arm
This is a classic symptom of cardiac ischemia (reduced blood flow to the heart), commonly seen in myocardial infarction (MI) or acute coronary syndrome (ACS).
The pain radiates to the jaw and arm due to referred pain, where nerves from the heart and upper body share pathways in the spinal cord (C3-T4).
Diaphoresis (Excessive Sweating)
Caused by activation of the sympathetic nervous system (SNS) in response to pain and stress.
The body releases epinephrine (adrenaline), which triggers sweat glands, preparing the body for a “fight-or-flight” response.
A common sign of MI, pulmonary embolism, or severe pain.
Dyspnea (Shortness of Breath)
The heart struggles to pump blood efficiently due to ischemia, leading to fluid buildup in the lungs (pulmonary congestion).
Seen in conditions like heart failure, MI, and pulmonary embolism.
Syncope (Fainting)
Occurs due to low cardiac output and poor blood flow to the brain.
Could be caused by severe hypotension, arrhythmias, or obstructed blood flow (e.g., aortic stenosis, massive pulmonary embolism).
Hypotension or Hemodynamic Instability
Seen in cardiogenic shock when the heart cannot pump blood effectively.
Can be due to a massive MI, severe arrhythmias, or internal bleeding.
Leads to multi-organ failure if untreated.
What is the recommended initial intervention for a suspected NSTEMI in-office?
A) Administer IV thrombolytics
B) Give chewable aspirin
C) Perform a stress test
D) Provide high-dose corticosteroids
Answer: B) Give chewable aspirin
Correct: Aspirin reduces clot progression in acute coronary syndrome.
Incorrect Choices:
Thrombolytics (A): Used for STEMI, not NSTEMI.
Stress test (C): Done after stabilization, not acutely.
Corticosteroids (D): Not used in ACS.
NON-ST ELEVATION MYOCARDIAL INFARCTION
(NSTEMI) / UNSTABLE ANGINA
Management:
* Urgent cardiology consultation for risk assessment.
* Medications:
◦ Dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor).
◦ Anticoagulation (such as heparin).
◦ Beta-blockers.
◦ Statins.
Which of the following is a hallmark clinical presentation of acute pericarditis?
A) Chest pain relieved by lying flat
B) Sharp, pleuritic chest pain relieved by sitting up and leaning forward
C) Chest pain that worsens with exertion and is relieved by rest
D) No chest pain, only shortness of breath
Correct Answer: B) Sharp, pleuritic chest pain relieved by sitting up and leaning forward is characteristic of pericarditis.
Why the others are wrong:
A is incorrect because pericarditis pain worsens when lying flat.
C describes stable angina, not pericarditis.
D is incorrect because pericarditis usually presents with chest pain, although shortness of breath can occur if a pericardial effusion develops.
ACUTE PERICARDITIS
Etiology:
* Inflammation of the pericardial sac.
* Causes include viral infections, autoimmune diseases, post- myocardial infarction syndromes, and malignancy.
Clinical Presentation:
* Sharp, pleuritic chest pain worsened by lying flat and
improved by sitting up or leaning forward.
* Pericardial friction rub heard on auscultation.
ACUTE PERICARDITIS
Diagnostic Criteria: (requires at least 2 of 4)
* Typical chest pain.
* Pericardial friction rub.
* Widespread ST-segment elevation and PR-segment
depression on Electrocardiogram (ECG).
* New or worsening pericardial effusion on echocardiogram.
More clarity
Is the pericarditis refering to the fascia tissue
Not exactly! Pericarditis refers to inflammation of the pericardium, which is a fibrous sac surrounding the heart, rather than fascia tissue.
Difference Between Pericardium and Fascia:
Pericardium: A double-layered sac that encloses the heart. It consists of:
Fibrous pericardium (tough outer layer) – provides structural support and anchors the heart.
Serous pericardium (inner layer) – has two sublayers:
Parietal layer (lines the fibrous pericardium).
Visceral layer (epicardium) (directly covers the heart).
Between these layers is the pericardial cavity, which contains a small amount of lubricating fluid to reduce friction.
Fascia: A connective tissue that surrounds muscles, blood vessels, and organs. It provides structural support and allows movement. While the fibrous pericardium shares some structural similarities with fascia, pericarditis is specifically inflammation of the pericardial layers, not general fascial tissue.
Which of the following differentiates NSTEMI from unstable angina?
A) ECG findings
B) The presence of chest pain
C) Elevated troponins
D) Duration of symptoms
Correct Answer: C) Elevated troponins indicate myocardial injury (NSTEMI), whereas unstable angina has normal troponins.
Why the others are wrong:
A ECG findings in both conditions may show ST-segment depression or T-wave inversion, but ST elevation is absent.
B Both conditions present with chest pain.
D Duration of symptoms alone does not distinguish the two.
