Module 3 - Cardiovascular and Medical Emergencies

Question 1

Hypoxic Hypoxia

Answer 1

aka Altitude Hypoxia Is a deficiency in the alveolar oxygen exchange, which can be caused by low barometric pressure.

Question 2

Hypemic hypoxia

Answer 2

Is a reduction in the oxygen-carrying capacity of the blood.

Question 3

Stagnant hypoxia

Answer 3

Occurs when conditions exist that result in reduced total cardiac output, pooling of the blood within certain regions of the body, a decreased blood flow to the tissues, or restriction of blood flow.

Question 4

Histotoxic hypoxia

Answer 4

aka tissue poisoning Occurs when metabolic disorders or poisoning of the cytochromic oxidase enzyme results in a cell’s inability to use molecular oxygen.

Question 5

Which patient is not affected with altitude temperature changes?

A. Cardiac patient

B. Burn patient

C. Head injured patient

D. Spinal cord injured patient

Answer 5

A: Cardiac patients are usually not affected with altitude temperature changes.

Question 6

Your patient presents with epigastric pain, nausea, and vomiting for the last hour. He describes his chest pain as “heavy in nature.” What does the following 12-lead ECG show? [inferior mi ecg]

Answer 6

C: Inferior wall MI presents with ST elevation in leads II, III, and aVF. Reciprocal changes are present in leads I, aVL, and V1-V4.

Question 7

Inferior MI - II, III, aVF would show reciprocal changes in

Answer 7

reciprocal changes seen in I, aVL, V1-V4

Question 8

Anterior-septal wall MI identified in V1-V4, would show reciprocal changes in

Answer 8

reciprocal changes seen in II, III, aVF, aVL

Question 9

Lateral wall MI identified in I, aVL, V5, V6 would show reciprocal changes in

Answer 9

reciprocal changes seen in II, III, aVF

Question 10

Posterior wall MI identified in V6 would show reciprocal changes in

Answer 10

reciprocal changes seen in V1-V4

Question 11

CPK as a marker

Answer 11

onset 4-6 hours, peaks 24 hours

Question 12

CPK-MB as a marker

Answer 12

onset 4-6 hours, peaks 12-20 hours

Question 13

LDH as a marker

Answer 13

onset 8-12 hours, peaks 2-4 days

Question 14

Troponin I normal range (most sensitive test)

Answer 14

0-0.1 ng/mL; onset 4-6 hours, peaks 12-24 hours, returns to normal in 4-7 days

Question 15

Troponin T normal range (most sensitive test)

Answer 15

0-0.2 ng/mL; onset 3-4 hours, peaks 10-24 hours, returns to normal in 10-14 days

Question 16

Your patient is experiencing left ventricular diastolic failure. Therapy should be focused on

A. Augmentation of left ventricular clearing

B. Decreasing afterload

C. Decreasing preload

D. Diuretics and relief of anxiety

Answer 16

D. Diuretics and relief of anxiety. Relieving ischemia, treating atherosclerosis, and correcting renal artery stenosis are most helpful. In addition, efforts to keep patients dry, maintain a slow sinus rhythm, and control blood pressure provide a basic approach to diastolic dysfunction. When

Question 17

Your patient is exhibiting ST elevation in leads II, III, and AVF. ST depression is noted in V1-V3. Which of the following may prove hazardous?

A. Isotonic fluid bolus

B. Heparin

C. GII/BIIIa inhibitors

D. Nitroglycerin

Answer 17

D. Nitroglycerin

Question 18

Explain consideration of Nitro administration with a RVI

Answer 18

Hypotension, with distended neck veins and clear lungs occurs in patients with (RVI). This is because of occlusion of the proximal right coronary artery, the blood supply to the right ventricle. RVI patients are volume dependent because of inadequate preload to the left ventricle. The basis of therapy for a RVI is large volumes of intravenous fluids prior to administering medications that may decrease preload and inotropic support. RVI accompanies inferior-posterior wall MIs in 30-50% of patients.

Question 19

Clot busting and prevention

Answer 19

ASA G2BIIIA inhibitors—Reopro Integrelin Aggrastat Heparin Thrombolytics—Retavase tPA Streptokinase

Question 20

Treatments for Heart rate and myocardial O2 demand reduction

Answer 20

Beta-blockers Calcium-channel blockers

Question 21

Thrombolytics - Relative & Absolute CI’s, Complications

Answer 21

Relative contraindications: HTN, recent trauma, pregnancy Absolute contraindications: Active internal bleeding, Suspected aortic dissection, Known intracranial neoplasm, Previous hemorrhagic stroke, Stroke within the last year. Complications: bleeding, intracranial hemorrhage, dysrhythmias, cardiac tamponade, pulmonary edema

Question 22

Preload reduction management for AMI/Unstable angina

Answer 22

Nitrates (5-200 μg/min) Morphine (2-4 mg every 5-15 minutes)

Question 23

Electrical alternans may be caused by

A. Pulmonary embolus

B. Pericardial tamponade/effusion

C. Tension pneumothorax

D. Diaphragmatic rupture

Answer 23

B. Pericardial tamponade/effusion

Question 24

Antidote for Coumadin overdose is

A. Protamine sulfate

B. Glucagon

C. Vitamin K, FFP

D. Physostigmine

Answer 24

C. Vitamin K, FFP

Question 25

Anterior infarct – Coronary artery involved?

Answer 25

LAD

Question 26

Inferior infarct – Coronary artery involved?

Answer 26

RCA

Question 27

Lateral infarct – Coronary artery involved?

Answer 27

LCX

Question 28

Septal infarct – Coronary artery involved?

Answer 28

LAD

Question 29

Posterior infarct – Coronary artery involved?

