CH 11 Cardiac Monitoring and Cardiopulmonary Resuscitation

A. The CK-MB and troponin I tests are specific for an MI. If the patient has had an MI, these two values will be elevated. The D-dimer test is diagnostic for a pulmonary embolism. It would be elevated with a PE but normal with an MI. The BUN (blood urea nitrogen) test is done to evaluate kidney function. The LDL (low density lipoprotein) test is one of several tests done to evaluate a patient's cholesterol values. A high LDL value is a risk factor for heart disease but is not specific for an MI.

A 48-year-old male patient has been admitted with a suspected MI. What blood tests should be performed to determine if he has had an MI? 1. CK-MB 2. Troponin I 3. D-Dimer 4. BUN 5. LDL A. 1 and 2 only B. 3 and 5 only C. 2, 3, and 4 only D. 1, 2, 3, and 5 only

A. The patient's symptoms indicate a cardiac problem. It is wise to begin ECG monitoring quickly in case the patient has an arrhythmia. An ABG sample can be drawn after ECG monitoring has been started. A chest radiograph also can be done after ECG monitoring has been started. A capnometer value to check the patient's exhaled carbon dioxide value is not indicated at this time.

A 59-year-old patient is brought to the hospital with a complaint of sudden, severe substernal chest pain and dyspnea. What initial thing should the respiratory therapist recommend? A. Begin ECG monitoring. B. Draw an ABG sample. C. Get a chest radiograph. D. Get a capnometer value.

A Blood flow through the coronary arteries can be performed only during a left-heart catheterization procedure. Right-heart catheterization evaluates the valves and functioning of the right side of the heart. A stress echocardiogram is helpful to evaluate the pumping ability of the left ventricle but does not evaluate the coronary arteries. A 12-lead ECG is diagnostic for a heart attack but does not directly evaluate the condition of the coronary arteries.

A 64-year-old woman was admitted with a diagnosis of MI. She was treated with a clot-dissolving medication and recovered quickly. What procedure should be performed to evaluate the condition of her coronary arteries? A. Left-heart catheterization B. Stress echocardiogram C. Right-heart catheterization D. 12-lead electrocardiogram

C A portable defibrillator must be with the patient in case it is needed. The other items are useful for monitoring but offer no way to treat a life-threatening arrhythmia.

A 65-year-old patient has been successfully resuscitated in the Emergency Department after suffering an MI. The patient is still unstable with frequent PVCs and needs to be transported to the cardiac care unit for management. Which of the following would be most important for monitoring the patient during the transportation? A. Pulse oximeter B. Portable capnography unit C. Portable ECG machine with defibrillator D. 12-lead ECG unit to record any arrhythmias

B. See Figure 11-22 for a tracing and explanation of a PVC.

A fully compensatory pause is seen after which type of heartbeat? A. NSR B. PVC C. PAT D. VT

A. ECG monitoring is justified because the patient's signs and symptoms could indicate a cardiac problem. An exercise program is not indicated in this situation and could be dangerous for the patient. A peak flow test is not indicated now and would not help with the diagnosis of exercise-induced asthma. It is best to wait at least 10 minutes after putting O2 on a patient before drawing an ABG sample to check on the patient's O2 level. Even if the ABG sample shows hypoxemia, there is no indication of the cause.

A male patient comes into the Emergency Department appearing ashen gray and complaining of sudden, severe pain beneath his sternum and shortness of breath. He says this began after he exercised vigorously for 45 minutes. After putting an O2 mask on the patient, what should be done? A. Start ECG monitoring. B. Recommend that he begin a supervised exercise program at the hospital. C. Perform a peak flow test to check on exercise-induced asthma. D. Immediately draw an ABG sample.

C. It is easy and quick to check the valve for proper position. Fix the valve if necessary, and attempt to ventilate the patient again. Because the patient's pulse has not yet been checked, there is no indication that chest compressions are needed. Getting a lateral neck radiograph will greatly delay (probably fatally) ventilating the patient. There is not yet an indication that the patient needs abdominal thrusts to clear an airway obstruction. If the patient cannot be ventilated by the fixed mouth-to-valve resuscitation device, check for an obvious obstruction in the mouth or throat. Reposition the head, and attempt to ventilate again. If the patient still cannot be ventilated, then perform abdominal thrusts.