What is the most common risk factor for aortic dissection?
A) Hypoxia
B) Hypertension
C) Hyperkalemia
D) Smoking
Correct Answer: B) Hypertension is the most significant risk factor for aortic dissection, as it increases stress on the aortic wall.
Why the others are wrong:
A Hypoxia does not directly cause aortic dissection.
C Hyperkalemia is associated with cardiac arrhythmias but not aortic dissection.
D Smoking is a risk factor for atherosclerosis but is not the primary cause of aortic dissection.
Which of the following is NOT a common management strategy for stable angina?
A) Beta-blockers
B) Aspirin
C) Immediate reperfusion therapy
D) Lifestyle modifications
Correct Answer: C) Immediate reperfusion therapy (e.g., PCI) is used for STEMI, not stable angina.
Why the others are correct:
A Beta-blockers reduce myocardial oxygen demand.
B Aspirin reduces the risk of clot formation.
D Lifestyle changes (such as smoking cessation and diet modification) are critical for managing stable angina.
What is the immediate action in-office for a patient experiencing ST-Elevation Myocardial Infarction (STEMI)?
A) Give the patient a glass of water and let them rest.
B) Call 911 immediately and administer 160-325 mg chewable aspirin if no contraindications.
C) Perform immediate pericardiocentesis.
D) Have the patient walk around to assess if symptoms improve.
Answer: B) Call 911 immediately and administer 160-325 mg chewable aspirin if no contraindications.
Explanation:
A is wrong: Simply resting is insufficient; STEMI is a medical emergency.
B is correct: Calling 911 ensures rapid emergency care, and aspirin helps reduce clot formation.
C is wrong: Pericardiocentesis is for cardiac tamponade, not STEMI.
D is wrong: Physical activity increases cardiac workload and worsens ischemia.
ST-ELEVATION MYOCARDIAL INFARCTION (STEMI)
ND Management in-office:
* Recognize symptoms of acute coronary syndrome (ACS).
* Call 911 immediately.
* If no contraindications, administer 160–325 mg chewable aspirin.
* Position patient comfortably (typically seated or semi-reclined) to
reduce cardiac workload.
* Keep the environment calm, monitor vitals.
* Be prepared to initiate CPR and AED use if the patient deteriorates into cardiac arrest.
For ST-Elevation Myocardial Infarction (STEMI), the recommended patient positioning is seated or semi-reclined, rather than lying flat or fully upright, due to the following reasons:
Why Not Flat?
Increases Cardiac Preload:
Lying flat increases venous return (preload) to the heart, which can worsen cardiac workload and exacerbate ischemia in an already struggling myocardium.
This can increase pulmonary congestion in patients with heart failure or pulmonary edema, making breathing more difficult.
Higher Risk of Pulmonary Edema:
Patients with acute heart failure or left ventricular dysfunction (common in STEMI) may develop pulmonary congestion due to fluid backing up into the lungs.
Lying flat can worsen shortness of breath and oxygenation.
Why Not Fully Erect?
May Cause Hypotension:
A fully upright position reduces venous return, which can lower blood pressure excessively, especially if the patient is already hypotensive from cardiogenic shock.
This could lead to reduced coronary perfusion, worsening the infarct.
Risk of Syncope:
If the patient experiences a sudden drop in blood pressure, they may faint, increasing the risk of injury.
Why Semi-Reclined or Seated?
Optimal balance between preload and afterload:
Sitting at a 45-degree angle or semi-reclined reduces cardiac workload while preventing excessive venous return.
Eases breathing:
This position helps reduce pulmonary congestion, making it easier to breathe.
More stable hemodynamics:
It prevents extreme blood pressure changes that could further compromise cardiac perfusion.
Summary
Flat = Too much preload → Worsens pulmonary congestion & cardiac strain
Fully upright = Too little preload → Risk of hypotension & syncope
Semi-reclined = Best balance for perfusion & breathing support
What distinguishes NSTEMI from unstable angina?
A) NSTEMI involves myocardial injury with elevated troponins, while unstable angina does not.
B) Unstable angina always presents with ST elevation.
C) NSTEMI is relieved by rest and nitroglycerin, while unstable angina is not.
D) Both conditions involve complete coronary artery occlusion.
Answer: A) NSTEMI involves myocardial injury with elevated troponins, while unstable angina does not.
Explanation:
A is correct: NSTEMI has elevated troponins, indicating myocardial injury, while unstable angina does not.
B is wrong: ST elevation is seen in STEMI, not in unstable angina.
C is wrong: Neither NSTEMI nor unstable angina is fully relieved by rest/nitroglycerin.
D is wrong: Complete occlusion occurs in STEMI, not NSTEMI/unstable angina.
