EMT Chapter 16: Cardiovascular Emergencies
In general, a maximum of___ dose(s) of nitroglycerin is/are given for any one episode of chest pain.
3
About ______ minutes after blood flow is cut off, some heart muscle cells begin to die.
30
Which of the following is the MOST reliable method of estimating a patient's cardiac output?
Assess the heart rate and strength of the pulse.
What are the major arteries that branch from the upper aorta supply and the lower aorta supply?
Upper: carotid supply head and subclavian supply upper extremities like arms Lower: left and right iliac arteries supply lower extremities
Which of the following cardiac dysrhythmias has the greatest chance of deteriorating into a pulseless rhythm?
Ventricular tachycardia
angina pectoris
When heart tissues are not getting enough oxygen for a brief time. can result from a spasm of an artery, but is usually a symptom of atherosclerotic coronary artery disease. Usually occurs when a heart's need for oxygen exceeds its supply, normally during physical activity or large emotional stress. when increased o2 demand goes away, pain goes away.
Thromboembolism is:
a blood clot floating through blood vessels until it reaches a narrow area and blocks blood flow downstream tissues face hypoxia
Acute coronary syndrome (ACS) is a term used to describe:
a group of symptoms that are caused by myocardial ischemia. this leads to chest pain through reduction of oxygen and nutrients to the tissues of the heart
The myocardium receives oxygenated blood from the __________, which originate(s) from the __________.
coronary arteries, aorta
Ischemic heart disease is defined as:
decreased blood flow to one or more portions of the myocardium.
Major risk factors for AMI include all of the following, EXCEPT:
hypoglycemia
When does the myocardium require more oxygen and what happens
in periods of physical exertion or stress. the arteries supplying the heart dilate, increasing cardiac output
Ischemia
lack of oxygen, generally because of decreased blood flow
What should you do if you restore heartbeat through use of an AED?
monitor for spontaneous respirations and use provide oxygen via BVM at 10-12 breaths/min, O2 sat at 95-99%. then see if they can follow commands
asystole
no heart electrical activity
Prior to assisting a patient with his or her prescribed nitroglycerin, the EMT must:
obtain authorization from medical control.
dissecting aneuysm
occurs when the inner layers of the aorta become separated, allowing blood to flow there - primary cause is uncontrolled HPN - signs: sudden chest pain in chest or shoulder blades, difference in bp in arms vs lower extremities
cardiogenic shock
often caused by a heart attack, heart lacks enough power to force the proper volume of blood through the circulatory system.
In contrast to AMI, a dissecting aortic aneurysm:
often presents with pain that is maximal from the onset.
When preparing to obtain a 12-lead ECG, the V1 and V2 electrodes should be placed:
on either side of the sternum
Common signs and symptoms of AMI include all of the following, EXCEPT:
pain exacerbated by breathing
A 67-year-old female presents with difficulty breathing and chest discomfort that awakened her from her sleep. She states that she has congestive heart failure, has had two previous heart attacks, and has been prescribed nitroglycerin. She is conscious and alert with adequate breathing. Her blood pressure is 94/64 mm Hg and her heart rate is 120 beats/min. Treatment for this patient includes:
placing her in an upright position.
During your treatment of a woman in cardiac arrest, you apply the AED, analyze her cardiac rhythm, and receive a "no shock advised" message. This indicates that:
she is not in ventricular fibrillation
In contrast to the sympathetic nervous system, the parasympathetic nervous system:
slows the heart and respiratory rates.
The purpose of defibrillation is to:
stop the chaotic, disorganized contraction of the cardiac cells.
consequences of AMI
sudden death, cardiogenic shock, congestive heart failure (CHF)
When treating a patient with chest pain, you should assume that he or she is having an AMI because:
the cause of the pain cannot be diagnosed in the field.
Acute Myocardial Infarction (AMI)
- A heart attack; death of heart muscle following obstruction of blood flow in a coronary artery. The death of heart muscle can lead to severe diminishment of the heart's ability to pump or cause it to stop completely. - Once dead, the cells cant be revived, which is why time is of the essence. After 30 mins, heart cells begin to die - needs thrombolytic medication or angioplasty, get to ED ASAP - more likely to occur in the left ventricle
common angina pectoris symptoms
- commonly described as crushing or squeezing - felt in mid portion, under sternum, but can radiate to the jaw and normally left arm - usually doesn't last longer than 15 minutes - shortness of breath, nausea, or sweating -disappears with nitroglycerin, rest, or supplemental oxygen
what can you do as an emt in a hypertensive emergency?