A mouth-to-valve resuscitation device is being used on an apneic patient. The respiratory therapist delivers a breath, but the patient's chest does not rise. What should be done next? A. Begin chest compressions. B. Request a lateral neck radiograph. C. Check the valve for proper position. D. Perform abdominal thrusts.

A. The rhythm strip shows ventricular fibrillation. The best way to treat this dangerous arrhythmia is to defibrillate the patient immediately. All of the other listed options are reasonable in a CPR attempt when appropriate. However, they are all secondary to treating the patient's ventricular fibrillation.

A paramedic and a respiratory therapist are performing CPR procedures on an adult patient. Upon looking at the ECG monitor, the following rhythm strip is seen. What should be recommended in this situation? A. Defibrillate the patient. B. Increase the oxygen flow to the manual resuscitation bag and mask. C. Change ventilation and chest compression duties. D. Intubate the patient

D Defibrillation should be performed as quickly as possible when a patient is in ventricular fibrillation. Figure 11-26 shows another example. All of the other options delay effective treatment.

A respiratory therapist notices that a patient with a 28% air-entrainment mask is unresponsive to questions. The ECG rhythm seen below is noticed on the monitor. What should be recommended as a first reaction? A. Check the calibration on the ECG machine. B. Replace the ECG leads. C. Increase the O2 percentage because the patient is hypoxic. D. Defibrillate the patient.

D. Sinus arrhythmia is shown in Figure 11-8. Review the associated discussion if needed. In a patient receiving mechanical ventilation and PEEP, it is possible to put too much pressure on the heart, which reduces venous return. If the returning blood volume is decreased, the cardiac output also will decrease. The patient should be monitored and key people informed. It is too early to decide whether the PEEP level is too high and should be reduced. The physician should be consulted before making any change. Atropine will increase the patient's heart rate and is not indicated in this situation. No indication suggests that the patient has an arrhythmia that requires synchronized cardioversion.

A ventilator-dependent patient is set up for routine ECG monitoring. Because of refractory hypoxemia, the physician orders 10 cm water of PEEP. Shortly after the PEEP therapy is added, it is noticed that sinus arrhythmia has developed. Which of the following is the best course of action to follow? A. Recommend the administration of atropine. B. Recommend synchronized cardioversion. C. Recommend decreasing the PEEP from 10 to 5 cm water. D. Make a record of the rhythm, and inform the nurse and physician of your observation.

B. The rhythm strip shows two identical premature ventricular contractions (unifocal PVCs). This, combined with the patient's history of sudden chest pain and shortness of breath, suggests a heart problem. A 12-lead ECG is indicated for the physician to be able to determine the patient's cardiac condition. Oxygen is indicated for the shortness of breath. In addition, the oxygen will help the heart if it is hypoxic. The patient's condition is not life threatening, and no need is seen for either synchronized cardioversion or defibrillation. A cardiac catheterization procedure is needed to identify any coronary artery blockages before angioplasty is indicated.

After an exercise routine, a 59-year-old man experiences sudden chest pain with shortness of breath. ECG monitoring in the Emergency Department reveals the following rhythm strip. What should the respiratory therapist recommend? 1. Synchronized cardioversion 2. 12-lead ECG 3. Defibrillation 4. Administer oxygen 5. Angioplasty A. 1 and 5 only B. 2 and 4 only C. 2, 3, and 4 only D. 1, 2, 3, 4, 5

B Current CPR guidelines state that effective ventilation can be achieved by an endotracheal tube, mouth-to-valve resuscitator, or manual resuscitator. A pneumatic (demand-valve) resuscitator is not recommended for use because it is difficult to control the delivered tidal volume and air tends to be forced into the patient's stomach.

All the following are acceptable ways to ventilate a patient during CPR EXCEPT: A. Endotracheal tube B. Pneumatic (demand-valve) resuscitator C. Mouth-to-valve resuscitator D. Manual resuscitator

D. See the text listing in Module C of the identifying traits of NSR. See Figure 11-2 showing a tracing of NSR and Table 11-1.

An NSR can be identified by: 1. A resting rate of 60-100 beats/min in an adult 2. A P wave before every QRS complex 3. A regular rhythm 4. A QRS complex after every P wave 5. An upright T wave in lead II A. 2 and 4 only B. 2, 3, and 4 only C. 1, 2, 3, and 5 only D. 1, 2, 3, 4, 5

B. Intravenous naloxone (Narcan) can be given to reverse the sedating effect of the anesthetic drugs that passed from the mother to the infant. Epinephrine and atropine are cardiac stimulants, not breathing stimulants. Bag/mask ventilation may be needed but will not get the sedated infant to breathe by itself.

