EMT-B, Ch 16: Cardiovascular Emergencies

Skill Drill: What are the four steps of the administration of nitroglycerin?

1) Obtain an order from medical control. Take the patient's blood pressure. Administer nitroglycerin only if the systolic blood pressure is greater than 100 mm Hg. 2) Check the medication and expiration date. Ask the patient about the last dose he or she took and its effects. Make sure that the patient understands the route of administration. Prepare to have the patient lie down to prevent fainting. 3) Ask the patient to lift his or her tongue. Place the tablet or spray the dose under the tongue (while wearing gloves), or have the patient do so. Have the patient keep his or her mouth closed with the tablet or spray under the tongue until it is dissolved and absorbed. Caution the patient against chewing or swallowing the tablet. 4) Recheck the blood pressure within 5 minutes. Record each medication and the time of administration. Reevaluate the chest pain and blood pressure, and repeat treatment if necessary.

Skill Drill: What are the eight steps of performing cardiac monitoring?

1) Take standard precautions. 2) Explain the procedure to the patient. Prepare the skin for electrode placement. 3) Attach the electrodes to the leads before placing them on the patient. 4) Position the limb electrodes on the patient. Place the leads on the torso if performing continuous monitoring, or on the limbs if you will be acquiring a 12-lead ECG. 5) If you plan to obtain a 12-lead ECG tracing, place the chest leads on the chest. 6) Turn on the monitor. 7) Record tracings. 8) Label each strip.

Skill Drill: What are the five steps of performing defibrillation?

1) Take standard precautions. Determine scene safety. Question bystanders. Determine responsiveness. Assess compression effectiveness if CPR is already in progress. If the patient is unresponsive and CPR has not been started yet, begin providing chest compressions and rescue breaths at a ratio of 30 compressions to 2 breaths and a rate of 100 to 120 compressions per minute, continuing until an AED arrives and is ready for use. 2) Turn on the AED. Apply the AED pads to the chest and attach the pads to the AED. Stop CPR. If a shock is not advised, perform five cycles (about 2 minutes) of CPR, beginning with chest compressions, and then reanalyze the cardiac rhythm. If a shock is advised, reconfirm that no one is touching the patient and push the Shock button. If at any time the AED advises to check the patient, quickly assess for a carotid or femoral pulse. This should not take longer than 5 to 10 seconds. If you feel a pulse, the patient has experienced ROSC (return of spontaneous circulation). Continue to monitor the patient. 3) Verbally and visually clear the patient. Push the Analyze button, if there is one. Wait for the AED to analyze the cardiac rhythm. If no shock is advised, perform five cycles (2 minutes) of CPR and then reanalyze the cardiac rhythm. If a shock is advised, recheck that all are clear, and push the Shock button. After the shock is delivered, immediately resume CPR beginning with chest compressions and remember to switch rescuers. 4) After five cycles (2 minutes) of CPR, reanalyze the cardiac rhythm. Do not interrupt chest compressions for more than 10 seconds. 5) If shock is advised, clear the patient, push the Shock button, and immediately resume CPR compressions. If no shock is advised, immediately resume CPR compressions and be sure to switch rescuers. After five cycles (2 minutes) of CPR, reanalyze the cardiac rhythm. Repeat the cycle of five cycles (2 minutes) of CPR, one shock (if indicated), and 2 minutes of CPR. Transport and contact medical control as needed.

All of the following are common signs and symptoms of cardiac ischemia, EXCEPT: A. headache. B. chest pressure. C. shortness of breath. D. anxiety or restlessness.

A. headache. --> Cardiac ischemia occurs when the heart's demand for oxygen exceeds the available supply. Common signs and symptoms of cardiac ischemia include chest pain or discomfort, shortness of breath (dyspnea), and anxiety or restlessness. Headache is not a common symptom of cardiac ischemia.