NON-ST ELEVATION MYOCARDIAL INFARCTION
(NSTEMI) / UNSTABLE ANGINA
Etiology:
* Partial blockage of a coronary artery due to a thrombus or plaque rupture.
* Unstable angina involves ischemia without myocardial injury (normal troponins).
* Non-ST Elevation Myocardial Infarction (NSTEMI) involves myocardial injury
(elevated troponins).
Clinical Presentation:
* Chest pain at rest or with minimal exertion.
* Pain not fully relieved by rest or nitroglycerin.
* Associated symptoms similar to STEMI (shortness of breath, diaphoresis, nausea).
Which diagnostic feature helps differentiate NSTEMI from STEMI?
A) STEMI shows ST-segment elevation, while NSTEMI does not.
B) NSTEMI always presents with normal ECG findings.
C) STEMI has normal troponin levels, while NSTEMI does not.
D) NSTEMI patients never experience chest pain.
Answer: A) STEMI shows ST-segment elevation, while NSTEMI does not.
Explanation:
A is correct: STEMI shows ST elevation, while NSTEMI may show ST depression or T wave inversion but no ST elevation.
B is wrong: NSTEMI may have ECG changes like ST depression or T-wave inversion.
C is wrong: STEMI and NSTEMI both have elevated troponins; unstable angina has normal troponins.
D is wrong: NSTEMI can cause chest pain at rest or with minimal exertion.
Which diagnostic feature helps differentiate NSTEMI from STEMI?
A) STEMI shows ST-segment elevation, while NSTEMI does not.
B) NSTEMI always presents with normal ECG findings.
C) STEMI has normal troponin levels, while NSTEMI does not.
D) NSTEMI patients never experience chest pain.
Answer: A) STEMI shows ST-segment elevation, while NSTEMI does not.
Explanation:
A is correct: STEMI shows ST elevation, while NSTEMI may show ST depression or T wave inversion but no ST elevation.
B is wrong: NSTEMI may have ECG changes like ST depression or T-wave inversion.
C is wrong: STEMI and NSTEMI both have elevated troponins; unstable angina has normal troponins.
D is wrong: NSTEMI can cause chest pain at rest or with minimal exertion.
What is the best way to manage a stable angina episode in-office if no signs of instability are present?
A) Perform CPR immediately.
B) Confirm predictable exertional chest pain history and ensure appropriate use of nitroglycerin.
C) Administer a thrombolytic agent.
D) Call 911 immediately for emergency angioplasty.
Answer: B) Confirm predictable exertional chest pain history and ensure appropriate use of nitroglycerin.
Explanation:
A is wrong: CPR is unnecessary unless the patient is pulseless and unresponsive.
B is correct: Stable angina is predictable and relieved by rest/nitroglycerin, so management includes patient education and medication adherence.
C is wrong: Thrombolytics are used for STEMI, not stable angina.
D is wrong: Calling 911 is unnecessary unless symptoms worsen or become unstable.
What is the best way to manage a stable angina episode in-office if no signs of instability are present?
A) Perform CPR immediately.
B) Confirm predictable exertional chest pain history and ensure appropriate use of nitroglycerin.
C) Administer a thrombolytic agent.
D) Call 911 immediately for emergency angioplasty.
Answer: B) Confirm predictable exertional chest pain history and ensure appropriate use of nitroglycerin.
Explanation:
A is wrong: CPR is unnecessary unless the patient is pulseless and unresponsive.
B is correct: Stable angina is predictable and relieved by rest/nitroglycerin, so management includes patient education and medication adherence.
C is wrong: Thrombolytics are used for STEMI, not stable angina.
D is wrong: Calling 911 is unnecessary unless symptoms worsen or become unstable.
Why is early CPR and AED use critical in cardiac arrest?
A) It increases survival rates from <10% to ~50%.
B) It can permanently cure coronary artery disease.
C) It prevents myocardial infarction from occurring.
D) It eliminates the need for hospital treatment.
Answer: A) It increases survival rates from <10% to ~50%.
Explanation:
A is correct: CPR and AED use significantly improve survival chances in cardiac arrest.
B is wrong: CPR does not cure coronary artery disease; it temporarily maintains circulation.
C is wrong: CPR does not prevent myocardial infarction but can sustain life until treatment.
D is wrong: CPR and AED are initial interventions; hospital care is still required.
Which of the following is a shockable rhythm that an AED can treat?
A) Ventricular Fibrillation (VF)
B) Pulseless Electrical Activity (PEA)
C) Asystole
D) Sinus Bradycardia
Answer: A) Ventricular Fibrillation (VF).
Explanation:
A is correct: VF is a chaotic rhythm with no effective cardiac output, and an AED can deliver a shock to restore normal rhythm.
B is wrong: PEA has electrical activity but no pulse, and an AED does not shock it.
C is wrong: Asystole (flatline) has no electrical activity, so shocking is ineffective—CPR is required.