Answer 29

LCX or RCA

Question 30

Wellen’s syndrome is ____ and it presents on ECG by __.

Answer 30

Associated with critical stenosis of the proximal LAD and impending infarct ECG: V2-V3 segment turns down into a negative T at a 60-90-degree angle

Question 31

A Transmural MI vs Subendocardial (nontransmural)

Answer 31

Extends through the full thickness of the myocardium and includes the endocardium and epicardium Vs. Necrosis is limited to the subendocardial surface

Question 32

Dressler’s syndrome

Answer 32

Is a secondary form of pericarditis that occurs in the setting of injury to the heart or the pericardium, the outer lining of the heart. It is also known as post MI syndrome and postcardiotomy pericarditis. Largely a self-limiting disease that very rarely leads to pericardial tamponade. Consisting of a persistent low-grade fever, chest pain (usually pleuritic in nature), a pericardial friction rub, and /or a pericardial effusion. The symptoms tend to occur within 2-5 days post MI but can be delayed for a few weeks or even months after infarction. It tends to subside in a few days.

Question 33

Pericardial effusion

Answer 33

Is the development of pericardial fluid as response to injury, acute pericarditis. Electrical alternans can be present on the ECG.

Question 34

Cardiac tamponade

Answer 34

Consists of cardiac output being compromised by the fluid around the heart. Beck’s triad can be indicative for the presence of tamponade, which includes muffled heart tones, hypotension, and jugular vein distension (JVD).

Question 35

Beck’s Triad is

Answer 35

can be indicative for the presence of tamponade which includes: muffled heart tones hypotension jugular vein distension (JVD).

Question 36

Management of cardiac tamponade

Answer 36

ABCs intravenous fluids pericardiocentesis

Question 37

S1 heart sound: Description - Location to hear - May indicate -

Answer 37

S1 heart sound: Description - A normal S1 sound is low pitched and of longer duration than S2. Location to hear - Best heard over the mitral area at the apex which is approximately at the fifth intercostal space, midclavicular left side of the chest. May indicate - Corresponds to the closure of the mitral and tricuspid valves (atrioventricular—AV valves) at the beginning of ventricular contraction or systole.

Question 38

S2 heart sound: Description - Location to hear - May indicate -

Answer 38

S2 heart sound: Description - A normal S2 sound is higher pitched and of shorter duration than S1 Location to hear - The second heart tone, or S2, “Dub” is best heard over the aortic area which is located at the second intercostal space at the base of the heart, right sternal border. A normal S2 sound is higher pitched and of shorter duration than S1. May indicate - Corresponds to closure of the aortic and pulmonic valves (semilunar valves) at the end of ventricular systole.

Question 39

S3 heart sound: Description - Location to hear - May indicate -

Answer 39

S3 heart sound: Description - Abnormal heart sound that may sound like the word “Ken-tu-cky” in three fairly evenly spaced sounds. Location to hear - The S3 sound is heard immediately after S2 and is normal in children and young adolescents but usually disappears after the age of thirty. May indicate - When heard in adults, an S3 is called a “gallop” and indicates left ventricular failure.

Question 40

S4 heart sound: Description - Location to hear - May indicate -

Answer 40

S4 heart sound: Description - Abnormal heart sound that may sound like the word “Tennessee” where the three syllables come quick followed by a pause. Location to hear - The S4 sound is heard immediately before the S1 and may be present in infants and children. May indicate - The S4 is produced with decreased compliance of the ventricle and may indicate MI or shock.

Question 41

Protamine sulfate is used for

Answer 41

heparin overdose

Question 42

Your patient has a chief complaint of dyspnea and weakness with the following vitals: BP 72/64, HR 112, RR 28, SpO2 88%, temp. 99.1°F. He is on 6 L/minute of oxygen via NC. The ECG shows ST with frequent PVCs. Physical exam reveals profound vesicular rales and bronchial wheezing. Your most likely diagnosis is

A. CHF

B. ARDS

C. Asthma

D. Cardiogenic shock

Answer 42

D. Cardiogenic shock

Question 43

Treatment for compensated bradydysrhythmias with a pulse and heart rate <60 beats per minute.

Answer 43

Compensated: SBP > 90-100 mmHg without S/S of shock Good LOC Treat the underlying cause, place combo pads as an anticipatory measure.

Question 44

Treatment for uncompensated bradydysrhythmias with a pulse and heart rate <60 beats per minute.

Answer 44

Decompensated: SBP < 90-100 mmHg, ALOC may be present and other S/S of shock present F—Fluids A—Atropine (not rec. in 2nd ˚ AVB Type II or CHB) E—External pacing D—Dopamine drip E—Epinephrine drip

Question 45

Treatment for compensated tachydysrhythmias with a pulse and heart rate >160 beats per minute.

Answer 45

Compensated: SBP > 90-100 mmHg without S/S of shock and good LOC Supportive care Vagal maneuvers—narrow complex tachycardia (SVT) Medications Application of combo pad as an anticipatory measure

Question 46

Treatment for uncompensated tachydysrhythmias with a pulse and heart rate >160 beats per minute.