After the AED has delivered a shock, the EMT should: Select one: A. immediately resume CPR. B. transport the patient at once. C. assess for a carotid pulse. D. re-analyze the cardiac rhythm.

A. immediately resume CPR.

A dissecting aortic aneurysm occurs when: Select one: A. the inner layers of the aorta become separated. B. a weakened area develops in the aortic wall. C. all layers of the aorta suddenly contract. D. the aorta ruptures, resulting in profound bleeding.

A. the inner layers of the aorta become separated.

Nitroglycerin is contraindicated in patients: Select one: A. who have experienced a head injury. B. who have taken up to two doses. C. with a history of an ischemic stroke. D. with a systolic blood pressure less than 120 mm Hg.

A. who have experienced a head injury.

Nitroglycerin is contraindicated in patients: A. with a systolic blood pressure less than 100 mm Hg. B. with chest pain of greater than 30 minutes duration. C. who are currently taking antibiotics for an infection. D. who are younger than 40 years of age and have diabetes.

A. with a systolic blood pressure less than 100 mm Hg. --> Nitroglycerin is a vasodilator and may cause a drop in BP; therefore, it is contraindicated in patients with a systolic BP of less than 100 mm Hg and in patients who have taken erectile dysfunction (ED) drugs within the past 24 to 48 hours. ED drugs are also vasodilators; if given in combination with nitroglycerin, severe hypotension may occur.

A 56-year-old man has an acute myocardial infarction. Which of the following blood vessels became blocked and led to his condition? A. Coronary veins B. Coronary arteries C. Pulmonary veins D. Pulmonary arteries

B. Coronary arteries --> The coronary arteries, which branch off the aorta, supply the myocardium (heart muscle) with oxygen-rich blood. Occlusion of one or more of these arteries results in a cessation of oxygenated blood beyond the area of occlusion and results in acute myocardial infarction (AMI).

A 66-year-old female with a history of hypertension and diabetes presents with substernal chest pressure of 2 hours' duration. Her blood pressure is 140/90 mm Hg, her pulse is 100 beats/min and irregular, her respirations are 22 breaths/min, and her oxygen saturation is 92%. The patient does not have prescribed nitroglycerin, but her husband does. You should: Select one: A. obtain a SAMPLE history and contact medical control for advice. B. administer oxygen, give her 324 mg of aspirin, and assess her further. C. give her one nitroglycerin and reassess her systolic blood pressure. D. give her high-flow oxygen, attach the AED, and transport at once.

B. administer oxygen, give her 324 mg of aspirin, and assess her further.

A 59-year-old woman presents with chest pressure. She is conscious and alert, but her skin is cool, pale, and clammy. Your first step in providing care (treatment) should be: A. apply the AED. B. administer oxygen. C. ask her if she takes nitroglycerin. D. take a complete set of vital signs.

B. administer oxygen. --> Any patient with suspected cardiac compromise should be given oxygen as soon as possible. Obtaining vital signs and inquiring about the use of nitroglycerin are appropriate; however, you should administer oxygen first. The AED is only applied to patients in cardiac arrest.

You and your partner arrive at the scene of a middle-aged man who collapsed about 5 minutes ago. He is unresponsive, apneic, and pulseless. Bystanders are present, but have not provided any care. You should: Select one: A. perform two-rescuer CPR for 5 minutes and request ALS backup. B. begin high-quality CPR and apply the AED as soon as possible. C. immediately apply the AED pads and analyze his cardiac rhythm. D. have your partner perform CPR while you question the bystanders.

B. begin high-quality CPR and apply the AED as soon as possible.

Angina pectoris occurs when: Select one: A. myocardial oxygen supply exceeds the demand. B. myocardial oxygen demand exceeds supply. C. one or more coronary arteries suddenly spasm. D. a coronary artery is totally occluded by plaque.