An infant daughter has just been delivered by cesarean section to an anesthetized mother. Because she is not breathing adequately, an endotracheal tube has been inserted. What can be done to improve the infant's condition and get her to breathe? A. Give IV epinephrine. B. Give IV naloxone (Narcan). C. Begin bag/mask ventilation with oxygen. D. Give endotracheal atropine (atropine sulfate).

D. Giving intravenous epinephrine should increase the patient's heart rate and blood pressure. Lidocaine is given to suppress PVCs. Although the patient is bradycardic and hypotensive, chest compressions are not yet indicated. Because the patient is already being ventilated with supplemental oxygen, endotracheal intubation will not provide any significant improvement.

Bag/mask ventilation with oxygen is being provided to a 57-year-old adult at a rate of 12/min. The patient's other vital signs include heart rate of 52/min and blood pressure 95/55 mm Hg. What can be done to improve the patient's vital signs? A. Administer endotracheal lidocaine (Xylocaine). B. Begin chest compressions. C. Intubate the patient. D. Administer intravenous epinephrine (adrenaline).

D. The femoral site is recommended because it is a large artery that should be relatively easy to hit and is away from the patient's chest during compressions.

Blood for an ABG measurement needs to be drawn during a CPR attempt. Which site should be recommended for this? A. Carotid B. Radial C. Brachial D. Femoral

C. Interpretation of the patient's ABG results shows hyperventilation with a metabolic acidosis. Intravenous sodium bicarbonate should be given to correct the patient's acidosis. It is appropriate to keep the patient's PaO2 at 210 torr during the CPR attempt to try to oxygenate the brain. Decreasing the respiratory rate or adding mechanical dead space to the manual resuscitator will increase the patient's carbon dioxide and further reduce the pH. If necessary, review ABG interpretation in Chapter 3.

CPR steps have been under way for 15 minutes when an ABG sample is drawn and sent off for analysis. The following results are obtained with 100% oxygen being used to ventilate the patient: pH, 6.97 PaCO2, 30 torr PaO2, 210 torr , 8 mEq/L What should the therapist recommend at this time? A. Decrease the oxygen percentage. B. Decrease the respiratory rate. C. Administer IV sodium bicarbonate. D. Add mechanical dead space to the manual resuscitator.

C See Figure 11-22 for a tracing of a PVC and explanation. Unifocal means that all of the PVCs originate from a single area. Multifocal means that PVCs originate from more than one area.

Counting from the left, the first and sixth rhythms on the ECG strip shown here represent: A. Atrial flutter B. Second-degree heart block C. Unifocal PVCs D. Multifocal PVCs

C. Pulseless ventricular tachycardia is a life-threatening arrhythmia. (See Fig. 11-24.) If the rate is so fast that a pulse cannot be felt, the cardiac output and blood pressure will be very low. The patient must be defibrillated as soon as possible to restore NSR. Second-degree heart block is treated with drugs or a pacemaker to speed the heart rate. Atrial flutter and sinus tachycardia are fast, but not life-threatening arrhythmias that are first treated with medications to slow the heart rate.

Defibrillation should be done immediately in which of the following patient situations? A. Second-degree heart block B. Atrial flutter C. Pulseless VT D. Sinus tachycardia

B. Current ACLS guidelines state that atropine, epinephrine, and lidocaine can be given via the endotracheal tube during a CPR attempt if the patient does not have a functioning IV line. Intraosseous (within the bone) injection of CPR drugs is approved for neonatal resuscitation attempts. Intracardiac injection of CPR drugs is no longer performed. Only Narcan can be given by the nasal route.

During a CPR attempt on a 50-year-old patient, the respiratory therapist successfully intubates the patient and begins ventilating with a manual resuscitator. The physician is unable to start an IV line. How should the CPR drugs be given? A. Intraosseous injection B. Endotracheal instillation C. Intracardiac injection D. Nasal spray

A. ECG monitoring will not provide any useful information about peripheral perfusion. The patient could have a normal heart rhythm and have altered perfusion. Electrolyte disturbances, especially the potassium (K+) level, can alter the heart's electrical conduction system. It is wise to monitor a patient with a known history of arrhythmias in case they return. Fast or excessive infusion of potassium can lead to serious arrhythmias that justify ECG monitoring.