Answer 46

Decompensated: SBP < 90-100 mmHg with S/S of shock; ALOC may be present. Consider sedation Synchronized cardioversion beginning at 100 joules Medications

Question 47

Tx for Cardiogenic shock (hypotension present with S/S of pulmonary edema—left ventricular failure)

Answer 47

Inefficient pumping of the heart with hypotension Dobutrex, dopamine, and Inocor to improve cardiac output Vasodilators such as Nipride, NTG, and Levophed IABP and LVAD therapy

Question 48

Right-side ventricular heart failure:

Answer 48

Back up of fluid to the right side of the heart and body Increased jugular venous distention (JVD) Sacral edema Pedal edema

Question 49

Left-side ventricular heart failure:

Answer 49

Back of fluid to the left side of the heart and lungs Rales

Question 50

Treatment of cardiac tamponade includes all of the following, except

A. Force fluids

B. Pericardiocentesis

C. Rapid transport

D. Needle thoracostomy

Answer 50

D. Needle thoracostomy Intravenous fluids, pericardiocentesis, and rapid transport are all indicated for management of a patient presenting with cardiac tamponade. Needle thoracostomy is indicated for a patient presenting with a tension pneumothorax.

Question 51

You are transporting a forty-five-year-old man with acute respiratory distress syndrome (ARDS) and MODS secondary to probable organ rejection after a heart transplant. During transport the patient becomes bradycardic with heart rate in the 30s with hypotension. Which of the following therapies will likely prove fruitless?

A. 250-500 mL saline bolus

B. Dopamine 5-20 μg/kg/min

C. Transcutaneous pacing

D. Atropine 0.5-1 mg IV push

Answer 51

D: The administration of Atropine will not work with patients who have had a heart transplant because of denervation of the vagus nerve. Atropine works by blocking the vagus nerves, thereby increasing heart rate. Symptomatic bradycardia, second degree Type II block, high-grade AVB and CHB require placement of a pacemaker. Complications of pacing can include oversensing and failure to sense; failure to capture, myocardial penetration/perforation, and cardiac tamponade.

Question 52

Your patient presents with following parameters: CVP 20, CI 1.1, PA S/D 8/4, wedge 3, and SVR 1,800. What is your diagnosis?

A. Hypovolemic shock

B. RVMI

C. CHF/LVF

D. Sepsis

Answer 52

B: RVI because of the low PAWP. Review

Question 53

You are transporting a fifty-year-old man from ICU to another facility for further evaluation. The patient has been diagnosed with AMI. He has been complaining of increasing CP, SOB, and dramatic weight loss. He appears very nervous, and you note tremors. His ECG shows AF at 148. The patient may be experiencing

A. Addison’s disease

B. Thyrotoxicosis (grave’s dieases)

C. Myxedema coma

D. Cushing’s syndrome

Answer 53

B: Thyrotoxicosis, also known as Grave’s disease, thyroid storm and hyperthyroidism. Avoid Aspirin because it increases T3, T4 levels and can worsen condition.

Question 54

Grave’s disease

Answer 54

Hyperthyroidism Exophthalmos— “Marty Feldman” or “Betty Davis” protruding eyeballs Atrial fibrillation is common Anxiety, tremors Weight loss Treatment: correct electrolytes and glucosteroids

Question 55

Myxedema coma

Answer 55

Hypothyroidism Infection common cause; coarse hair, deep voice, thinning or loss of the outer third of the eyebrows (Queen Ann’s sign) Women > 60 years; occurs in the winter months Fatigue Weight gain Treatment: levothyroxine

Question 56

Addison’s disease

Answer 56

Acute renal insufficiency Hypotension is common: caution with etomidate administration Fatigue Weight loss Treatment: supportive care

Question 57

Cushing’s disease

Answer 57

Hyperaldosteronism Hypertension Women have facial hair, moon-face, buffalo hump Upper body obesity, thin arms and legs Treatment: decrease or initiate steroids

Question 58

The formula to calculate MAP is:

A. 2/3 DBP × SBP

B. 2 × DBP + SBP divided by 3

C. 2 × SBP + DBP

D. 2 + DBP × SBP divided by 3

Answer 58

B: (2 × DBP) + SBP divided by 3 = MAP. Normal MAP is 80-100 mmHg.

Question 59

Normal coronary perfusion pressure (CPP) is

A. 50-60 mmHg

B. 70-90 mmHg

C. 80-100 mmHg

D. <50 mmHg

Answer 59

A: Normal coronary perfusion pressure is 50-60 mmHg. It can be calculated by using the following formula: DBP − PWCP. Remember that your HEAD is higher than your HEART (50-60 mmHg).

Question 60

Cerebral perfusion pressure can be calculated by using the following formula: MAP − ICP. Normal range for cerebral perfusion pressure is 70-90 mmHg. Remember that your HEAD is higher than your HEART.

Answer 60

MAP − ICP. Normal range for cerebral perfusion pressure is 70-90 mmHg. Remember that your HEAD is higher than your HEART (50-60 mmHg).

Question 61

When performing a pericardiocentesis, the insertion site is

A. Below the subxyphoid process

B. Just right of the subxyphoid process

C. Just left of the subxyphoid process

D. Above the subxyphoid process

Answer 61

C: The emergent treatment of choice is pericardiocentesis. A large bore needle is placed just to the left of the patient’s sub-xyphoid process and with negative pressure applied to the syringe, it is directed toward the left scapula (shoulder) while monitoring the ECG for the presence of ventricular ectopy. As little as 15-20 mL of blood to improve the patient’s condition.

Question 62

The initial treatment of a patient with a suspected cardiac tamponade

Answer 62

The initial treatment of a patient with a suspected cardiac tamponade is a rapid intravenous fluid bolus. This measure improves filling pressures and temporarily improves cardiac output until pericardiocentesis can be performed.

Question 63

You are transporting a seventy-five-year-old man with a diagnosis of inferior wall MI. During the flight you note the following rhythm. Vital signs are: 70/palp, HR 150, RR 24, SpO2 94% on high flow oxygen with NRM at 15 L/min. He is awake and complains of chest pain and SOB. How will you manage this patient? [image vtach]

A. Administer lidocaine and nitroglycerin

B. Administer normal saline bolus

C. Consider sedation and synchronize cardiovert at 100 joules

D. Have the patient cough forcefully

Answer 63

C. Consider sedation and synchronize cardiovert at 100 joules

Question 64

sixty-year-old man complains of chest pain for three days with a low-grade fever. Patient complains of increased pain when lying in supine position and states that the chest pain decreases when sitting forward. What is the most likely diagnosis?