B. myocardial oxygen demand exceeds supply.

When preparing to obtain a 12-lead ECG, the "LL" and "RL" electrodes should be placed: Select one: A. on the lower abdomen. B. on the thighs or ankles. C. anywhere on the arms. D. on either side of the chest.

B. on the thighs or ankles.

After administering a nitroglycerin tablet to a patient, the EMT should: A. check the expiration date of the nitroglycerin. B. reassess the patient's blood pressure within 5 minutes. C. instruct the patient to chew the tablet until it is dissolved. D. ensure that the nitroglycerin is prescribed to the patient.

B. reassess the patient's blood pressure within 5 minutes. --> Nitroglycerin is a vasodilator and can lower the patient's BP; therefore, you should reassess the patient's BP within 5 minutes after giving nitroglycerin. Instruct the patient to allow the nitroglycerin to dissolve under his or her tongue; it should not be chewed. You should check the drug's expiration date and ensure that it is prescribed to the patient before administering it.

A patient in cardiac arrest is wearing an external defibrillator vest, which is interfering with effective chest compressions. The EMT should: Select one: A. perform ventilations only and allow the vest device to defibrillate. B. remove the battery from the monitor and then remove the vest. C. remove the battery from the monitor and leave the vest in place. D. leave the battery attached to the monitor and remove the vest.

B. remove the battery from the monitor and then remove the vest.

Most AEDs are set up to adjust the voltage based on the impedance, which is the: Select one: A. distance between the two AED pads on the chest. B. direction that the electrical flow takes in the body. C. resistance of the body to the flow of electricity. D. actual amount of energy that the AED will deliver.

C. resistance of the body to the flow of electricity.

Which of the following is NOT a common sign or symptom associated with malfunction of an implanted cardiac pacemaker? Select one: A. Heart rate less than 60 beats/min B. Generalized weakness C. A rapid heart rate D. Syncope or dizziness

C. A rapid heart rate

Deoxygenated blood from the body returns to the: Select one: A. right ventricle. B. left ventricle. C. right atrium. D. left atrium.

C. right atrium.

The electrical impulse generated by the heart originates in the: Select one: A. bundle of His. B. atrioventricular node. C. sinoatrial node. D. coronary sinus.

C. sinoatrial node.

A 49-year-old male presents with an acute onset of crushing chest pain and diaphoresis. You should: Select one: A. administer up to 324 mg of baby aspirin. B. administer up to three doses of nitroglycerin. C. assess the adequacy of his respirations. D. obtain vital signs and a SAMPLE history.

C. assess the adequacy of his respirations.

Major controllable risk factors for an AMI include: A. older age. B. family history. C. cigarette smoking. D. male sex.

C. cigarette smoking. --> Smoking is a major controllable risk factor for any cardiovascular disease.

A patient with cardiac arrest secondary to ventricular fibrillation has the greatest chance for survival if: A. CPR is initiated within 10 minutes. B. oxygen and rapid transport are provided. C. defibrillation is provided within 2 minutes. D. paramedics arrive at the scene within 5 minutes.

C. defibrillation is provided within 2 minutes. --> Survival from cardiac arrest secondary to ventricular fibrillation is highest if CPR is provided immediately and defibrillation is provided within 2 minutes of the patient's cardiac arrest. Early high-quality CPR and defibrillation are the two most important factors that influence survival from cardiac arrest.

Prior to attaching the AED to a cardiac arrest patient, the EMT should: Select one: A. contact medical control. B. perform CPR for 30 seconds. C. dry the chest if it is wet. D. assess for a pulse for 20 seconds.

C. dry the chest if it is wet.

The EMT should use an AED on a child between 1 month and 8 years of age if: Select one: A. special pads are used and the child has profound tachycardia. B. his or her condition is rapidly progressing to cardiac arrest. C. pediatric pads and an energy-reducing device are available. D. he or she is not breathing and has a weakly palpable pulse.

