chapter 15: EMT: Shock and Resuscitation: Study Guide/Questions
What is the formula for computing the lower limit of normal for a systolic blood pressure in a patient who is 7 years old? A. 90 minus− 2 times the patient age B. 70 plus+ 2 times the patient age C. 90 plus+ 2 times the patient age D. 70 minus− 2 times the patient age
70 plus+ 2 times the patient age Normal vital sign findings vary with age for pediatric patients. For children younger than 10 years of age, a systolic blood pressure of 70 mmHg plus two times the age in years is a lower limit of normal. A systolic blood pressure less than the lower limit would be considered hypotensive. Hypotension is a late finding in pediatric patients and often leads to cardiac arrest.
Which of the following situations would NOT result in hypovolemic shock? A. Plasma loss from significant burns B. Fluid and electrolyte loss due to prolonged vomiting C. Significant blood loss D. A massive heart attack of the left ventricle
A massive heart attack of the left ventricle 414-419 When the heart fails, the result is known as cardiogenic shock, or pump failure. Hypovolemic shock occurs when the body loses too much fluid volume to maintain an adequate perfusion pressure. This loss of volume could be from significant blood loss, fluid loss from prolonged vomiting (or diarrhea), or plasma loss in burn shock.
While taking a CPR class, you are asked by the instructor to describe the American Heart Association's Chain of Survival. Which of the following provides the BEST description? A. A treatment plan that, if followed, guarantees the survival of the patient who is in cardiac arrest B. A sequence of steps that provides instructions on how to properly use an AED C. A treatment plan that helps to prevent and treat cardiac arrest in the general population D. A sequence of coordinated events that provides the best chance for surviving cardiac arrest
A sequence of coordinated events that provides the best chance for surviving cardiac arrest (426) Successfully resuscitating a cardiac arrest patient in the prehospital setting can rarely be done solely with CPR. Rather, success depends on a sequence of events that the American Heart Association has termed the Chain of Survival. The Chain of Survival identifies key components for successful cardiac arrest resuscitation and recovery. The Chain of Survival will incorporate the AED, but it is not geared as a preventive strategy, nor does it guarantee the survival of arrested patients.
Which of the following is TRUE about AEDs? A. AEDs cannot be used unless the patient is an adult (18 years of age or older). B. The operator of an AED must know how to recognize various heart rhythms. C. AEDs allow hands-free defibrillation, which is safer for EMS personnel. D. AEDs require advanced life support personnel to operate them
AEDs allow hands-free defibrillation, which is safer for EMS personnel. (428) Because defibrillation is the delivery of electricity, there are some inherent risks to the provider who is delivering the countershock. To minimize this risk, AEDs are made in such a way that the shock is delivered hands-free, which means that no one is in contact with the patient. The AED can be used on patients in all age brackets, not just adults, and you do not need to be an ALS provider to use the device. Finally, the AED removes the need for the EMT to recognize a rhythm, because the machine does its own analysis.
Maintaining adequate perfusion to the body implies that what two components are intact? A. Adequate blood pressure and adequate removal of excess glucose from the cells B. Adequate breathing, adequate heart rate, and prevention of hyperoxia C. Adequate heart rate and adequate carbon dioxide delivery to the body D. Adequate blood flow to the tissues and adequate oxygenation of the blood
Adequate blood flow to the tissues and adequate oxygenation of the blood Rationale To maintain proper cellular perfusion, several components must be functioning adequately. The most important of these is the ability of the body to deliver an adequate amount of oxygen to the cells. To do this, the body must be adequately oxygenating the blood and then adequately delivering this oxygenated blood to the peripheral tissues via the blood.
You get a call for cardiac arrest. Upon your arrival, you find out that the family did CPR for about 3 minutes before the pulse returned and the patient awoke. The patient is now conscious and has a chief complaint of heart palpitations and dyspnea. She has a very fast pulse and feels dizzy. What should you do? A. Administer oxygen, and call for ALS. B. Analyze the rhythm with the AED. C. Administer one shock, and start chest compressions. D. Lay her down in Trendelenburg position.
Administer oxygen, and call for ALS. (431-436) With a patient in cardiac arrest, out of cardiac arrest, or even suspected of being in cardiac arrest before arrival, the EMT should keep the American Hospital Association's Chain of Survival in mind. The fourth link of that chain is effective advanced cardiac life support (ACLS). It would make sense that an ALS provider may be able to provide other therapies such as medications to prevent the patient from deteriorating back into arrest. Applying the AED is not indicated, since the patient has a pulse, nor is starting chest compressions. Use of the Trendelenburg position is no longer recommended.
If the body's cells exist too long with insufficient oxygen during a shock syndrome, what metabolic process will start to prevail? A. Anaerobic metabolism B. Hypercapnic drive C. Aerobic metabolism D. Hypoxic drive
Anaerobic Metabolism (15 2.2) With a lack of oxygen in the cell from a shock syndrome, it causes a shift from aerobic to anaerobic metabolism. Aerobic metabolism is the creation of ATP in the presence of oxygen. When there is a lack of available oxygen, anaerobic metabolism takes place that results in a drastically lower production of ATP and the creation of lactic acid as a by-product. This is the initiating event that causes cellular death and eventual organ failure and system failure. Hypoxic drive and hypercapnic drive are both processes for stimulating breathing, not part of the shock syndrome.
If there is adequate perfusion to the capillary beds but inadequate levels of oxygen in the bloodstream, what could be the result? A. Aerobic metabolism B. Anaerobic metabolism C. Hypertension D. Hyperoxia
Anaerobic Metabolism 410-413 To maintain cellular perfusion, several components must be functioning adequately. One of the most important is the ability of the body to deliver an adequate amount of oxygen to the cells. If oxygen delivery is insufficient because of either a lack of perfusion or a lack of oxygen in the bloodstream, the outcome of the body shifting to anaerobic metabolism would be the same. Aerobic metabolism occurs in the presence of oxygen, hyperoxia refers to high levels of oxygen in the bloodstream, and hypertension would be unlikely, since the failure to oxygenate would eventually lead to failure of the vasomotor center in the brainstem with resultant vasodilation.
You arrived on the scene of a 42-year-old male patient who has been experiencing crushing chest pain for the past hour. As you enter the kitchen of his home, he suddenly arrests and is pulseless. What should you do, assuming that each intervention could be done immediately? A. Apply the AED. B. Administer high-concentration oxygen. C. Start positive pressure ventilations for a minimum of 2 minutes. D. Begin CPR with ventilations.
Apply the AED (426-427) Research from the American Heart Association revealed that communities with early defibrillation programs, even those with no prehospital ACLS services, had improved survival rates of patients with cardiac arrest. Research also verified that the earlier defibrillation took place, the better the outcome. If a patient arrests in front of you and you have an AED available, you should apply the AED and follow the prompted instructions.