A. Pulmonary embolism

B. Pleurisy

C. Pericarditis

D. Pericardial tamponade

Answer 64

C: Pericarditis is an inflammation of the pericardium which can present with chest pain radiating to the back and relieved by sitting up forward and worsened by lying down, is the classical presentation. Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety.

Question 65

How is the coronary perfusion pressurecalculated?

A. DBP − PCWP

B. DBP + PCWP

C. SBP − DBP

D. SBP − PCWP

Answer 65

A. DBP − PCWP

Question 66

Inferior wall MI is caused by an occlusion of which coronary artery?

A. LAD

B. RCA

C. Circumflex

D. Inferior vena cava

Answer 66

B. RCA

Question 67

What medications would you expect to administer to a patient presenting with severe chest/abdominal pain, diaphoresis, and is restless? SBP is 170/palp and heart rate in 116. You note a difference in blood pressures when taken on each arm.

A. Nitroglycerin and atenolol

B. Nipride and b-blockers

C. Lasix and nitroglycerin

D. Bumex and Dobutrex

Answer 67

B: Nipride and Beta-blockers.

Question 68

Three types of Aortic dissection

Answer 68

Debakey classification system describes three types: I = occurs in the ascending aorta and extends distally beyond the aortic arch II = process is limited to the ascending aorta (Marfan’s) III = dissection distal to the origin of the left subclavian artery and extends distally to abdominal aorta.

Question 69

Most common site for aortic dissection

Answer 69

Ascending aorta

Question 70

Classic S&S of Aortic Dissection

Answer 70

S/S: severe pain, originating in the back or sub-sternal region

Question 71

CXR findings of Aortic dissection

Answer 71

CXR Findings: Mediastinal widening Extension of aortic shadow beyond calcified aortic wall Localized bulge on aortic arch Tracheal deviation Left pleural effusion

Question 72

Management of Aortic dissection

Answer 72

Management: Lower SBP to 100-110 mmHg Beta-blockers blockers to slow the heart rate and decrease ejection fraction (metoprolol, esmolol), pain analgesics Fluids only if hypotensive HTN crisis: Nipride, Hyperstat to patient’s normal within 30-60 min Surgery

Question 73

All of the following are signs of cardiac tamponade, except

A. Pulsus paradoxus

B. Pulsus alternans

C. Kussmual’s sign

D. Pulseless electrical activity (PEA)

Answer 73

B: The patient suspected of having a cardiac tamponade will exhibit signs and symptoms of decreased cardiac output such as, cool, clammy skin, altered mental sratus, tachycardia, pulsus paradoxus (a drop in systolic blood pressure > 15 mmHg during normal inspiration), distant muffled heart tones, jugular venous distention, unless the patient is hypovolemic, hypotension, and electrical alternans.

Question 74

A sign of hyperventilation and hypocalcemia is

A. Kehr’s

B. Grey Turner’s

C. Trousseau’s

D. Brudzinski’s

Answer 74

C: Trousseau’s sign is observed in patients with low calcium. This sign may be present before other manifestations of hypocalcemia such as hyperreflexia and tetany and is generally more sensitive than the Chvostek sign of hypocalcemia. https://www.youtube.com/watch?v=Ry5Rh3wO8Sw

Question 75

You are transporting a sixty-year-old man complaining of severe chest pain and midscapular pain. He is short of breath and is hypertensive in the upper extremities. You auscultate a harsh systolic murmur. Your diagnosis of this patient is

A. Cardiac tamponade

B. Aortic rupture

C. Myocardial rupture

D. Tension pneumothorax

Answer 75

B: Aortic rupture with 90% of patients who die at the scene. Chest x-ray findings: widening mediastinum and loss of aortic knob shadow

Question 76

The MD has ordered a brain natriuretic peptide (BNP), which would evaluate the patient for

A. Sepsis

B. Hypovolemia

C. Right ventricular MI

D. CHF

Answer 76

D: BNP is a blood test used to measure the amount of BNP hormone in the blood. BNP is produced by the heart and shows how well the heart is functioning. Normally, only a low amount of BNP is found in the heart. But if the heart has to work harder for a longer period of time, such as in heart failure, the heart releases more BNP, increasing the blood level of BNP. Lab findings— normal BNP level: 0-99 picograms per milliliter (pg/mL); Abnormal BNP level: 100 pg/mL or greater is indicative that heart failure may be present.

Question 77

Levine’s sign relates to

A. Meningitis; neck pain

B. Pancreatitis; periumbilical bruising

C. Cardiac; clenched fist over chest

D. Splenic injury; left shoulder

Answer 77

Clutching of the chest, may be cardiac in origin

Question 78

Murphy’s sign

Answer 78

RUQ pain, may indicate gallbladder disease

Question 79

Grey Turner’s

Answer 79

Retroperitoneal bruising, may indicate pancreatitis or trauma

Question 80

Cullen’s

Answer 80

Periumbilical bruising, may indicate pancreatitis or intra-abdominal bleeding

Question 81

Kehr’s

Answer 81

Shoulder pain, may indicate spleen injury on the left side or ectopic pregnancy/rupture on either side

Question 82

Halstead’s

Answer 82

Marbled appearance of the abdomen, may indicate necrosis of the pancreas

Question 83

Hamman’s

Answer 83

Crunching sound heard with auscultation, may be synchronized with heart rate/pulse, may indicate tracheobronchial injury

Question 84

Kussmaul’s sign is a

A. Rise in venous pressure with inspiration

B. Crunching sound synchronized to heart beat

C. Decrease of the SBP of > 10 mmHg with inspiration

D. Marbled appearance of the abdomen

Answer 84

A: Kussmual’s sign is a rise in venous pressure with inspiration (JVD), which can be indicative of (RVI) and cardiac tamponade.