Electrocardiogram monitoring is justified with a patient in the Intensive Care Unit in all of the following situations EXCEPT: A. If it is used to evaluate peripheral perfusion. B. If the patient has an electrolyte disturbance. C. If the patient has a history of arrhythmias. D. If the patient is being given a rapid infusion of potassium.

C. Reversing the arm electrodes results in the heart's electrical signal being received by the ECG machine in the opposite direction of normal. This results in reversal of the ECG signal. A loose electrode or shivering would cause different types of artifacts. Miscalibration would not cause inversion of the QRS complex.

It is noticed during a diagnostic ECG that the QRS complex is inverted on lead II. What would most likely cause this? A. An electrode is loose. B. The patient is shivering. C. The arm electrodes are reversed. D. The unit is out of calibration.

D. All are correct except that the air/O2 intake valve should not open when the resuscitation bag is squeezed. This allows the gas to escape rather than be directed to the patient.

To ensure that a manual ventilator is ready for use, what should be done? 1. Make sure that no gas escapes through the outlet port when it is closed off and the bag is squeezed. 2. Squeeze the bag, and make sure that the air/O2 reservoir intake valve closes properly. 3. Squeeze the bag, and make sure the nonrebreathing valve opens properly. 4. Feel for air leaving the outlet port when the bag is squeezed. 5. Squeeze the bag, and make sure that the air/O2 reservoir intake valve opens properly. A. 4 and 5 only B. 2 and 3 only C. 1, 2, and 5 only D. 1, 2, 3, and 4 only

C. An echocardiogram is indicated to evaluate the functioning of the mitral valve (and other heart valves) and blood flow through it. If there is a leak through the mitral valve, the echocardiogram will detect the blood flow. Because the mitral valve is on the left side of the heart, a right-heart catheterization could not detect any problem with it. A PA chest radiograph will indicate the size of the heart but is not able to detect any valve problems. A stress test will evaluate the patient's ability to exercise. But, any limitation cannot be specified to the mitral or any other heart valve.

The physician has heard a heart murmur on a 24-year-old patient. A mitral valve regurgitation is suspected. What procedure should be performed to determine if that is the case? A. Right-heart catheterization B. Posteroanterior chest radiograph C. Echocardiogram D. Stress test

A. Direct instillation into the patient's airways and lungs offers the fastest way to administer the medications when an IV line is not available.

Two respiratory therapists are performing chest compressions, manually ventilating an intubated patient during a resuscitation attempt. The nurse and physician are both unable to start an IV line to give medications. What should be recommended? A. Instill the medications down the endotracheal tube. B. Keep trying new sites from which to start the IV line. C. Nebulize the medications. D. Give the medications by subcutaneous injection.

B Defibrillation is indicated if the patient has VT and is without pulse or blood pressure. The patient should then be evaluated for full CPR efforts. The other options would delay effective treatment.

Upon entering a patient's room, the respiratory therapist notices that the ECG monitor shows VT. A carotid pulse cannot be felt and the nurse says that he cannot find a blood pressure. What should be recommended? A. Check the other arm for a blood pressure. B. Defibrillate the patient. C. Intubate the patient and start the patient on a ventilator. D. Initiate synchronized cardioversion of the patient.

D. Current ACLS guidelines state that atropine, epinephrine (both for bradycardia), and lidocaine (to suppress ventricular arrhythmias) can be given via the endotracheal tube during a CPR attempt if the patient does not have a functioning IV line. Potassium chloride can be given only intravenously.

Which of the following medications can be administered down the endotracheal tube during a CPR attempt on an adult? 1. Epinephrine 2. Potassium chloride 3. Atropine 4. Lidocaine A. 1 only B. 2 and 3 only C. 1 and 4 only D. 1, 3, and 4 only

B. A mouth-to-valve device allows for quick ventilations without the risk of an infection being spread from the patient to the rescuer. Mouth-to-mouth ventilation should be avoided if possible in this situation. The other options would unnecessarily delay ventilations.

While doing O2 equipment rounds, the respiratory therapist comes upon a cyanotic patient who is not breathing. After repositioning the patient and hyperextending the neck, it is noticed that the patient has open lip ulcers. What would be the best way to ventilate this patient? A. Perform mouth-to-mouth ventilation. B. Use a mouth-to-valve device stored in the room for this purpose. C. Run to the CPR crash cart and get a manual resuscitation bag and mask. D. Wait for the anesthesiologist to intubate the patient's airway, then use a manual resuscitation bag.