While managing a cardiac arrest patient on whom the AED was used, your partner states that she can now feel a slow carotid pulse. What should you do? A. Reanalyze the heart rhythm with the AED. B. Resume CPR if the heart rate is less than 60/minute. C. Remain on scene until the patient regains consciousness. D. Assess for breathing.
Assess for breathing. (431-434) As soon as a carotid pulse is palpable in a patient whom you are managing for a cardiac arrest, the next step is to check for breathing. The EMT should not reanalyze the rhythm, as this is not an indication for the AED. Resuming CPR is inappropriate, as is waiting on scene until the patient regains consciousness (the patient may never regain consciousness).
As you arrive at your patient's side, the patient goes into cardiac arrest. You should: A. begin CPR and apply the AED only after another EMT has arrived. B. attach the AED and deliver a single shock as indicated. C. perform 2 minutes of CPR before applying the AED. D. insert an oropharyngeal airway and ventilate for 2 minutes before applying the AED.
Attach the AED and deliver a single shock as indicated (431-434) If a patient goes into cardiac arrest in front of you, you should apply the AED and allow it to assess the patient to determine whether a shock is indicated. If the patient had been down for several minutes before your arrival, 2 minutes of CPR would be indicated before the use of the AED. Providing airway, ventilatory, or circulatory support to a patient who arrested in front of you would delay the provision of a defibrillatory shock if one was needed.
You are assessing a 27-year-old male who was in a high-speed collision. He was NOT wearing his seat belt and was complaining of pain in his upper left quadrant from striking the steering column. Which of the following signs would indicate this patient is experiencing the late signs of hypoperfusion already? A. Increased respiratory rate B. A heart rate of 108 C. Restlessness D. A B/P of 80/68 mmHg
A B/P of 80/68 mmHg (421) Decompensatory shock, also commonly referred to as decompensated shock or progressive shock, is an advanced stage of shock in which the body's compensatory mechanisms are no longer able to maintain a blood pressure and perfusion of the vital organs. If the shock state continues unopposed and is not managed effectively, the compensatory mechanisms become exhausted or overwhelmed, leading to a failure to maintain pressure inside the vessels and perfusion of the vital organs. Restlessness, tachypnea, and tachycardia are all earlier findings in a shock stage.
You arrive on the scene of an unconscious middle-aged male patient. On assessment, you find that the patient is in cardiac arrest. The witness states that she saw him fall and called for help. She did NOT initiate chest compressions. What should you do NEXT? A. Immediately apply the AED and shock the patient. B. Compress the chest 1.5 to 2 inches for two minutes. C. Give the patient two full breaths and then begin chest compressions. D. Begin chest compressions at the rate of at least 100 per minute.
Begin chest compressions at the rate of at least 100 per minute (426-427) Research has shown that immediate CPR can double or even triple the chance of survival from ventricular-fibrillation-induced sudden cardiac arrest. In a situation such as this, when the patient arrested several minutes ago, CPR should be initiated, beginning with chest compressions, immediately upon recognition of cardiac arrest. Minimize interruption of chest compressions during the event.
Which of the following mechanisms have been found to cause distributive shock in a patient? A. Pulmonary embolism B. Cardiac valve failure C. Blood infection D. Blood loss
Blood Infectiom (418) Distributive shock may result from increasing capillary permeability, which can occur with a severe blood infection or anaphylaxis (other causes do exist). The infection causes general vasodilation, precapillary sphincter dilation, capillary engorgement, and fluid movement into the interstitial compartment.
What assessment parameter is the EMT interpreting if the patient's pulse pressure is determined to be narrowing? A. Pulse oximeter B. Respiratory rate C. Blood pressure D. Heart rate
Blood Pressure (15. 11.2) The pulse pressure is the difference between the systolic and diastolic values. For example, a blood pressure of 120/80 would have a pulse pressure of 40 mmHg. The pulse pressure has a tendency to narrow in a shock state from hypovolemia. Normal pulse pressure is typically between 30 and 40 mmHg.
At the scene of a multisystem trauma patient, you are contemplating applying the pneumatic anti-shock garment (PASG). What vital sign indication that would warrant the application of this device? A. Blood pressure <90 mmHg B. Heart rate <90/min C. Heart rate >90/min D. Blood pressure >90 mmHg
Blood pressure <90 mmHg During the management of a trauma patient, the EMT should consider application of the pneumatic anti-shock garment (PASG) if a pelvic fracture is suspected and the systolic blood pressure is <90 mmHg, intra-abdominal hemorrhage is suspected with severe hypotension, or retroperitoneal hemorrhage is suspected with hypotension. The PASG is not warranted if the blood pressure is <90 mmHg and is not based upon an absolute value of the heart rate. OK
What is the initiating event that eventually leads to cellular death during the shock syndrome? A. Failure of anaerobic metabolism and creation of high levels of hydrogen ions by aerobic metabolism B. Decreasing levels of carbon dioxide in the blood and failure of the pulmonary system C. A drop in the patient's blood pressure or an increase in the heart rate D. Cellular shift from aerobic metabolism to anaerobic metabolism
Cellular shift from aerobic metabolism to anaerobic metabolism
"Push hard and push fast" is a recommendation for what intervention in an arrested patient? A. Encouraging your fellow EMS providers to perform flawlessly during a cardiac arrest B. Transferring a patient on the wheeled cot C. Chest compression D. Bag-valve-mask ventilations
Chest compressions (426-427) The American Heart Association advocates "push hard and push fast" to provide effective chest compressions. Compressions that are delivered at a rate of at least 100/minute have been shown to provide suitable blood flow to essential organs during cardiac arrest.
What two stages of shock typically have findings that are so similar in nature that the stages of shock are difficult to distinguish? A. Progressive and compensated B. Compensated and progressive C. Decompensated and irreversible D. Early and irreversible
Decompensated and Irreversible (421) Irreversible shock is the stage in which, regardless of the intervention, the outcome is death. There are no definitive clinical signs indicating the transition from decompensated to irreversible shock. Cell, tissue, and organ failure and damage are so pervasive and severe that no matter what treatment is provided, the shock cannot be reversed and organ death is inevitable.
You are assessing a patient who was stabbed during a robbery. The patient presents unresponsive, has a low blood pressure, a heart rate of 138/min, and absent peripheral pulses. What stage of shock is this patient likely experiencing? A. Compensated shock B. Early shock C. Cardiopulmonary failure shock D. Decompensated shock
Decompensated shock (421) During decompensated shock, common findings include altered mental status, hypotension, tachycardia >120/min, absent peripheral pulses, tachypnea, and skin that is white, waxy, and cold. Patients in early shock and compensated shock will typically have acceptable vitals and a normal mental status. Cardiopulmonary failure shock is a fictitious term.