Question 85

A S3 Heart Tone is

Answer 85

Abnormal heart sound “ventricular gallop” that is associated with CHF, mitral regurgitation, and cardiomyopathy.

Question 86

A S4 Heart Tone is

Answer 86

Abnormal heart sound “atrial gallop” that is associated with dilated or restrictive cardiomyopathy, aortic, and pulmonic stenosis.

Question 87

Orthopnea

Answer 87

Increased shortness of breath in supine/lying position and is relieved by sitting and/or standing up.

Question 88

Paroxysmal nocturnal dyspnea (PND)

Answer 88

Medical symptom, also known as cardiac asthma. It is defined as sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing. It is most closely associated with CHF. PND commonly occurs several hours after a person with heart failure has fallen asleep.

Question 89

Dilated cardiomyopathy

Answer 89

Ventricular dilation, contractile dysfunction, and symptoms of heart failure.

Question 90

Hypertropic cardiomyopathy

Answer 90

Inappropriate LV hypertrophy (thickening of left ventricle) with preserved or enhanced contractile function. Systolic murmur can be present. Etiology unclear—IHSS (idiopathic hypertrophic subaortic stenosis).

Question 91

Restrictive cardiomyopathy

Answer 91

Least common. Endocardial scarring of the ventricle with impaired diastolic filling.

Question 92

Cardiomegaly

Answer 92

A medical condition wherein the heart is enlarged.

Question 93

Drug of choice for treating a GI bleed is

A. Normal saline

B. Nipride

C. Whole blood

D. Sandostatin

Answer 93

30. D: Sandostatin (octreotide) is a vasoactive peptide used in the management of upper gastrointestinal esophageal varices. The mechanism of action is believed to be a reduction of splanchnic blood flow. Treatment is primarily with endoscopic banding and IV octreotide.

Question 94

A common problem seen with hepatic encephalopathy is

A. Hyperkalemia

B. Increased ammonia levels

C. Low protein levels

D. Low BUN

Answer 94

B. Increased ammonia levels Most ammonia in the body forms when protein is broken down by bacteria in the intestines. The liver normally converts ammonia into urea, which is then eliminated in urine. Ammonia levels in the blood rise when the liver is not able to convert ammonia to urea. This may be caused by cirrhosis or severe hepatitis.

Question 95

You are transporting a fifty-year-old man from a rural facility. Your patient’s ECG is demonstrating ST at 112 with peaked P waves. The ABG indicates pH 7.2, pCO2 18, HCO3 12 and pO2 108. CMP reveals Na 130, K 2.3, Cl 95, HCO3 10, BUN 48, creat 2.2, and glucose of 685. The most appropriate diagnosis would be

A. Cardiogenic shock

B. DKA

C. Hyperglycemic, hyperosmolar nonketotic syndrome

D. Dehydration

Answer 95

Diabetic ketoacidosis (DKA) is problem with insulin. Treatment goal for both are aimed at administering fluids, insulin, and correcting electrolyte imbalances to control the hyperglycemia and to prevent shock and other complications.

Question 96

Main problem with DKA is

Answer 96

Lack of or low insulin production

Question 97

Main problem with HHNK is

Answer 97

Problem is high sugar with high serum osmolarity

Question 98

DKA is most likely to occur in an

Answer 98

insulin-dependent patient

Question 99

HHNK is most likely to result in

Answer 99

Severe dehydration

Question 100

DKA results in ____ in the urine and ____ pH levels

Answer 100

keytones Acidotic (low pH)

Question 101

DKA serum glucose is usually <

Answer 101

<1000 mg/dL

Question 102

HHNK serum glucose is usually >

Answer 102

>1000 mg/dL

Question 103

Recommended urinary output when caring for an adult patient should be

A. 100 mL/hr

B. 30-50 mL/hr

C. 1-2 cc/kg/hr

D. >200 mL/hr

Answer 103

B: Normal adult urinary output ranges from 30-50 mL/hour. Pediatric range is from 1-2 mL/kg/hour.

Question 104

Expected urinary output in electrical injuries is for adults and pedi

Answer 104

100 mL/hour in the adult patient 2-4 mL/kg/hour in the pediatric patient.

Question 105

A patient presenting with meningitis may exhibit which sign on assessment?

A. Cullen’s

B. Grey Turner’s

C. Kernig’s

D. Levine’s

Answer 105

C: Kernig’s and Brudzinski’s signs are physical examination results that are strongly suggestive of meningitis. A “stiff neck” is one of the general warning signs of meningitis, and these are some of the first steps to investigate such a finding.

Question 106

Pericarditis can be misdiagnosed as: What is the classic sign of pericarditis, and what are some other common signs?

Answer 106

MI and vice versa. The classic sign of pericarditis is a friction rub. Other signs include diffuse ST-elevation and PR-depression on ECG in all leads except aVR and V1; cardiac tamponade (pulsus paradoxus with hypotension), and CHF (elevated jugular venous pressure with peripheral edema).

Question 107

Test to determine if the friction rub heard is pleuritic versus pericardial…

Answer 107

Ask Pt to hold their breath while auscultating the chest. If the friction rub is still heard while the patient is holding their breath, it is most likely a pericardial friction rub. If the friction rub is not heard, then it is most likely a pleuritic friction rub.