D is wrong: Sinus bradycardia is a slow but regular rhythm, not a cardiac arrest rhythm.
SHOCKABLE VS. NON-SHOCKABLE RHYTHMS
* Shockable rhythms (AED can deliver a shock):
* Ventricular Fibrillation (VF): Chaotic electrical activity, no effective cardiac
output.
* Pulseless Ventricular Tachycardia (VT): Rapid, ineffective contractions with no
pulse.
* Non-shockable rhythms (CPR only):
* Asystole: No electrical activity; flatline.
* Pulseless Electrical Activity (PEA): Electrical activity without mechanical
contraction.
What is the primary cause of acute pericarditis?
A) Atherosclerotic plaque rupture
B) Viral infection, autoimmune disease, or post-MI inflammation
C) Complete occlusion of a coronary artery
D) High cholesterol levels
Answer: B) Viral infection, autoimmune disease, or post-MI inflammation.
Explanation:
A is wrong: Plaque rupture causes myocardial infarction (MI), not pericarditis.
B is correct: Acute pericarditis is often due to viral infections, autoimmune conditions, or post-MI Dressler’s syndrome.
C is wrong: Coronary artery occlusion causes STEMI, not pericarditis.
D is wrong: High cholesterol contributes to atherosclerosis but does not directly cause pericarditis.
Why does sitting up help relieve pericarditis pain?
A) It reduces pressure on the pericardium by decreasing venous return to the heart.
B) It increases heart rate, improving perfusion.
C) It stops the inflammatory process.
D) It eliminates pericardial effusion.
Answer: A) It reduces pressure on the pericardium by decreasing venous return to the heart.
Explanation:
A is correct: Leaning forward reduces the heart’s contact with the pericardium, decreasing pain.
B is wrong: Increasing heart rate does not relieve pericarditis pain.
C is wrong: The inflammatory process is treated with medications, not sitting up.
D is wrong: Sitting up does not eliminate pericardial effusion; drainage (pericardiocentesis) may be required if severe.
Pericarditis can lead to what life-threatening complication?
A) Aortic dissection
B) Pulmonary embolism
C) Cardiac tamponade
D) Ventricular septal defect
Answer: C) Cardiac tamponade.
Explanation:C is correctPericardial effusion can accumulate and compress the heart, leading to tamponade.
A is wrong: Aortic dissection is a separate vascular emergency.
B is wrong: Pulmonary embolism involves a clot in the lungs, unrelated to pericarditis.
D is wrong: Ventricular septal defect is a congenital heart issue, not a complication of pericarditis.
Why is CPR critical in cardiac arrest?
A) It restores oxygenation and perfusion.
B) It eliminates the need for advanced interventions.
C) It can double or triple survival rates.
D) It reduces the risk of brain and organ damage.
Answer: A, C, and D
(A) Correct – CPR helps circulate oxygenated blood, keeping organs viable.
(B) Incorrect – CPR does not eliminate the need for advanced interventions like defibrillation or medications.
(C) Correct – Effective CPR significantly improves survival rates.
(D) Correct – CPR prevents brain and organ damage by maintaining circulation Brain damage risk: Irreversible brain damage begins within 4-6 *
minutes without circulation.
WHY EARLY RECOGNITION MATTERS
* Out-of-hospital cardiac arrest (OHCA) statistics: ~356,000 cases/year in the U.S.
* Survival rates: Without intervention, survival is <10%; early CPR +
AED use improves survival to ~50%.
* Role of bystanders: Most arrests occur outside the hospital—prompt
intervention is key.
* CPR is indicated when:
* Unresponsive, no normal breathing, no pulse.
* Respiratory arrest with a risk of cardiac arrest.
* AED is indicated when:
* Victim is unconscious, pulseless, and not breathing normally.
* Shockable rhythms detected (VF, pulseless VT).
Which of the following is true about high-quality CPR select more than 1?
A) Compression depth should be at least 2 inches (5 cm) in adults.
B) The compression rate should be 80-100 compressions per minute.
C) Full chest recoil should be allowed after each compression.
D) Compressions should be interrupted frequently for pulse checks.
Answer: (A) Correct – Proper depth ensures effective circulation.
(C) Correct – Full chest recoil allows the heart to refill with blood.
Incorrect:
(B) Incorrect – The correct rate is 100-120 compressions per minute, not 80-100.
(D) Incorrect – Minimizing interruptions improves outcomes; only check pulses if a rhythm change is suspected.
CPR – WHY IT’S CRITICAL
* Restores oxygenation and perfusion.
* Buys time until advanced interventions can be initiated.
* Reduces risk of brain and organ damage.
* Effective CPR doubles or triples survival rates.
* High-quality compressions are key:
* Depth: At least 2 inches (5 cm) in adults.