If normal compensatory mechanisms for shock fail to return the body to normality, blood pressure starts to falter and initiates what next stage of shock? A. Compensatory B. Decompensatory shock C. Initial shock D. Cardiogenic shock
Decompensatory Shock (421) Decompensatory shock, also commonly referred to as decompensated shock or progressive shock, is an advanced stage of shock, in which the body's compensatory mechanisms are no longer able to maintain a blood pressure and perfusion of the vital organs. Initial shock or compensated shock does not have this drop in blood pressure, and cardiogenic shock is an etiology of shock in which the body is failing because of a failing myocardium. This is a type of shock, not a progressive stage of shock.
When the heart goes into cardiac arrest that is precipitated by ventricular fibrillation, the likelihood of successful resuscitation roughly decreases by what percentage with each passing minute that no care is rendered? A. 20% B. 5% C. 10% D. 15%
10% (425) Time is a critical issue in cardiac arrest. As time passes, the heart continues to deteriorate from a lack of oxygen and glucose and begins to undergo changes that lead to severe myocardial cell ischemia and eventually organ death. As soon as the patient goes into cardiac arrest, the resuscitation clock is ticking. The chance of a successful resuscitation decreases by 10 percent for every minute the patient is in ventricular fibrillation. If it is 5 minutes after the arrest before someone finds the patient and calls 9-1-1 and you have a 5-minute response time to get to the patient's side, you are already 10 minutes into the cardiac arrest, which results in a less than favorable condition of the myocardium to begin resuscitative efforts.
Which of the following is the CORRECT choice for the compression-to-ventilation rate in performing one-person CPR? A. 15 compressions to 2 ventilations B. 15 compressions to 1 ventilation C. 30 compressions to 2 ventilations D. 30 compressions to 1 ventilation
30 compressions to 2 ventilations (427) The following recommendations are made for delivering CPR and automated defibrillation to sudden cardiac arrest patients: In performing chest compressions, "push hard and push fast" to maximize the pressures needed for blood circulation; deliver compressions at a rate of 30 compressions to 2 ventilations to minimize the interruption of chest compressions; and after defibrillation, immediately resume CPR with chest compressions without a pulse check to reduce the interruption in the delivery of chest compressions.
When should the EMT NOT start resuscitation on a patient found in cardiac arrest? A. When the patient displays rigor B. When the patient has not been seen in 15 minutes C. When the patient has cool extremities D. When the patient was found arrested on the floor, beside his bed
When the patient displays rigor (426) There are some situations in which you will not begin resuscitation on a patient who is in cardiac arrest. Some of these situations may include a patient with a valid do-not-resuscitate (DNR) order, physician orders for life-sustaining treatment (POLST), or medical orders for life-sustaining treatment (MOLST); a patient with injuries that are not compatible with life, such as a decapitation; and obvious death in a patient who is in rigor and beyond the point of a resuscitation effort. Be sure to follow your local protocol when considering a decision to withhold resuscitation.
You arrive on scene and find a patient who was in a car accident and was thrown through the windshield. You identify that the head has been almost completely severed from the body, with only a few pieces of tissue on the back of the neck still intact. There is neither heartbeat nor breathing. What should you do first? A. Contact ALS for intercept. B. Fully immobilize the patient. C. Withhold resuscitation. D. Start CPR.
Withhold resuscitation (426) There are some situations in which you will not begin resuscitation on a patient who is in cardiac arrest. Some of these situations may include a patient with a valid do-not-resuscitate (DNR) order, physician orders for life-sustaining treatment (POLST), or medical orders for life-sustaining treatment (MOLST); a patient with injuries that are not compatible with life, such as a decapitation; and obvious death in a patient who is in rigor and beyond the point of a resuscitation effort. Be sure to follow your local protocol when considering a decision to withhold resuscitation.
You arrive on scene for a patient in cardiac arrest. The patient was trapped under a car when it fell off a jack. You can see that the patient's head has been crushed, and brain matter is exposed. It will take 10 minutes for the fire department to lift the vehicle in order to extricate the patient. What should you plan to do when the patient has been extricated? A. Fully immobilize the patient. B. Withhold resuscitation. C. Start CPR. D. Contact ALS for intercept.
Withhold resuscitation. (426) There are some situations in which you will not begin resuscitation on a patient in cardiac arrest. Some of these situations may include a patient with a valid do-not-resuscitate (DNR) order, physician orders for life-sustaining treatment (POLST), or medical orders for life-sustaining treatment (MOLST); a patient with injuries that are not compatible with life, such as a decapitation (or a crush injury with brain matter exposed); and obvious death in a patient who is in rigor and beyond the point of a resuscitation effort. Be sure to follow your local protocol when considering a decision to withhold resuscitation.
You are treating a patient whom you suspect is in shock. He was thrown from his motorcycle and was found unresponsive. He has two fractured femurs and other injuries. Aside from securing and maintaining his airway, each of the following is an appropriate treatment for this patient EXCEPT: A. maintain body temperature. B. apply splints to each individual femur fracture. C. stop external bleeding as quickly as possible. D. administer supplemental oxygen.
apply splints to each individual femur fracture. If a patient is in shock and also has two fractured femurs, you should skip the traction splints and use a long spine board, control external bleeding, as well as provide oxygen cover with a blanket to keep the patient warm. Call for ALS to meet you en route to the ED. Do not delay transport to perform individual fracture splinting.
Why is defibrillation so important to a patient with either pulseless ventricular tachycardia or ventricular fibrillation? A. Defibrillation will help to maintain a systolic blood pressure during the first moments of cardiac arrest. B. Defibrillation works most effectively if the heart has not cooled down from the cardiac arrest. C. Defibrillation causes a sustained contraction of the myocardium to promote blood flow from the ventricles. D. Defibrillation has been shown to be the most effective emergency care to terminate the dysrhythmia.
Defibrillation has been shown to be the most effective emergency care to terminate the dysrhythmia. (427) Ventricular fibrillation is the most common presenting rhythm in out-of-hospital sudden cardiac arrest. The American Heart Association provides many reasons for the importance of delivering early defibrillation by EMS, which includes the fact that the most effective emergency care intervention to terminate ventricular fibrillation or ventricular tachycardia is defibrillation. Defibrillation does not cause blood flow, nor does it contribute to the systolic blood pressure. And while hypothermia decreases defibrillation effectiveness, the body does not cool down that fast after going into cardiac arrest.
If the patient has suffered a spinal cord injury that has caused widespread peripheral vasodilation, what would be the MOST immediate effect seen by the EMT? A. Sudden drop in the blood glucose levels of the body, causing unresponsiveness B. Drop in the systolic blood pressure C. Elevation in the core temperature and respiratory rate D. Elevation of the heart rate to combat hypotension
Drop in systolic blood pressure (412-413) To have an adequate blood pressure, the tone of the vessels must be maintained. The tone is related to the size of the vessel and the resistance that is created within it and is referred to as the systemic vascular resistance. If the vessel size increases because of massive vasodilation from a spinal cord injury, the resistance decreases and the blood pressure and perfusion will drop. In this case, the patient has not lost any blood volume; however, there is no longer enough intravascular blood volume to fill the vascular space because of the increase in vessel size. The result is a decrease in vascular resistance and a decrease in blood pressure and perfusion.