Question 108

To elicit Trousseau’s sign…

Answer 108

A blood pressure cuff is placed around the patient’s arm and inflated to a pressure greater than the systolic blood pressure and held in place for three minutes. This will occlude the brachial artery. In the absence of blood flow, the patient’s hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm. The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct. https://www.youtube.com/watch?v=Ry5Rh3wO8Sw

Question 109

Chvostek sign

Answer 109

It refers to an abnormal reaction to the stimulation of the facial nerve. When the facial nerve is tapped at the angle of the jaw, the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcemia (i.e. from hypoparathyroidism, pseudohypoparathyroidism, hypovitaminosis D) with resultant hyperexcitability of nerves.

Question 110

How PND and simple Orthopnea differ when laying down/sitting up….

Answer 110

PND is often relieved by sitting upright but not as quickly as simple orthopnea. Also unlike orthopnea, it does not develop immediately upon lying down.

Question 111

If an acute hemorrhage episode occurs during transport,

Answer 111

maintenance of airway and circulating volume is the first priority.

Question 112

Hepatic encephalopathy

Answer 112

(also known as portosystemic encephalopathy) is the occurrence of confusion, altered level of consciousness, and coma as a result of liver failure. In the advanced stages, it is called hepatic coma or coma hepaticum. It may ultimately lead to death. It is caused by accumulation in the bloodstream of toxic substances that are normally removed by the liver.

Question 113

Hepatic encephalopathy is reversible with treatment. This relies on suppressing the production of the toxic substances in the intestine. This is most commonly done with

Answer 113

with the laxative lactulose or with nonabsorbable antibiotics.

Question 114

Kernig’s sign is a way to demonstrate that the neck is not simply “stiff” but is irritated. To test…

Answer 114

With the patient lying flat, the examiner flexes the hip ninety degrees and then attempts to extend the lower leg at the knee. Pain on extension is a positive sign. If positive but the straight leg raise also produces back pain, the combined sign may be due to low back muscle spasm, herniated disk, or sciatic nerve inflammation.

Question 115

To test for Brudzinski’s sign

Answer 115

The patient lies on his or her back, and the examiner puts one hand behind the patient’s head and the other on the chest. Using the hand behind the neck to raise the head but pressing on the chest with the other hand, if the hips and knees flex, the neck sign is positive. Chin to chest the hips will flex

Question 116

Gestational Diabetes

Answer 116

Results when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of Type II diabetes. Risks to the fetus include macrosomia (high birth weight); increased fetal insulin may inhibit surfactant production. A cesarean section may be performed if there is marked fetal distress or an increased risk of injury associated with macrosomia, such as shoulder dystocia.

Question 117

Murphy’s sign would indicate which of the following conditions?

A. Splenic injury

B. Cardiac problem

C. Pancreatitis

D. Gallbladder

Answer 117

D. Gallbladder Right upper quadrant pain, may indicate gallbladder disease

Question 118

Treatment of pancreatitis would include all of the following, except

A. Fluid resuscitation

B. NPO and place OG/NG tube

C. Morphine for pain

D. Antibiotics for sepsis

Answer 118

C: Morphine has been contraindicated for pain treatment in acute pancreatitis because of its presumed opioid-induced sphincter of Oddi dysfunction.

Question 119

Pancreatitis is _____ Commonly triggered by _____ and ______ .

Answer 119

Pancreatitis is the inflammation of the pancreas caused by the release of activated pancreatic enzymes. The most common triggers are biliary tract disease and chronic heavy alcohol consumption.

Question 120

2 Forms of Pancreatitis

Answer 120

Acute pancreatitis is sudden. Chronic pancreatitis is characterized by recurring or persistent abdominal pain with or without steatorrhea (presence of excess fat in the feces, foul-smelling stools that float because of high fat content) or diabetis mellitus.

Question 121

Hallmark sign of pancreatitis

Answer 121

Severe upper abdominal pain, with radiation through to the back, is the hallmark of pancreatitis.

Question 122

Liver Function Tests

Answer 122

Ammonia - NH3 Albumin - Alb Alkaline Phosphatase - ALP Immunoglobulins - Serum Electrophoresis Prothrombin time - PT Platelets - PLT Alanine Aminotransferase - ALT Asperate Aminotransferase - AST Gamma-glutamyl-Transpeptidease - GGT Billirubin - Indirect/direct Bili

Question 123

The patient presenting with HHNK has a problem with

A. Sugar

B. Insulin

C. Overhydration

D. Ketoacidosis

Answer 123

A. Sugar Problem is usually higher levels of sugar (higher than DKA), high serum osmolarity, severe dehydration, lack of ketones, and acidosis. Patient with HHNK may also experience more severe and sudden neurologic changes than the patient with DKA.

Question 124

The treatment of diabetes insipidus is

A. Aggressive fluid replacement and vasopressin

B. Restrict fluids and mannitol

C. Aggressive fluid replacement and Dilantin

D. Aggressive fluid replacement and octreotide

Answer 124

Aggressive fluid replacement and the administration of vasopressin (Pitressin). Vasopressin increases peripheral vascular resistance, which in turn increases arterial blood pressure. It plays a key role in the regulation of water, glucose, and salts in the blood.

Question 125

Vasopressin MOA

Answer 125

Vasopressin is a peptide hormone which is synthesized by the hypothalamus and is stored in the pituitary gland. It controls the reabsorption of molecules in the tubules of the kidneys by affecting the tissue’s permeability. Vasopressin increases peripheral vascular resistance, which in turn increases arterial blood pressure. It plays a key role in the regulation of water, glucose, and salts in the blood.