* Rate: 100–120 compressions per minute.
* Allow full chest recoil.
What is the correct sequence when using an AED?
A) Turn on the AED and attach pads to the patient’s chest.
B) Deliver a shock first before analyzing the rhythm.
C) Ensure no one is touching the patient while the AED analyzes.
D) Follow the AED prompts for shock or CPR.
Answer: A, C, and D
(A) Correct – The first step is to turn on the AED and attach electrode pads.
(B) Incorrect – The AED analyzes the rhythm before deciding if a shock is needed.
(C) Correct – Touching the patient can interfere with rhythm analysis.
(D) Correct – Following AED prompts ensures correct intervention.
HOW TO USE AN AED
* Turn on the AED.
* Attach electrode pads to the patient’s bare chest.
* Ensure no one is touching the patient during analysis.
* Follow AED prompts:
* If shock advised → Press shock button.
* If no shock advised → Continue CPR.
* Continue cycles of CPR and AED analysis until EMS arrives.
Which of the following medications is used for acute coronary syndrome (ACS)?
A) Atropine
B) Nitroglycerin
C) Aspirin
D) Epinephrine
Answer: B and C
(B) Correct – Nitroglycerin reduces myocardial oxygen demand by vasodilation.
(C) Correct – Aspirin prevents further platelet aggregation, reducing clot formation.
Incorrect:
(A) Incorrect – Atropine is used for bradycardia, not ACS.
(D) Incorrect – Epinephrine is used for cardiac arrest, not first-line ACS treatment.
What is the correct aspirin dose for suspected ACS?
A) 160-325 mg chewed immediately
B) 81 mg daily
C) 0.5 mg IV bolus
D) 325 mg IV push
Answer: A
(A) Correct – The correct loading dose for ACS is 160-325 mg chewed.
(B) Incorrect – 81 mg is the maintenance dose, not the emergency dose.
(C) Incorrect – Aspirin is not given IV; it is taken orally.
(D) Incorrect – 325 mg IV push is not a standard administration route for aspirin.
Which of the following is not a contraindication for nitroglycerin?
A) Systolic blood pressure (SBP) <90 mmHg
B) Recent use of sildenafil (Viagra)
C) Tachycardia
D) Severe aortic stenosis
Answer: (C) Incorrect – Tachycardia is not a contraindication, though it may be a side effect.
(A) Correct – Nitroglycerin lowers blood pressure, so it is contraindicated in hypotension.
(B) Correct – Using PDE5 inhibitors (e.g., sildenafil) with nitroglycerin can cause a dangerous drop in blood pressure.
(D) Correct – In severe aortic stenosis, nitroglycerin can cause hemodynamic collapse.
What is the primary action of atropine in emergency cardiac care?
A) Blocks parasympathetic stimulation to increase heart rate
B) Causes vasodilation to reduce blood pressure
C) Inhibits platelet aggregation to prevent clot formation
D) Reduces myocardial oxygen demand
Answer: A
(A) Correct – Atropine blocks vagal tone, increasing heart rate in bradycardia.
(B) Incorrect – Atropine does not cause vasodilation.
(C) Incorrect – Aspirin, not atropine, inhibits platelet aggregation.
(D) Incorrect – Nitroglycerin, not atropine, reduces myocardial oxygen demand.
What is NOT common side effects of nitroglycerin?
A) Hypertension
B) Headache
C) Hypotension
D) Reflex tachycardia
(A) Incorrect– Nitroglycerin lowers blood pressure, so it does not cause hypertension.
(B) True – Vasodilation causes headaches.
C) True – Hypotension is a major side effect, especially in patients with low baseline BP.
(D) True – Reflex tachycardia occurs as the heart compensates for lowered BP.
What is the most important factor in improving survival for cardiac arrest patients?
A) Immediate administration of aspirin
B) Early recognition, CPR, and AED use
C) Administering nitroglycerin as soon as possible
D) Giving atropine to increase heart rate
Answer: (B) Correct – Early recognition, CPR, and AED use are critical in cardiac arrest because they improve survival rates
(A) Incorrect – Aspirin is important for ACS but does not directly restart the heart in cardiac arrest.
(C) Incorrect – Nitroglycerin is useful for angina or ACS but is not a priority in cardiac arrest.
(D) Incorrect – Atropine is used for bradycardia but is not the primary treatment for cardiac arrest.
Which cardiac rhythms are considered shockable by an AED?
A) Asystole and Pulseless Electrical Activity (PEA)
B) Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (VT)
C) Normal Sinus Rhythm and Bradycardia
D) Atrial Fibrillation and Supraventricular Tachycardia
Answer: (B) Correct – VF and Pulseless VT are the two shockable rhythms recognized by an AED.
(A) Incorrect – Asystole and PEA are non-shockable rhythms. CPR and medications are needed instead.