Which of the following is NOT a link in the American Heart Association's Chain of Survival? A. Early CPR B. Early access to the EMS system C. Early advanced life support D. Early hospitalization
Early Hospitalization (426) Successfully resuscitating a cardiac arrest patient in the prehospital setting can rarely be done solely with CPR. Rather, success depends on a sequence of events that the American Heart Association has termed the Chain of Survival. The Chain of Survival identifies key components for successful cardiac arrest resuscitation and recovery. Although the last link is integrated post-cardiac-arrest care, that is not the same as early hospitalization.
Which of the following patient populations will likely have the LEAST effective compensatory mechanism during an episode of cardiogenic shock? A. Elderly male B. School-age male C. Adult female D. Adolescent female
Elderly Male (424) Elderly persons and newborns do not compensate well for shock and therefore have a tendency to deteriorate rapidly. Children and young adults compensate very well, often exhibiting only minor signs and symptoms for a long period of time and then decompensating suddenly.
Which of the following patients would decompensate the fastest after falling down a flight of stairs and becoming critically injured? A. Female child B. Adult male C. Elderly female D. Male infant
Elderly female (424) Elderly persons and newborns do not compensate well for shock and therefore have a tendency to deteriorate rapidly. Children and young adults compensate very well, often exhibiting only minor signs and symptoms for a long period of time and then decompensating suddenly.
What is the first phase of cardiac arrest that is described as occurring immediately, while the heart still has a good supply of oxygen and glucose? A. Pre-arrest phase B. Metabolic phase C. Electrical phase D. Circulatory phase
Electrical Phase (425) The electrical phase begins immediately upon cardiac arrest and ends 4 minutes afterward. During this early and initial phase, the heart still has a good supply of oxygen and glucose; therefore, aerobic metabolism is maintained with continued energy production for cell function and prevention of mass production of acid. The circulatory phase begins at 4 minutes and lasts through 10 minutes after the cardiac arrest. During this phase, the oxygen stores have been exhausted, and the myocardial cells shift from aerobic to anaerobic metabolism. The metabolic phase begins 10 minutes after cardiac arrest. At this point, the heart is starved of oxygen and glucose and has a large amount of acid buildup. The tissues are very ischemic and may begin to die. The chances of survival drop dramatically during this phase. The pre-arrest phase is a fictitious term.
During the initial stages of shock, the skin becomes pale and the heart rate increases. These findings are due to what hormone(s)? A. Epinephrine and norepinephrine B. Epinephrine and glucagon C. Norepinephrine D. Norepinephrine, epinephrine, and glycogen
Epinephrine and norepinephrine (418-421) When a patient is in shock, exhibiting signs of hypoperfusion, the adrenal glands release epinephrine and norepinephrine into the bloodstream. The norepinephrine will initially cause pale, cool skin from vasoconstriction. Other effects of norepinephrine include pupillary dilation and stimulation of the sweat glands. During early shock, however, there is not an increase in urine output (if anything, it would decrease). The pupils would dilate, not become constricted. Finally, tachycardia is from the release of epinephrine, not norepinephrine.
Which catecholamines cause the MOST rapid response to hemorrhage and cardiovascular insufficiency? A. Norepinephrine and angiotensin B. Epinephrine and arginine vasopressin (AVP) C. Antidiuretic hormone and angiotensin D. Epinephrine and norepinephrine
Epinephrine and norepinephrine (419-421) Epinephrine and norepinephrine, called catecholamines, cause the most rapid hormonal response to hemorrhage and cardiovascular insufficiency. Both have alpha-1 properties. Additionally, epinephrine has beta-1 and beta-2 properties. Together, they help to increase vascular resistance and cardiac output in order to raise the systolic perfusion pressure.
During the metabolic phase of sudden cardiac arrest, the primary cause of cellular death is: A. a significant rise in the pH. B. systemic hypercapnia. C. failure of the sodium/potassium pump. D. cellular hypoxia.
Failure of the sodium/potassium pump (411-413) The sodium/potassium pump is responsible for maintaining sodium and potassium levels across cell membranes. When the pump fails, extracellular sodium begins to diffuse into the cell. Water ultimately follows sodium into the cell, resulting in cellular swelling. If allowed to progress untreated, the cell will rupture and die. This is a major mechanism for cell death after cardiac arrest.
What is the greatest detrimental effect on the body if hemorrhage continues beyond the stage of cellular ischemia? A. Increase in the blood sugar level B. A shift from anaerobic metabolism to aerobic metabolism C. Promotion of vasoconstriction in the capillary beds by increased carbon dioxide levels D. Failure of the sodium/potassium pump
Failure of the sodium/potassium pump (411)
What would be one of the initial findings in a patient who is going into shock after significant blood loss? A. Respiratory rate of 12/min B. BGL of 128 mg/dL C. Heart rate of 104/minute D. Blood pressure of 88/60 mmHg
Heart rate of 104/minute 418-419 Direct nerve stimulation of the heart by the sympathetic nervous system increases the heart rate and contractility in an attempt to increase cardiac output. This occurs within seconds of the fall in pressure; hence a tachycardic pulse would be an early finding of shock. A blood glucose level of 128 mg/dL is elevated, but that is not an initial finding of shock, nor is a blood pressure below 90 mmHg systolic (this is a late finding of shock). Finally, a respiratory rate of 12/minute is still normal.
Your patient is bleeding profusely from a stab wound. Which of the following types of shock is she most likely experiencing? A. Distributive B. Hypovolemic C. Cardiogenic D. Obstructive
Hypovolemic 15.2 (414)
If a patient is found to be hypotensive after a stabbing to the thigh, what is the most likely type of shock? A. Respiratory shock B. Obstructive shock C. Cardiogenic shock D. Hypovolemic shock
Hypovolemic shock "Hypo-" means low or inadequate, "vol" refers to volume, and "-emic" pertains to blood. Thus, the term "hypovolemic shock" means shock that is caused from a low blood volume. Hypovolemic shock is the most common form of shock. It can be due to blood loss or loss of some other fluid; basically any condition or injury that decreases the blood content or the fluid portion of the blood. The most common cause of hypovolemic shock is hemorrhage. Cardiogenic shock results from a dysfunctional heart, obstructive shock occurs due to a blockage of blood moving forward, and respiratory shock occurs when the body is unable to oxygenate the blood stream.
Which of the following conditions would lead to a drop in preload to the heart and subsequent shock? A. Myocardial infarction B. Increased systemic vascular resistance C. Failing left ventricle D. Inadequate blood volume
Inadequate blood volume 411-413 A patient who has a decreased blood volume will have a decrease in preload, which in turn will cause the stroke volume and cardiac output to fall. A decrease in cardiac output will cause a drop in the systolic blood pressure. The systolic blood pressure is responsible for transporting the oxygenated blood throughout the systemic circulation. Therefore, a decrease in systolic blood pressure can result in inadequate tissue perfusion. A failing left ventricle causes blood to back up behind the heart, which is not a cause of poor preload, and increased systemic vascular resistance would increase blood pressure and not drop preload. Myocardial infarction, like a failing left ventricle, would cause fluid to back up behind the heart, not cause a drop in preload.