- monitor bp - make them comfortable with head elevated - rapid transport, consider ALS meet up
stable angina
- pain in chest relieved by what it is normally relieved by like rest or nitro
unstable angina
- pain or discomfort in the chest of coronary origin that occurs in response to progressively less exercise or fewer stimuli than usually needed to provoke a response - typically not as much nitroglycerin relieves the pain - if untreated can lead to AMI
signs/symptoms of AMI
- sudden weakness, nausea, sweating - chest pain, discomfort, or pressure that is often crushing or squeezing and does not change with each breath - pain, discomfort, or pressure in lower jaw, arms, abdomen, or neck - irregular heartbeat, syncope - dyspnea - pink/frothy sputum - sudden death
How AMI pain differs from angina pain
1. can occur at any time, does not have to be caused by exertion 2. does not resolve in a few minute, can last for 30 mins to hours 3. may/may not be relieved by rest or nitro
ventricular tachycardia
A rapid heart rhythm in which the electrical impulse begins in the ventricle (instead of the atrium), which may result in inadequate blood flow and eventually deteriorate into cardiac arrest. Usually 150-200 bpm.
Aortic aneurysm
A weakness in the wall of the aorta that makes it susceptible to rupture. the aorta dilates at this point
What three components allow for good perfusion?
A well functioning pump, adequate amount of volume, properly sized container/pipes
Cardiogenic shock can occur within 24 hours of a(n):
Acute Myocardial Infarction. this is due to decreased pumping force of the heart muscle
hypertensive emergency
An emergency situation created by excessively high blood pressure, typically systolic > 180 mm Hg - common signs: severe headache, strong bounding pulse, ringing, nausea, dizziness, warm skin, nose bleed, altered mental status - untreated, it could lead to stroke or aneurysm
cardiac output
CO = HR x SV, typically SV cant increase much, so HR increases a lot in times of stress
What is the most effective way to assist a person with CHF to breath adequately?
CPAP
Rapid, labored breathing in a patient with signs and symptoms of AMI should make you suspicious for:
Congestive Heart Failure
Which of the following is a function of the sympathetic nervous system?
Constriction of blood vessels in the digestive system and dilation in the muscles for more energy to be directed to that fight or flight response
A 40-year-old man is in cardiac arrest. Your partner is performing CPR. You are attaching the AED when the patient's wife tells you that he has an automatic implanted cardiac defibrillator (AICD). The AED advises that a shock is indicated. What should you do?
Deliver the shock followed by immediate resumption of CPR
ventricular fibrillation
Disorganized, ineffective twitching of the ventricles, resulting in no blood flow and a state of cardiac arrest. using up energy without pumping any blood. Patient becomes unconscious and the only way to stop this is to defibrillate (shock) the heart
While obtaining a 12-lead ECG prior to ALS arrival, you note the presence of artifacts on the tracing. Which of the following is the MOST likely cause of this?
Excessive movement of the patient
Which of the following is LEAST important when obtaining a medical history from a patient complaining of chest discomfort?
Family history of hypertension
Where does an electrical impulse in the heart start from and travel?
It begins at the SA node, then travel across both atria, causing them to contract. Then between the atria and ventricles, it passes the AV node where slows it down so blood can travel from the atria to the ventricles. Then they exit the atrioventricular node and spread throughout both ventricles, causing them to contract.
Which of the following statements regarding the pain associated with AMI is correct?
It can occur during exertion or when the patient is at rest.
What is the function of the left atrium?
It receives oxygenated blood from the lungs.
Which of the following statements regarding nitroglycerin is correct?
Nitroglycerin usually relieves anginal chest pain within 5 minutes.
______ are inserted when the electrical control system of the heart is so damaged that it cannot function properly.
Pacemakers
At 0500 hours, you respond to the home of a 76-year-old man complaining of chest pain. Upon arrival, the patient states that he had been sleeping in the recliner all night due to indigestion, when the pain woke him up. He also tells you he has taken two nitroglycerin tablets. His vital signs are as follows: respirations, 16 breaths/min; pulse, 98 beats/min; blood pressure, 92/76 mm Hg. He is still complaining of chest pain. What actions should you take to intervene?
Provide high-flow oxygen
Which of the following veins is located inferior to the trunk?
Saphenous
dependent edema
Swelling in the part of the body closest to the ground, caused by collection of fluid in the tissues; a possible sign of congestive heart failure.
_____is the maximum pressure exerted by the left ventricle as it contracts.
Systolic blood pressure
Which of the following statements regarding the AED and defibrillation is correct?
The AED will not analyze the rhythm of a moving patient.
stroke volume
The amount of blood ejected from the heart in one contraction.
Automaticity
This allows a cardiac muscle cell to contract spontaneously without a stimulus from a nerve source. additionally, if no impulse comes from the SA node, then the other myocardial cells are capable of creating their own impulses and stimulating contraction of the heart at a slower rate.
artifact
an ECG tracing that is the result of interference
When, for a brief period of time, heart tissues do not get enough oxygen, the pain is called:
angina
The MOST common reason that many people experiencing AMI do not seek immediate medical attention is because they:
are in denial
Upon arriving at the residence of a patient with a possible cardiac problem, it is MOST important to:
assess the scene for potential hazards
The electrical stimulus that originates in the heart's primary pacemaker is controlled by impulses from the brain that arrive by way of the:
autonomic nervous system.