C. pediatric pads and an energy-reducing device are available.

If a patient with an implanted pacemaker is in cardiac arrest, the EMT should: A. avoid defibrillation with the AED and transport at once. B. not apply the AED until he or she contacts medical control. C. place the AED pads away from the pacemaker. D. apply the AED pads directly over the implanted pacemaker.

C. place the AED pads away from the pacemaker. --> The only modification required for cardiac arrest patients with an implanted pacemaker is to ensure that the AED pads are away from the pacemaker. Placing the AED pads directly over the pacemaker will result in a less effective defibrillation and may damage the pacemaker.

A patient tells you that he has a left ventricular assist device (LVAD). Which of the following conditions should you suspect that he has experienced? Select one: A. Thoracic aortic aneurysm B. Uncontrolled hypertension C. Obstructive lung disease D. Acute myocardial infarction

D. Acute myocardial infarction

The main advantage of the AED is: A. it provides quick delivery of a shock. B. it is easier than performing CPR. C. there is no need for ALS providers to be on scene. D. All of the above.

D. All of the above. --> The AED provides quick delivery of a shock, is easier to perform than CPR, and does not require ALS providers to operate it.

Which of the following signs is commonly observed in patients with right-sided heart failure? Select one: A. Labored breathing B. Flat jugular veins C. Pulmonary edema D. Dependent edema

D. Dependent edema

While palpating the radial pulse of a 56-year-old man with chest pain, you note that the pulse rate is 86 beats/min and irregular. This indicates: A. pain. B. fear. C. anxiety. D. dysrhythmia.

D. dysrhythmia. --> An irregular pulse in a patient with a cardiac problem suggests dysrhythmia — an abnormality in the heart's electrical conduction system. Patients with signs of cardiac compromise, who have an irregular pulse, must be monitored closely for cardiac arrest.

Risk factors for AMI that cannot be controlled include: Select one: A. hyperglycemia. B. lack of exercise. C. excess stress. D. family history.

D. family history.

Signs and symptoms of a hypertensive emergency would MOST likely be delayed in patients who: Select one: A. have had a stroke in the past. B. regularly take illegal drugs. C. are older than 40 years of age. D. have chronic hypertension.

D. have chronic hypertension.

A patient with atherosclerotic heart disease experiences chest pain during exertion because: Select one: A. the coronary arteries suddenly spasm and cause a marked reduction in myocardial blood flow. B. the ragged edge of a tear in the coronary artery lumen causes local blood clotting and arterial narrowing. C. tissues of the myocardium undergo necrosis secondary to a prolonged absence of oxygen. D. the lumen of the coronary artery is narrowed and cannot accommodate increased blood flow.

D. the lumen of the coronary artery is narrowed and cannot accommodate increased blood flow.

True/False: Percutaneous transluminal coronary angioplasty works by bypassing the coronary artery.

False: Percutaneous transluminal coronary angioplasty aims to dilate, rather than bypass, the coronary artery.

True/False: The factors involved in the defibrillation include voltage, current, and amperage.

False: The factors involved in the defibrillation include voltage, current, and impedance.

True/False: Cardiac arrest is indicated in the field by the absence of a carotid pulse.

True

True/False: The link in the chain of survival that is the most common determinant for survival is the third link—rapid defibrillation.

True

Most often, low blood flow to heart tissue is caused by what? a. Atherosclerosis b. Thromboembolism c. Acute myocardial infarction d. Ventricular fibrillation

a. Atherosclerosis --> Most often, low blood flow to heart tissue is caused by atherosclerosis, where calcium and cholesterol build up and form a plaque inside the walls of blood vessels.

What is the most effective way to assist a person with CHF to breathe effectively and prevent an invasive airway management technique? a. CPAP b. Nasal cannula c. BVM with 100% oxygen d. Nonrebreathing mask

a. CPAP --> The most effective way to assist a person with CHF to breathe effectively and prevent an invasive airway management technique is CPAP.