You are treating a patient who is hypotensive and unresponsive. The ALS partner with whom you are working states that the patient is having a massive heart attack according to the 12-lead ECG findings. Why might this cause a hypotensive patient? A. Inadequate pump function B. Inadequate vessel tone C. Inadequate oxygen levels D. Inadequate blood volume
Inadequate pump function (412) Cardiogenic shock occurs when the pumping ability of the heart is diminished, causing poor forward movement of blood and poor peripheral perfusion. This is often seen by the EMT during a heart attack. Hypovolemic shock occurs when the body loses intravascular volume, distributive shock occurs from peripheral vasodilation, and metabolic or respiratory shock occurs when there is inadequate oxygenation of the blood.
Shock (or hypoperfusion) is generally defined as what? A. Decreased mental status. B. Low blood pressure. C. Inadequate tissue perfusion. D. Lack of a radial pulse.
Inadequate tissue perfusion. 15.1 (410)
A patient has suffered a cervical cord injury and is in a state of hypoperfusion. What type of shock is this MOST likely? A. Inadequate vessel tone B. Inadequate blood volume C. Inadequate pump function D. Inadequate oxygen levels
Inadequate vessel tone (412-413) In order to have an adequate blood pressure, the tone of the vessels must be maintained. The tone is related to the size of the vessel and the resistance created within it and is referred to as the systemic vascular resistance. With high cord damage, the nerve stimulation causing vasoconstriction is lost, thereby dropping systemic vascular resistance and the patient's pressure with it.
What is one of the most immediate effects of the sympathetic nervous system during early shock that relates to perfusion pressures? A. Slowing of the heart rate B. Elevation in the blood glucose level C. Increased cardiac output D. Vasodilation of the arterioles
Increased cardiac output (Compensatory shock: 419-421) Direct nerve stimulation of the heart by the sympathetic nervous system increases the heart rate and contractility in an attempt to increase cardiac output. This occurs within seconds of the fall in pressure. There would not be a slowing of the heart rate, as this would further drop cardiac output, as would vasodilation of the arterioles. Finally, the blood glucose level does increase in shock, but this is not an immediate change.
What is the final stage of shock that a hypovolemic patient will experience if the treatment provided has been either insufficient or inappropriate? A. Compensated shock B. Early shock C. Progressive shock D. Irreversible shock
Irreversible shock (421) Irreversible shock is the final stage of shock before death. In this stage, there is failure of the body systems and multiple organ dysfunction. Early shock, also known as compensated shock, is treatable and reversible. With proper treatment, progressive shock may be reversed. Irreversible shock, however, generally leads to death of the patient.
When managing the patient whom you suspect is in shock, why is it important NOT to hyperventilate this patient? A. It will promote increased bleeding into the nervous tissue. B. It makes the blood alkalotic and reduces off-loading of oxygen from the hemoglobin. C. It will increase the blood pressure too dramatically. D. It will increase the body temperature.
It makes the blood alkalotic and reduces off-loading of oxygen from the hemoglobin. Hyperventilation is rarely helpful. Breathe at a normal rate to not increase volume in the chest, reduce coronary blood flow, and avoid making the blood alkalotic from hyperventilating. The problem with alkalotic blood is that it reduces the off-loading of oxygen from the hemoglobin, which is essential for oxygenation at the cellular level.
Why does the American Heart Association advocate "push hard and push fast" in performing CPR? A. It increases the amount of oxygen in the alveoli for the body. B. It ensures that the EMT will stop to give ventilations. C. It decreases the likelihood of causing a rib fracture from the compressions. D. It provides more effective blood flow.
It provides more effective blood flow. (426-427) The American Heart Association advocates "push hard and push fast" to provide effective chest compressions. Compressions that are delivered at a rate of at least 100/minute have been shown to provide suitable blood flow to essential organs during cardiac arrest. The American Heart Association also advocates a uniform compression- to-ventilation ratio of 30:2 for all patients (other than two-rescuer CPR for infants and children). The 30:2 ratio delivered over 1 minute will result in fewer breaths per minute overall, but in cardiac arrest, the patient's need for oxygen is diminished (so fewer breaths are needed). This phrase is not for a reminder about ventilations, nor is it intended to decrease the incidence of rib fractures from compressions. Finally, ventilations are what puts oxygen in the alveoli, not compressions.
During what phase of cardiac arrest is successful resuscitation LEAST likely, owing to widespread death of heart tissue? A. Electrical phase B. Metabolic phase C. Terminal phase D. Circulatory phase
Metabolic Phase (425) The electrical phase begins immediately upon cardiac arrest and ends 4 minutes afterward. During this early and initial phase, the heart still has a good supply of oxygen and glucose; therefore, aerobic metabolism is maintained with continued energy production for cell function and prevention of mass production of acid. The circulatory phase begins at 4 minutes and lasts through 10 minutes after the cardiac arrest. During this phase, the oxygen stores have been exhausted, and the myocardial cells shift from aerobic to anaerobic metabolism. The metabolic phase begins 10 minutes after cardiac arrest. At this point, the heart is starved of oxygen and glucose and has a large amount of acid buildup. The tissues are very ischemic and may begin to die. The chances of survival drop dramatically during this phase. The terminal phase is a fictitious term.
Following cardiac arrest, cardiac muscle cells begin to die off during what phase of arrest? A. Metabolic phase B. Circulatory phase C. Electrical phase D. Terminal phase
Metabolic Phase (425) The metabolic phase begins 10 minutes after cardiac arrest. At this point, the heart is starved of oxygen and glucose and has a large amount of acid buildup. The tissues are very ischemic and may begin to die. The chances of survival drop dramatically during this phase. The electrical phase is when arrest starts and there are still adequate levels of glucose and oxygen. The circulatory phase is the shifting of the heart from aerobic to anaerobic metabolism. The terminal phase is a fictitious term.
Which type of shock is caused by a mechanism by which there is an interruption in the communication pathway between the central nervous system (CNS) and the body? A. Cardiogenic B. Septic C. Anaphylactic D. Neurogenic
Neurogenic (418) Neurogenic shock results from an interruption in the communication pathway between the CNS and the body. A spinal injury, or in some cases a head injury, either temporary or permanent, disrupts nervous system control (generally the sympathetic nervous system) over vasculature distal to the injury. Arterioles dilate, the vascular container expands, and fluid is driven into the interstitial space. Anaphylactic and septic shock can cause distributive shock, but neither is from a lack of sympathetic tone to the blood vessels, and cardiogenic shock results from a failing left ventricle.