Question 126

Diabetes insipidus (DI) is _______ and is commonly caused by _____

Answer 126

A condition where the kidneys are able to conserve water; hence the phrase “peeing like a racehorse.” The most common cause is a deficiency of arginine vasopressin (AVP), also known as antidiuretic hormone (ADH)

Question 127

Syndrome of inappropriate antidiuretic hormone (SIADH) is _______ and is commonly caused by _____

Answer 127

Occurs when excessive levels of antidiuretic hormones (arginine vasopressin, AVP) are produced, which causes the body to retain water. Common causes include heart failure, diseased or injured hypothalamus, certain cancers, such as lung cancer, brain tumors.

Question 128

Symptoms of Diabetes Insipidus

Answer 128

Symptoms include excessive thirst and excretion of large amounts of severely diluted urine.

Question 129

Symptoms of SIADH

Answer 129

Symptoms include weight gain, nausea, vomiting, altered mentation, irritability, and seizures.

Question 130

Adrenal insufficiency, weight loss, hypotension—the patient may be experiencing

A. Addison’s disease

B. Thyrotoxicosis (Grave’s diease)

C. Myxedema coma

D. Cushing’s syndrome

Answer 130

A: Acute renal insufficiency, also known as Addison’s disease. Hypotension is common: caution with etomidate administration, Symptoms: fatigue and weight loss.

Question 131

Myxedema coma is also known as

A. Thyroid storm

B. Adrenal insufficiency

C. Hypothyroidism

D. Hyperaldosteronism

Answer 131

C: Hypothyroidism Infection common cause; coarse hair, deep voice, thinning or loss of the outer third of the eyebrows (Queen Ann’s sign) Women > 60 years; occurs in the winter months Fatigue, weight gain

Question 132

Tx for myxedema

Answer 132

Myxedema aka Hypothyroidism - Tx: Levothyroxine

Question 133

Most common presentation of a patient with hypothyroidism are all of the following, except

A. Cold intolerance with coarse hair

B. Almost exclusively over the age of sixty

C. >90% of cases occur in the winter

D. Primarily in men

Answer 133

D: Hypothroidism occurs primarily in women, almost exclusively over the age of sixty, with 90% of the cases occurring in the winter months.

Question 134

Drug of choice for profound hypotension in septic shock is

A. Isotonic crystalloid solution

B. Levophed

C. Nipride

D. Dobutamine

Answer 134

B: Levophed (norepinephrine) indication is mainly used to treat patients in vasodilatory shock states such as septic and neurogenic shock. Levophed functions as a peripheral vasoconstrictor (alpha-adrenergic action) and as an inotropic stimulator of the heart and dilator of coronary arteries (beta-adrenergic action).

Question 135

You are managing a patient who has been diagnosed with hepatic encephalopathy. His ammonia levels are elevated. Your management in preparing this patient for transport is to inhibit elevated protein level by

A. Administering whole blood

B. Stop GI bleeding and evacuate bowel of blood

C. Aggressive fluid resuscitation

D. Aggressive pain control

Answer 135

B. Stop GI bleeding and evacuate bowel of blood Evacuation of gut-derived toxins (intestinal blood, bacteria) and administration of Lactulose (orally or as an enema) is one of the cornerstones of the treatment of hepatic encephalopathy.

Question 136

Lactulose works by

Answer 136

Lactulose may be given orally to acidify the ammonia in the colon and form the ammonium that can be easily excreted. It is used as a laxative for evacuating blood from intestines and for reducing ammonia production by intestinal bacteria.

Question 137

Grey Turner’s sign may indicate

A. Meningitis

B. Splenic injury

C. Pancreatitis

D. Gallbladder

Answer 137

Grey Turner’s sign refers to bruising of the flank areas. It can take up to twenty-four to forty-eight hours to appear, and it can predict a severe attack of acute pancreatitis. May also be accompanied by Cullen’s sign (periumbilical bruising) or Halstead’s sign (marbled abdomen), which then may be indicative of pancreatic necrosis with retroperitoneal or intra-abdominal bleeding.

Question 138

Repeated doses of etomidate can cause

A. Increased ICP

B. Acute adrenal insufficiency

C. AMI

D. Pulmonary edema

Answer 138

B: Etomidate (Amidate), which is classified as a sedative-hypnotic can block the adrenal gland’s production of cortisol and other steroid hormones, possibly resulting in temporary adrenal gland failure. This may cause abnormal salt and water balance, lowered blood pressure, and, ultimately, shock.

Question 139

A type of angina that can occur at rest, while sleeping, or after exercise is called

A. Silent

B. Prinzmetal’s

C. Stable

D. Unstable

Answer 139

B. Prinzmetal’s Can occur at rest, while sleeping, or after exercise

Question 140

A clinical sign that indicates hypocalcemia may be present is

A. Kehr’s

B. Grey Turner’s

C. Chvostek’s

D. Brudzinski’s

Answer 140

C: Chvostek’s sign also known as the Weiss sign, is one of the signs of tetany seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve.

Question 141

Your patient presents upper body obesity with thin arms and legs. He has a rounded face “buffalo hump” and is complaining fatigue. He is hypertensive and hyperglycemic. What condition is he most likely presenting?

A. Myxedema coma

B. Thyroid storm

C. Addison’s disease

D. Cushing’s syndrome

Answer 141

D: Cushing’s syndrome.

Question 142

Causes other than Pancreatitis of Grey Turner’s sign

Answer 142

Other causes of Grey Turner’s sign can include blunt abdominal trauma, ruptured abdominal aortic aneurysm, and ruptured/hemorrhagic ectopic pregnancy.

Question 143

Patients with known Addison’s disease should not be given what sedative?