________ is calculated by multiplying the heart rate by the volume of blood ejected with each contraction. a. Cardiac output b. Perfusion c. Stroke volume d. ROSC

a. Cardiac output

You are treating a 50-year-old woman who has just finished a 10k run. She is complaining of crushing pain in the chest radiating down her left arm and nausea, which came on suddenly. She is sweating profusely. What condition should you suspect? a. Acute myocardial infarction b. Angina pectoris c. Congestive heart failure d. Cardiogenic shock

b. Angina pectoris --> Her symptoms and the fact that she has just exerted herself suggest angina.

You are treating a 63-year-old patient whose vital signs are as follows: pulse, 140 beats/min and irregular; respiratory rate, 28 breaths/min; and blood pressure, 90/50 mm Hg. He is complaining of chest pain. Given this information, why would nitroglycerin be contraindicated? a. He may have already exceeded the dosage limit. b. His blood pressure is too low. c. He may be allergic to it. d. He may have taken Viagra in the last 24 hours.

b. His blood pressure is too low. --> If the systolic blood pressure is less than 100 mm Hg, you should not give nitroglycerin.

Acute coronary syndrome is a group of symptoms caused by what? a. Bradycardia b. Ischemia c. Occlusion d. Thromboembolism

b. Ischemia --> Acute coronary syndrome is a group of symptoms caused by ischemia, a lack of oxygen that deprives tissues of necessary nutrients, resulting from partial or complete blockage of blood flow.

You are dispatched to a 60-year-old man reporting chest pain and shortness of breath. The patient has angina and is taking nitroglycerin, furosemide, and atorvastatin. You hear crackles when listening to his breath sounds. The patient's difficulty breathing and crackles are due to blood backing up in which part of the body? a. The heart b. The lungs c. The vessels d. The arteries

b. The lungs --> Crackles is a sign of blood backing up into the lungs.

Which of the following represents the MOST appropriate method of assisting a patient with his or her prescribed nitroglycerin tablet? a. Encourage the patient to chew the tablet to increase its effectiveness. b. Place the medication under the tongue and have the patient swallow it. c. Administer the medication sublingually and allow it to dissolve or absorb. d. Wait 15 minutes and reassess the patient's blood pressure prior to administering another dose.

c. Administer the medication sublingually and allow it to dissolve or absorb. --> To appropriately assist the patient with nitroglycerin, place the tablet under the patient's tongue and have the patient keep his or her mouth closed with the tablet under the tongue until it is dissolved and absorbed.

You are transporting a patient with angina and he loses consciousness on the way to the hospital. When you check, you cannot feel a pulse. What should you do? a. Tell your partner to drive faster as you begin CPR on the patient. b. Immediately apply the AED and wait for it to analyze the rhythm before taking any other action. c. Have your partner pull over the ambulance and come back to help you with CPR and the AED. d. Begin CPR and after 2 minutes stop to apply the AED while your partner continues driving to the hospital.

c. Have your partner pull over the ambulance and come back to help you with CPR and the AED.

Which of the following symptoms would you see in a patient with a dissecting aneurysm? (Select all that apply) a. Gradual onset of pain with additional symptoms b. Peripheral pulses equal c. Sharp or tearing pain d. Pain does not abate once it has started

c. Sharp or tearing pain d. Pain does not abate once it has started

What is cardiac output? a. The number of times the heart contracts in 1 minute b. The volume of blood pumped out by the left ventricle in one contraction c. The amount of blood pumped out of the left ventricle in 1 minute d. The amount of venous flow return to the right atrium

c. The amount of blood pumped out of the left ventricle in 1 minute

Which dysrhythmia is the most common cause of sudden death in a cardiovascular emergency? a. Bradycardia b. Tachycardia c. Ventricular tachycardia d. Ventricular fibrillation

d. Ventricular fibrillation --> Ventricular fibrillation is the dysrhythmia that commonly causes sudden death.