You are managing an adult patient who was in cardiac arrest but now has a pulse. If the patient is NOT breathing, how fast should the EMT ventilate? A. 30 times a minute B. Once every 10 seconds C. Once every 6 seconds D. 20 times a minute
Once every 6 seconds (427) (432) The EMT should maintain a ventilatory rate at one breath every 5 to 6 seconds if the patient has a pulse but is not breathing spontaneously. Once every 10 seconds is too slow, and ventilating at a rate of 20 to 30 times a minute is too fast and potentially detrimental.
What is the underlying cause for all the clinical findings that are seen in irreversible shock? A. Conversion from anaerobic metabolism to aerobic metabolism B. Electrolyte imbalance C. Overall system failure D. Hyperglycemia and hyponatremia
Overall system failure (421) Irreversible shock is the stage in which, regardless of the intervention, the outcome is death. There are no definitive clinical signs indicating the transition from decompensated shock to irreversible shock. Cell, tissue, and organ failure and damage are so pervasive and severe that no matter what treatment is provided, organ death is inevitable and cannot be reversed. During this time, the body is undergoing anaerobic metabolism and changes to the electrolyte and glucose levels as the result of the organ failure.
Which of the following findings is MOST consistent with a patient who is going into shock from volume loss? A. Expiratory wheezing B. Pale, cool, clammy skin C. Pulse ox of 95% D. Constricted pupils
Pale, cool, clammy skin (422-423: Physical exam) During the assessment for findings that are consistent with shock, the EMT should recognize that the presence of pale, cool, and clammy skin is consistent with early hypovolemic shock. A drop in the pulse ox is not specific early shock, expiratory wheezing is typically a sign of a pulmonary disorder, and the pupils would be dilated in a shock state (owing to sympathetic tone), not constricted.
Which of the following patient populations will likely have the MOST robust compensatory mechanism during a traumatic incident with hypoperfusion? A. Elderly male B. Older adult C. Pediatric male D. Elderly female
Pediatric male (424) Elderly persons and newborns do not compensate well for shock and therefore have a tendency to deteriorate rapidly. Children and young adults compensate very well, often exhibiting only minor signs and symptoms for a long period of time and then decompensating suddenly.
When the AED has been applied to a patient and it does NOT recommend a shock, what is the MOST appropriate response of the EMT when treating an adult male in cardiac arrest? A. Call the emergency department to speak to medical control. B. Wait for ALS unit to arrive. C. Provide five cycles of compressions/ventilations and reassess. D. Transport the patient immediately.
Provide five cycles of compressions/ventilations and reassess. (431-434) If the AED's analysis determines that a shock is appropriate, it provides a "Deliver Shock" message. In that case, proceed with defibrillation by depressing the shock or defibrillation button. If the AED's analysis determines a nonshockable rhythm, it gives a "No Shock" message. In that case, immediately resume CPR, beginning with chest compressions.
What is the recommendation for the EMT when providing chest compressions? A. Push hard and push completely. B. Push deep and push often. C. Push shallow and push fast. D. Push hard and push fast.
Push hard and push fast. (427) The American Heart Association advocates "push hard and push fast" to provide effective chest compressions. Compressions that are delivered at a rate of at least 100/minute have been shown to provide suitable blood flow to essential organs during cardiac arrest. The American Heart Association advocates a uniform compression-to-ventilation ratio of 30:2 for all patients (other than two-rescuer CPR for infants and children). The 30:2 ratio delivered over 1 minute will result in fewer breaths per minute overall; but in cardiac arrest, the patient's need for oxygen is diminished (so fewer breaths are needed).
What is the first link in the American Heart Association's Chain of Survival? A. Early ALS B. Recognition and activation C. Early CPR D. Early defibrillation
Recognition and activation (426) The steps (or links) in the Chain of Survival are immediate recognition and activation, early CPR, rapid defibrillation, effective ALS, and integrated post-arrest care.
Which of the following BEST describes why anaphylaxis can result in a shock state? A. Ingestion of a caustic agent causing perforation of the stomach B. Release of chemical mediators that cause systemic vasodilation C. Failure of the left ventricle to pump an adequate amount of blood D. Blood loss due to massive vasodilation
Release of chemical mediators that cause systemic vasodilation (417) Anaphylactic shock is a type of distributive shock. Chemical mediators that are released in the anaphylactic reaction cause massive systemic vasodilation. These chemical mediators also cause the capillaries to become very permeable and to leak. The dilated vessels cause a reduction in the systemic vascular resistance, resulting in a decrease in blood pressure and perfusion. The loss of fluid from the capillary further reduces the intravascular volume, causing the preload, stroke volume, cardiac output, systolic blood pressure, and perfusion to decrease, resulting in a shock state.
If the AED gives you a "no shock indicated" message and your patient is still in cardiac arrest, you should: A. resume CPR immediately for 2 minutes and then reassess. B. continue to have the AED reassess the rhythm until a shockable rhythm is detected. C. contact medical direction for permission to override the AED and defibrillate the patient. D. contact medical direction for permission to discontinue resuscitation.
Resume CPR immediately for 2 minutes and then reassess (432-433) If the AED's analysis determines that a shock is appropriate, it provides a "Deliver Shock" message. In that case, proceed with defibrillation by depressing the shock or defibrillation button. If the AED's analysis determines a non-shockable rhythm, it gives a "No Shock" message. In that case, immediately resume CPR, beginning with chest compressions.
The patient has been in cardiac arrest for 15 minutes now, and you are still 10 more minutes away from the hospital. ALS intercept did not occur due to the ALS units all being assigned to another call. During transport, the AED analyzed the patient and gave a "No Shock Advised" message. What should the EMT do? A. Attempt defibrillation anyway to "start" the heart. B. Resume compressions C. Contact medical direction to ask if a defibrillatory shock can be administered anyway. D. Decrease the oxygen flow rate in case the patient is becoming hyperoxic.
Resume compressions Most ALS systems have a "termination" protocol that outlines when a cardiac arrest in the prehospital environment can be terminated. Regularly these types of protocols require the presence of ALS providers and the use of advanced airways and medications prior to terminating efforts. As such, if the EMTs are transporting the patient to the hospital, they should continue the same arrest care until they arrive at the hospital and turn care over to the ED staff.
This type of distributive shock occurs after a large body-wide infection. A. Obstructive B. Septic C. Hemorrhagic D. Cardiogenic
Septic 418
You are assessing a female patient who is bleeding internally. As a response, epinephrine is released into the body to cause all the following changes EXCEPT? A. Vasoconstriction. B. Sodium reabsorption in the kidney C. Increased heart rate D. Increased contractility
Sodium reabsorption in the kidney (419) The effect on the body of the release of epinephrine during hypoperfusion includes increased heart rate, increased contractility, and vasoconstriction. All of this helps to increase the patient's blood pressure. There is also reabsorption of fluid by the kidneys, but this is done by the release of hormones other than epinephrine.