(C) Incorrect – Normal sinus rhythm does not require a shock, and bradycardia is treated with atropine or pacing.
(D) Incorrect – Atrial fibrillation and supraventricular tachycardia are not immediately shockable in an emergency setting.
What is the mechanism of action of aspirin in acute coronary syndrome (ACS)?
A) It dissolves existing blood clots
B) It prevents platelet aggregation by inhibiting thromboxane A2
C) It acts as a vasodilator to improve blood flow
D) It slows heart rate to reduce myocardial oxygen demand
Answer: (B) Correct – Aspirin inhibits thromboxane A2, preventing platelets from clumping together and forming new clots.
(A) Incorrect – Aspirin prevents new clot formation but does not dissolve existing clots (thrombolytics like tPA do that).
(C) Incorrect – Vasodilation is the action of nitroglycerin, not aspirin.
(D) Incorrect – Aspirin does not directly affect heart rate. Beta-blockers or calcium channel blockers do.
A patient with suspected ACS should receive what initial dose of aspirin?
A) 160-325 mg chewed
B) 81 mg swallowed whole
C) 500 mg IV
D) 325 mg sublingually
Answer: (A) Correct – 160-325 mg of aspirin should be chewed immediately in ACS to allow for rapid absorption.
(B) Incorrect – 81 mg is the maintenance dose, not the initial loading dose.
(C) Incorrect – Aspirin is not given IV in ACS.
(D) Incorrect – Aspirin is taken orally, not sublingually.
Which of the following is a contraindication for aspirin use?
A) Hypertension
B) History of peptic ulcer disease with active GI bleeding
C) Diabetes mellitus
D) COPD
(B) Correct – Active gastrointestinal bleeding is a contraindication due to aspirin’s increased risk of bleeding.
(A) Incorrect – Hypertension alone is not a contraindication, though caution is needed in severe cases.
(C) Incorrect – Diabetes is not a contraindication, though aspirin use in diabetics should be considered carefully.
(D) Incorrect – COPD is not a contraindication, but aspirin can trigger bronchospasm in some asthmatics.
Why must nitroglycerin not be given to a patient with systolic blood pressure (SBP) below 90 mmHg?
A) It can cause severe hypertension
B) It may cause excessive hypotension and worsen perfusion
C) It will increase heart rate dangerously
D) It interacts with aspirin
Answer: (B) Correct – Nitroglycerin is a vasodilator, and if the BP is already low, it can cause dangerous hypotension and shock.
(A) Incorrect – Nitroglycerin causes hypotension, not hypertension.
(C) Incorrect – Reflex tachycardia can occur, but the main danger is severe hypotension.
(D) Incorrect – Nitroglycerin does not interact with aspirin in a harmful way.
NITROGLYCERIN – OVERVIEW
* Class: Nitrate (Vasodilator)
* Mechanism of Action: Relaxes vascular smooth muscle,
reducing myocardial oxygen demand.
* Main Use: Angina, Acute Coronary Syndrome (ACS)
NITROGLYCERIN – DOSE & ADMINISTRATION
* Sublingual (SL): 0.3-0.6 mg every 5 minutes (maximum 3
doses)
* Intravenous (IV) infusion: 5 mcg/min, titrate as needed
* Topical (patches/ointment): Used for long-term prophylaxis
NITROGLYCERIN – CONTRAINDICATIONS & SIDE
EFFECTS
* Contraindications:
* Hypotension (SBP <90 mmHg)
* Recent use of PDE5 inhibitors (e.g., Sildenafil)
* Severe aortic stenosis
* Side Effects:
* Headache
* Hypotension
* Reflex tachycardia
What is a major contraindication for nitroglycerin use?
A) Taking sildenafil (Viagra) in the last 24 hours
B) Hypertension
C) Bradycardia
D) Having a history of angina
Answer: (A) Correct – Taking PDE5 inhibitors (like sildenafil) within 24 hours can cause severe hypotension when combined with nitroglycerin.
(B) Incorrect – Nitroglycerin is actually used to treat hypertension in some cases.
(C) Incorrect – Bradycardia is not a direct contraindication, but caution is needed.
(D) Incorrect – A history of angina is an indication, not a contraindication.
What is the mechanism of action of atropine?
A) It blocks parasympathetic stimulation, increasing heart rate
B) It increases parasympathetic activity, slowing heart rate
C) It acts as a vasodilator to reduce blood pressure
D) It directly stimulates the myocardium
Answer: A) Correct – Atropine blocks parasympathetic stimulation (via the vagus nerve), which increases heart rate.
(B) Incorrect – Atropine does the opposite—it decreases parasympathetic activity.
(C) Incorrect – Atropine does not directly affect blood pressure as a vasodilator.