You and your EMT partner are the first to arrive at the scene of an unresponsive 70-year-old man. Your assessment reveals that he is apneic and pulseless. A paramedic unit is en route to the scene and will arrive in approximately 5 minutes. You should:
begin CPR, apply the AED, and deliver a shock if it is indicated.
You are dispatched to a residence for a 56-year-old male with an altered mental status. Upon arrival at the scene, the patient's wife tells you that he complained of chest pain the day before, but would not allow her to call EMS. The patient is semiconscious; has rapid, shallow respirations; and has a thready pulse. You should:
begin ventilatory assistance
The posterior tibial pulse can be palpated:
behind the medial malleolus, on the inside of the ankle.
The inferior vena cava returns deoxygenated blood to the right side of the heart from all of the following areas, EXCEPT the:
brain
The head and brain receive their supply of oxygenated blood from the:
carotid arteries
It would be MOST appropriate for a patient to take his or her prescribed nitroglycerin when experiencing:
chest pain that does not immediately subside with rest.
Nitroglycerin
dilates blood vessels, allowing blood to perfuse indications: chest pain of cardiac origin (heart attack or angina) contraindications: hypotension(less than 100 mm Hg); use of sildenafil (viagra) or another treatment for erectile dysfunctoin within the previous 24 hours; head injury route: SL tablet or spray dose: 0.3-0.4 mg side effects: headache, burning under tongue, hypotension, nausea caution: make sure ALS is en route --if chest pain persists, repeat dose every 5 minutes according to med control. max 3 doses
A percutaneous transluminal coronary angioplasty (PTCA) restores blood flow to the ischemic myocardium by:
dilating the affected coronary artery with a small inflatable balloon.
Nitroglycerin relieves cardiac-related chest pain by:
dilating the coronary arteries and improving cardiac blood flow.
Atherosclerosis
disorder in which calcium and cholesterol build up and form a plaque inside the walls of blood vessels, obstructing flow and interfering with their ability to dilate or contract. Eventually, this can result in complete occlusion (blockage) of the artery. if there is partial occlusion, these calcium deposits typically make the arteries more brittle and they may not be able to accommodate increased blood flow in times of need
The MOST common error associated with the use of the AED is
failure of the EMT to ensure the battery is charged.
congestive heart failure (CHF)
failure of the heart when the ventricular heart muscle is so damaged it can no longer keep up with the return flow of the heart. Also happens if it is damaged by disease or chronic hypertension. In all these situations, the heart tries to maintain adequate CO by increasing HR and enlarging left ventricle. When this isnt effective, CHF sets in and blood backs up to pulmonary arteries (results in pulmonary edema)
You are dispatched to a convenience store for a patient who passed out. Upon arriving at the scene, you find two off-duty EMTs performing CPR on the patient, a 58-year-old male. Your initial action should be to:
feel for a pulse while compressions are ongoing.
The iliac arteries immediately subdivide into the:
femoral arteries
Blood that is ejected from the right ventricle:
flows into the pulmonary arteries
The only vein(s) in the body that carry oxygenated blood is/are the:
pulmonary veins
The AED has delivered a shock to an elderly male in cardiac arrest. Following 2 minutes of CPR, you re-analyze the patient's cardiac rhythm and receive a "no shock advised" message. After further resuscitation, you restore a palpable carotid pulse. Your next action should be to:
reassess airway and breathing and treat accordingly.
After assisting your patient with prescribed nitroglycerin, you should:
reassess his or her blood pressure within 5 minutes to detect hypotension.
You are assessing a 49-year-old man who complains of chest pressure that began the night before. He is conscious, but anxious, and tells you he has a history of angina and hypertension. After applying high-flow oxygen, you expose his chest to auscultate his lungs and note that he has a nitroglycerin patch on his right upper chest. His skin is cool and pale, his blood pressure is 78/50 mm Hg, and his pulse is 110 beats/min and irregular. You should:
remove the nitroglycerin patch, place him in a supine position and elevate his lower extremities, and prepare for immediate transport.
The right coronary artery supplies blood to the:
right ventricle and inferior wall of the left ventricle.
lumen
the inside diameter of the artery. typically narrows in cases of athersclerosis.
Ventricular tachycardia causes hypotension because:
the left ventricle does not adequately fill with blood.
Cardiac output may decrease if the heart beats too rapidly because:
there is not enough time in between contractions for the heart to refill completely.
external defibrillator vest
this is a vest with built in monitoring electrodes and defibrillation pads which is worn by the patient under their clothing. - blue gel under electrodes = delivered at least one shock - keep on while doing chest compressions but if it gets in the way, remove battery and then remove vest + AED
Most patients are instructed by their physician to take up to _______ doses of nitroglycerin before calling EMS.
three
Infarction
tissue death
The descending aorta divides into the two iliac arteries at the level of the:
umbilicus (navel).
When documenting a patient's description of his or her chest pain or discomfort, the EMT should:
use the patient's own words
Sudden death following AMI is MOST often caused by:
ventricular fibrillation.