If a razor is NOT available, how should the EMT place the AED electrodes on a patient with an extremely hairy chest? A. Place the pads over the hairy areas, and use weights (such as jump bags or shoes) to compress the electrodes closer to the skin. B. Stick one set of pads to the patient's chest, and quickly pull them off to remove the hair. Then place the second set of pads. C. With gloved hands, press the electrodes firmly onto the skin while the AED is analyzing the patient's rhythm, and quickly remove your hands before it delivers a shock. D. Move the pads to areas of the shoulder and torso with less hair.
Stick one set of pads to the patient's chest, and quickly pull them off to remove the hair. Then place the second set of pads. 435-437 Firmly press down on the pad in an attempt to stick it to the chest wall skin. If this does not work because of the hair growth, pull the original set of electrodes off quickly, as this will remove some of the hair in the area. Then apply a new set of electrodes with firm pressure applied to the pad. Moving the pads to a location with less hair may put them too far from the heart and decrease the effectiveness of the shock. You should never be in contact with the pads during the AED sequence or use weights to help hold them down.
When a patient's heart stops, the patient goes into cardiac arrest. There are three phases after cardiac arrest that lead to biological death. The phases include each of the following EXCEPT: A. sudden death. B. circulatory phase. C. metabolic phase. D. electrical phase.
Sudden Death (425) The three phases that immediately follow cardiac arrest and lead to biological death are the electrical phase, the circulatory phase, and the metabolic phase. Sudden death is the cardiac arrest of a patient within one hour of the onset of cardiac symptoms.
During a hypoperfusion state in the body, what division of the autonomic nervous system is responsible for initiating the negative feedback systems? A. Sympathetic B. Somatic C. Voluntary D. Parasympathetic
Sympathetic When shock occurs, the sympathetic nervous system is activated and stimulates primarily the vessels and the heart in an attempt to restore the blood pressure in the arteries. The parasympathetic nervous system does not mediate these negative feedback systems, as this is the "feed or breed" system, and the voluntary (sometimes called somatic) nervous system is responsible for muscle movement.
Which division of the autonomic nervous system will the body employ in shock as it attempts to increase peripheral perfusion in patients who have a failing myocardium? A. Somatic nervous system B. Spinal nerve root reflexes C. Sympathetic nervous system D. Parasympathetic nervous system
Sympathetic nervous system In most types of disturbance in the body, the only real mechanism to enhance the body's processes is through sympathetic tone. Through direct nerve stimulation and the release of hormones by the adrenal glands, the body will enter into a hyperdynamic state, in which the blood pressure increases, the heart rate increases, and so forth to return the perfusion pressure back toward normal. The parasympathetic nervous system operates to slow the body down and increase digestion (which would be detrimental in a shock state), the somatic nervous system controls skeletal muscle, and the peripheral nervous system is a functional division of the nervous system and includes the nervous system outside the brain and spinal cord.
Which of the following findings in your patient with a stab wound to the abdomen can be indicative of an early stage of shock? A. Increased pulse pressure B. Tachycardia C. Pulse ox of 95 percent D. Unresponsiveness
Tachycardia When the pressure in the aorta and carotid bodies decreases, the arterial wall tension is reduced, which triggers the baroreceptors to send decreased signals to the hypothalamus. This is an indication that the pressure is falling in the large arteries. In response, the hypothalamus activates a whole cascade of organ and gland stimulation and hormone releases in an attempt to increase the blood pressure to restore the arterial wall tension. Direct nerve stimulation of the heart by the sympathetic nervous system increases the heart rate and contractility in an attempt to increase cardiac output. This occurs within seconds of the fall in pressure. Unresponsiveness and a dropping pulse ox would occur later in the syndrome, and the pulse pressure typically narrows, not increases.
What is one reason the EMT should summon ALS to the scene of a cardiac arrest patient who experienced return of spontaneous circulation (ROSC)? A. After one shock by the EMT, any additional shocks must be performed by the ALS provider. B. State law requires ALS on every cardiac arrest. C. Only ALS providers can adequately ventilate a patient once an advanced airway is in place. D. The ALS interventions may prevent arrest from recurring.
The ALS interventions may prevent arrest from recurring. (426) As an EMT, you can operate an AED without advanced life support personnel on scene. In cases of cardiac arrest, however, you should keep the American Hospital Association's Chain of Survival in mind. The fourth link of that chain is effective advanced cardiac life support (ACLS). It would make sense that an ALS provider may be able to provide other therapies such as medications to prevent the patient from deteriorating back into arrest.
What does the "all clear" command mean during a cardiac arrest situation? A. The patient has just started seizing. B. The patient has died. C. The patient has vomit in the airway that was suctioned out. D. The patient is about to be defibrillated.
The Patient is about to be defibrillated During an arrest situation, when someone announces, "All clear," it usually means that the person are about to defibrillate the patient. To avoid being harmed by the electric shock, position yourself so that you are not in contact with the patient or with anything that the patient is touching that will conduct electricity.
Your patient is having a heart attack, and although the heart is still pumping, there is a continued slowing of the heart rate. Why can this lead to a state of hypoperfusion? A. The body will not vasoconstrict if the pulse is slow. B. A slow heartbeat is a weak heartbeat, which drops blood pressure. C. The drop in the heart rate decreases cardiac output. D. As the heart slows, blood volume leaves the vascular space, causing hypotension.
The drop in the heart rate decreases cardiac output Rationale Cardiac output is defined by the heart rate and stroke volume. If the heart rate slows, the cardiac output will drop. A drop in cardiac output will then drop the blood pressure as the blood pressure is determined between the degree of vasoconstriction (SVR) multiplied by the cardiac output.
What is the relationship between AED use and the conversion of ventricular fibrillation? A. The later the shock is applied, the higher the conversion rate. B. The earlier the shock is applied, the higher the conversion rate. C. The lower the energy level that is used to shock, the higher the conversion rate. D. The higher the energy level that is used to shock, the lower the conversion rate.
The earlier the shock is applied, the higher the conversion rate (427) Ventricular fibrillation is the most common presenting rhythm in out-of-hospital sudden cardiac arrest. The American Heart Association provides many reasons for the importance of delivering early defibrillation by EMS, including the fact that the most effective emergency care intervention to terminate ventricular fibrillation or ventricular tachycardia is defibrillation. In using the AED, the earlier the shock, the better. Also, energy levels can be too low to work or can be too high and cause more damage. The energy levels that the AED provides are not adjustable by the EMT.
To ensure adequate oxygenation of the tissues, what component of oxygen delivery and perfusion must be present? A. The patient must have a heart rate between 60 and 100/min. B. The patient must have at least 5 liters of blood. C. The patient must be breathing in sufficient oxygen with each inhalation. D. The patient must have a respiratory rate between 12 and 20/min.