(D) Incorrect – Atropine does not directly stimulate the myocardium; it works on the autonomic nervous system.
Class: Anticholinergic
Mechanism of Action: Blocks parasympathetic stimulation,
increasing heart rate.
Main Use: Bradycardia, AV block
ATROPINE – DOSE & ADMINISTRATION
* Intravenous (IV) Bolus: 0.5 mg every 3-5 minutes (maximum 3
mg)
ATROPINE – CONTRAINDICATIONS & SIDE EFFECTS
* Contraindications:
* Glaucoma
* Tachycardia
* Obstructive gastrointestinal disorders
* Side Effects:
* Dry mouth
* Blurred vision
* Urinary retention
When treating a patient with chest pain, what is the most important first step?
A) Give nitroglycerin immediately
B) Perform a primary assessment using the ABCDE approach
C) Administer aspirin first
D) Start an IV and give fluids
Answer: (B) Correct – The ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) is the foundation of emergency assessment.
(A) Incorrect – Nitroglycerin should only be given after assessing BP and contraindications.
(C) Incorrect – Aspirin is important but should follow the assessment.
(D) Incorrect – IV fluids may be necessary, but assessment should come first.
Which of the following is the correct order of the Basic Emergency Management Framework?
A) Recognition → Stabilization → Assessment → Treatment → Disposition
B) Assessment → Recognition → Treatment → Disposition → Stabilization
C) Recognition → Assessment → Stabilization → Treatment → Disposition
D) Recognition → Treatment → Assessment → Disposition → Stabilization
Answer: C) Recognition → Assessment → Stabilization → Treatment → Disposition
✅ Correct Explanation: The correct sequence follows a logical emergency response progression: identifying the condition (Recognition), evaluating the patient (Assessment), providing immediate life-saving interventions (Stabilization), implementing proper medical treatment (Treatment), and finally deciding on the level of care (Disposition).
❌ Incorrect Explanations:
(A) Puts Stabilization before Assessment, but we need to evaluate the patient before intervening.
(B) Recognition must come first, as it involves identifying the emergency.
(D) Assessment must occur before Treatment to ensure proper management.
INTRODUCTION TO THE BASIC EMERGENCY
MANAGEMENT FRAMEWORK
* Recognition: Identify signs and symptoms of critical conditions.
* Assessment: Perform primary and secondary surveys.
* Stabilization: Provide immediate interventions.
* Treatment: Initiate evidence-based management.
* Disposition: Determine the appropriate level of care
(hospitalization, outpatient follow-up, etc.).
Which of the following is NOT a common cause of chest pain in emergency settings?
A) Myocardial infarction (MI)
B) Costochondritis
C) Esophageal spasm
D) Appendicitis
Answer: D) Appendicitis ✅ Correct Explanation: Appendicitis causes abdominal pain, not chest pain. The common causes of chest pain include cardiac (e.g., MI, angina), pulmonary (e.g., PE, pneumothorax), gastrointestinal (e.g., GERD, esophageal spasm), and musculoskeletal (e.g., costochondritis).
❌ Incorrect Explanations:
(A) MI is a cardiac cause of chest pain.
(B) Costochondritis is a musculoskeletal cause of chest pain.
(C) Esophageal spasm is a gastrointestinal cause of chest pain.
ch of the following is a red flag symptom in a patient with chest pain?
A) Sharp chest pain that worsens with movement
B) Diaphoresis, dyspnea, and syncope
C) Mild epigastric discomfort after eating spicy food
D) Localized tenderness to palpation of the chest wall
Answer: B) Diaphoresis, dyspnea, and syncope
✅ Correct Explanation: These symptoms suggest a cardiac emergency such as a myocardial infarction (MI) or acute coronary syndrome (ACS).
❌ Incorrect Explanations:
(A) Sharp pain that worsens with movement is more likely musculoskeletal.
(C) Mild epigastric discomfort after spicy food suggests GERD, which is not an immediate emergency.
(D) Localized tenderness suggests costochondritis, which is non-life-threatening.
RECOGNITION OF CHEST PAIN IN EMERGENCY
SETTINGS
* Key Red Flags:
* Crushing, pressure-like chest pain radiating to the jaw/arm.
* Diaphoresis, dyspnea, syncope.
* Hypotension or hemodynamic instability.
Which of the following is the correct order of the ABCDE approach in primary assessment?
A) Airway → Breathing → Circulation → Disability → Exposure
B) Airway → Circulation → Breathing → Disability → Exposure
C) Circulation → Airway → Breathing → Disability → Exposure
D) Airway → Breathing → Exposure → Circulation → Disability
Which of the following is the correct order of the ABCDE approach in primary assessment?