Answer 143

Patients with known Addison’s disease (acute renal insufficiency) should not be given etomidate. Etomidate can block the adrenal gland’s production of cortisol and other steroid hormones, possibly resulting in temporary adrenal gland failure.

Question 144

Cullen’s sign may indicate

A. Meningitis

B. Pancreatitis

C. Gallbladder disease

D. Cardiac problem

Answer 144

B. Pancreatitis Periumbilical bruising, may indicate pancreatitis or intra-abdominal bleeding

Question 145

Stable angina is defined as

Answer 145

Onset with physical exertion or emotional stress • Pain lasts 1-5 minutes • Pain is relieved by rest

Question 146

Unstable angina is defined as

Answer 146

Stable angina that has changed in frequency, quality, duration, or intensity • Pain lasts longer than 10 minutes despite rest and NTG therapy

Question 147

Variable angina is defined as

Answer 147

Spontaneous episodes of chest pain frequently noted at rest or on early rising • Circadian pattern • Relieved by NTG

Question 148

Silent angina is defined as

Answer 148

Objective evidence of ischemia in asymptomatic patients

Question 149

Mixed angina is defined as

Answer 149

Combination of stable and variant angina

Question 150

Hemoglobin Test - Normal Range - High/Low

Answer 150

Normal Range 10-12 Low levels is called anemia, which can be caused by hemorrhage, lead poisoning, sickle cell anemia, suppression by chemotherapy agents and other causes. High levels: Dehydration can cause falsely high levels, which disappears once proper fluids have been administered. Or living at high altitudes and smoking.

Question 151

Hematacrit Test - Normal Range - High/Low

Answer 151

Normal Range 36-52% High in COPD patients Low in dehydrated or hemorrhage.

Question 152

Platelets Test - Normal Range - High/Low

Answer 152

Normal: 140K - 400K Low levels of < 100 is called thrombocytopenia, can be caused by infection with hepatitis C, chronic liver disease, infection with HIV, pregnancy (HELLP), chemotherapy, systemic lupus, chronic lymphocytic leukemia, treatment with certain medications such as heparin and quinidine, and aplastic anemia (blood disorder that causes the body to stop making enough new blood cells). Thrombocytosis - High levels of platelets. (Kawasakis Disease)

Question 153

WBC Test - Normal Range - High/Low

Answer 153

Normal : 4.5-10.5 Increases with infection and is known as leukocytosis. A decrease is called leucopenia.

Question 154

Sickle-cell disease (SCD) or sickle cell anemia is

Answer 154

a genetic blood disorder characterized by red blood cells that assume an abnormal, rigid sickle shape.

Question 155

Vaso-occlusive crisis (painful crisis) is managed with

Answer 155

hydration, analgesics, and NSAIDs.

Question 156

Diphenhydramine is often administered for itching associated with

Answer 156

opioid administration

Question 157

A hemolytic crisis may require

Answer 157

blood transfusions.

Question 158

Sodium labs: normal values & significant findings

Answer 158

Normal: 135-145 <120 can cause seizures, managed with slow IV administration of hypertonic saline. Recommended to be maintained at 155 for head injured/bleed patient to help reduce ICP.

Question 159

Potassium labs: normal values & significant findings

Answer 159

Normal: 3.5-5.5 >7.0 can cause ventricular dysrhythmias, peaked/tented T waves >5 mm in height on the ECG.

Question 160

Calcium labs: normal values & significant findings

Answer 160

Normal: 8.8-10.4 Chvostek’s and Trouseau’s sign.

Question 161

Chloride labs: normal values & significant findings

Answer 161

Normal: 95-112

Question 162

SaCO2 labs: normal values & significant findings

Answer 162

Normal 24-30 <20 may indicate dehydration; assess for acidosis

Question 163

BUN labs: normal values & significant findings

Answer 163

Normal: 6-23 - Should be approx. 10-20x Creatinine level May indicate blood in the gut, dehydration, or renal failure. Should be approximately 10-20x Creatinine level

Question 164

Creatinine labs: normal values & significant findings

Answer 164

Normal: 0.6-1.4 > 1.4 may indicate renal failure.

Question 165

Serum OS labs: normal values & significant findings

Answer 165

Normal: 285-295 Maintain at <320 in head injured/bleed patients to reduce ICP and maintain adequate CPP. Serum OS can be decreased with the administration of mannitol, hypertonic saline, and furosemide.

Question 166

Magnesium labs: normal values & significant findings

Answer 166

Normal: 1.5-2.5 Levels of 4-8 are indicated to prevent seizures in the pre-eclamptic pregnant patient. Levels >10 can be toxic and may require the administration of calcium.

Question 167

Ammonia labs: normal values & significant findings

Answer 167

Normal: Adult: 14-45 Pediatrics: 40-80 Increases in Reye’s syndrome, hepatic encephalopathy.

Question 168

Anasarca

Answer 168

Also known as “extreme generalized edema” is a medical condition characterised by widespread swelling of the skin due to effusion of fluid into the extracellular space. It is usually caused by either congestive cardiac failure, liver failure (cirrhosis of the liver), or renal failure/disease.

Question 169

Ascites

Answer 169

is an accumulation of fluid in the peritoneal cavity.

Question 170

Whipple’s Triad

Answer 170

Is a collection of three criteria that suggest a patient’s symptoms result from hypoglycemia.

Question 171

Wellen’s syndrome

Answer 171

Is associated with critical stenosis of the proximal LAD and impending infarct. V2-V3 segment turns down into a negative T wave at a 60-96-degree angle.

Question 172

Acute arterial occlusion is S&S’s

Answer 172

Sudden interruption of blood flow o Pain o Pallor o Pulselessness—distally o Parethesias—burning o Cool extremity