A) Airway → Breathing → Circulation → Disability → Exposure
B) Airway → Circulation → Breathing → Disability → Exposure
C) Circulation → Airway → Breathing → Disability → Exposure
D) Airway → Breathing → Exposure → Circulation → Disability
Answer: A) Airway → Breathing → Circulation → Disability → Exposure
✅ Correct Explanation: The ABCDE approach ensures immediate life-threatening conditions are addressed in the correct order: securing the airway, assessing breathing, ensuring adequate circulation, checking neurological status, and evaluating exposure-related factors (e.g., cyanosis, JVD).
❌ Incorrect Explanations:
(B) Circulation should be checked after Breathing, as oxygenation is prioritized.
(C) Circulation is important but comes after Airway and Breathing.
(D) Exposure should be last, not before Circulation or Disability.
A patient presents with chest pain radiating to the jaw and left arm, diaphoresis, and hypotension. What is the first intervention?
A) Administer sublingual nitroglycerin
B) Give 2 baby aspirin (162 mg total)
C) Apply oxygen via nonrebreather mask
D) Check airway, breathing, and circulation
Answer: D) Check airway, breathing, and circulation
✅ Correct Explanation: Before administering medications, ABC assessment is the priority to determine if the patient is stable enough for further interventions.
❌ Incorrect Explanations:
(A) Nitroglycerin is given only if systolic BP is ≥ 90 mmHg.
(B) Aspirin is given after confirming the patient is stable.
(C) Oxygen can be helpful but is not the first step before the ABCs.
Which of the following is a contraindication for aspirin (ASA) administration in chest pain?
A) Patient has a history of asthma with aspirin sensitivity
B) Patient has diabetes
C) Patient has a history of GERD
D) Patient has hypertension
Answer: A) Patient has a history of asthma with aspirin sensitivity
✅ Correct Explanation: Patients with aspirin-sensitive asthma can experience bronchospasm, rhinitis, and anaphylaxis, making ASA contraindicated.
❌ Incorrect Explanations:
(B) Diabetes is not a contraindication for aspirin.
(C) GERD can cause dyspepsia but is not a strict contraindication.
(D) Hypertension does not prevent ASA use.
Marburg Heart Score
1. According to the Marburg Heart Score, at what score should a patient be taken to the ER due to a high likelihood of coronary heart disease?
A) 1 or more
B) 2 or more
C) 3 or more
D) 4 or more
✅ Correct Answer: C) Hyperactive bowel sounds
Why? Hyperactive bowel sounds are more related to gastrointestinal motility disorders, not emergency chest pain evaluation.
❌ Wrong Answers:
A) Murmurs, gallops (S3/S4): Important for cardiovascular assessment (e.g., heart failure).
B) Crackles, diminished breath sounds: Critical for respiratory issues (e.g., pulmonary embolism, pneumothorax).
D) Epigastric tenderness, distension: Assesses for gastrointestinal causes (e.g., GERD, esophageal spasm).
2. What is the Marburg Heart Score?
The Marburg Heart Score is a risk assessment tool for determining the likelihood of coronary heart disease (CHD) in patients with chest pain.
Interpreting the Score:
0-2 points: Low risk of coronary heart disease.
3+ points: High risk (≥25% chance of CHD), requiring urgent ER evaluation.
Scoring System (Each Item = 1 Point)
✅ The patient scores 1 point for each of the following:
Age ≥ 55 (men) or ≥ 65 (women)
Pain aggravated by physical exertion
Patient assumes cardiac origin of pain
Known history of vascular disease (e.g., previous MI, stroke, peripheral artery disease)
No pain reproducible by palpation (suggesting it’s not musculoskeletal)
- When administering sublingual nitroglycerin (NITROSTAT), what is the MAXIMUM total dose a patient can receive?
A) 0.6 mg
B) 1.2 mg
C) 1.8 mg
D) 2.4 mg
✅ Correct Answer: C) 1.8 mg
Why? The patient can take up to 3 doses of 0.6 mg each, spaced 5 minutes apart, not exceeding 1.8 mg total.
❌ Wrong Answers:
A) 0.6 mg: This is a single dose, not the max total.
B) 1.2 mg: This accounts for only two doses, but three are allowed.
D) 2.4 mg: Exceeds the maximum safe limit of 1.8 mg.
Incident Reporting
4. After providing emergency care, what form should the member complete?
A) Patient Discharge Summary
B) Paramedic Transfer Sheet
C) Accident, Injury, and Incident Report Form
D) Emergency Medical Release Form
✅ Correct Answer: C) Accident, Injury, and Incident Report Form
Why? This form is required to document medical emergencies, including actions taken and patient outcomes.
❌ Wrong Answers:
A) Patient Discharge Summary: Used in hospital settings, not emergency response.
B) Paramedic Transfer Sheet: Completed by paramedics, not the responding member.
D) Emergency Medical Release Form: Used for legal consent, not emergency documentation.