The patient must be breathing in sufficient oxygen with each inhalation. To maintain cellular perfusion, several components must be functioning adequately. One of the most important is the ability of the body to deliver an adequate amount of oxygen to the cells. For this to happen, the patient must first be breathing an adequate concentration of oxygen (FiO2) with each breath. If the oxygen content of the ambient air that is being inhaled is diminished, the amount of oxygen in the alveoli available for gas exchange will also decrease. Since the heart rate, respiratory rate, and blood volume all change throughout the various age brackets (infant, children, and adults), any specific value of these variables is not individually predictable of adequate or inadequate oxygenation.
If rapid defibrillation is NOT provided to an arrested patient in ventricular fibrillation, what will be the likely outcome? A. The heart rhythm will return spontaneously. B. There will be a further decrease in myocardial output. C. Blood will fill the heart, causing it to distend and rupture. D. The patient will go into asystole.
The patient will go into asystole (427) Ventricular fibrillation is the most common presenting rhythm in out-of-hospital sudden cardiac arrest. The American Heart Association provides many reasons for the importance of delivering early defibrillation by EMS, including the fact that the most effective emergency care intervention to terminate ventricular fibrillation or ventricular tachycardia is defibrillation. Left untreated, ventricular fibrillation will quickly deteriorate to asystole, which has a very low rate of successful resuscitation.
In which of the following interventions may the EMT participate with ALS providers for a patient who has a return of spontaneous circulation? A. Facilitated oxygenation B. High-frequency ventilation C. Hyperbaric therapy D. Therapeutic hypothermia
Therapeutic hypothermia ( ) Therapeutic hypothermia is a common practice in the cardiac arrest patient with a return of spontaneous circulation and is often initiated by ALS or the receiving facility. Hyperbaric therapy and high-frequency ventilations have not been shown to be beneficial in post-arrest patients. Facilitated oxygenation is a fictitious term.
What is the likelihood of successful resuscitation and survival of a patient who has been in cardiac arrest for 10 minutes before the onset of resuscitation efforts? A. Impossible B. Very good C. Unlikely D. Certain
Unlikely (425) Time is a critical issue in cardiac arrest. As time passes, the heart continues to deteriorate from a lack of oxygen and glucose and begins to undergo changes that lead to severe myocardial cell ischemia and eventually organ death. Unfortunately, the time is in minutes and begins immediately upon the onset of cardiac arrest. As soon as the patient goes into cardiac arrest, the resuscitation clock is ticking. The chance of a successful resuscitation decreases by 10 percent for every minute the patient is in ventricular fibrillation. If it is 5 minutes after the arrest before someone finds the patient and calls 9-1-1 and you have a 5-minute response time to get to the patient's side, you are already 10 minutes into the cardiac arrest, which results in a less than favorable condition of the myocardium to begin resuscitative efforts. The brain is the organ that is most sensitive to cardiac arrest and undergoes irreversible changes after 4 to 6 minutes. Therefore, although resuscitation is not impossible, it is very unlikely to occur.
During a shift on the ambulance, your EMT partner asks you to describe what ventricular fibrillation is. How would you respond? A. Ventricular fibrillation is the absence of electrical activity and pumping action of the heart. B. Ventricular fibrillation is a rhythm, but the heart muscle does not respond to the electrical activity. C. Ventricular fibrillation is a very fast heart rhythm that is generated in the ventricle instead of the SA node. D. Ventricular fibrillation is a disorganized cardiac rhythm that produces no pulse or cardiac output.
Ventricular fibrillation is a disorganized cardiac rhythm that produces no pulse or cardiac output. (428) Ventricular fibrillation (VF or V-fib) is a disorganized cardiac rhythm that produces no pulse or cardiac output. It is commonly associated with advanced coronary artery disease, though it may have other causes. Somewhere between 50 and 60 percent of cardiac arrests will be in ventricular fibrillation during the first eight minutes after becoming pulseless. V-fib is most commonly the rhythm that the AED defibrillates.
If a patient who was attached to an ECG monitor suddenly went into cardiac arrest, the monitor would most likely show which ECG rhythm that is considered shockable? A. Pulseless electrical activity or ventricular fibrillation B. Bradycardia or ventricular tachycardia C. Ventricular fibrillation or ventricular tachycardia D. Asystole or normal sinus rhythm
Ventricular fibrillation or ventricular tachycardia (428-429) When the patient is initially in cardiac arrest, two common rhythms that may be present that require defibrillation by the AED are ventricular fibrillation and ventricular tachycardia without a pulse. Asystole, bradycardia, and pulseless electrical activity are not considered shockable rhythms.
The cardiac arrest rhythms for which defibrillation is appropriate include: A. asystole. B. ventricular tachycardia. C. bradycardia. D. pulseless electrical activity.
Ventricular tachycardia (428-429) When the patient is initially in cardiac arrest, two common rhythms that may be present that require defibrillation by the AED are ventricular fibrillation and ventricular tachycardia without a pulse. Asystole, bradycardia, and pulseless electrical activity are not considered shockable rhythms.
On what surface would an attempted defibrillation of a patient possibly cause the EMT to feel the electrical current while kneeling at the patient's side? A. Wooden floor B. Carpeted floor C. Wet floor D. Cement floor
Wet floor (435-437) Water is an excellent conductor of electricity. The AED should not be operated if the machine or the patient is lying in water, the patient's chest is covered with water, or the patient is extremely diaphoretic. If the patient is lying in water, it may be necessary to move the patient to a dry and safe area before using the AED. Cement, carpet, and wood do not conduct electricity well, and are safer for the EMT.
When should the EMT NOT start resuscitation on a patient who was found in cardiac arrest? A. When a valid DNR is available B. When the patient has an unknown downtime C. When ALS backup is more than 15 minutes away D. When no family is available
When a valid DNR is available (426) There are some situations in which you will not begin resuscitation on a patient in cardiac arrest. Some of these situations may include a patient with a valid do-not-resuscitate (DNR) order, physician orders for life-sustaining treatment (POLST), or medical orders for life-sustaining treatment (MOLST); a patient with injuries that are not compatible with life, such as a decapitation; and obvious death in a patient who is in rigor and beyond the point of a resuscitation effort. Be sure to follow your local protocol when considering a decision to withhold resuscitation.
After using the AED to deliver a single shock to a 60-year-old male who was found pulseless, and subsequent analysis has yielded a "No Shock Advised" notification, the EMT has been told by dispatch that ALS will not be available for 5 to 8 minutes. The EMT should: A. continue cycles of 30 compressions to two ventilations until ALS arrives or intercepts. B. maintain ventilations at a rate of 20/minute. C. keep reanalyzing the patient's rhythm every 30 seconds until ALS arrives. D. call medical direction for approval of nitroglycerin.
continue cycles of 30 compressions to two ventilations until ALS arrives or intercepts. (426) (427-440) As an EMT, you can operate an AED without advanced life support personnel on scene. In cases of cardiac arrest, however, you should keep the American Hospital Association's Chain of Survival in mind. The fourth link of that chain is effective advanced cardiac life support (ACLS). It would make sense that an ALS provider may be able to provide other therapies such as medications to prevent the patient from deteriorating back into arrest. Until the ALS team can arrive or intercept you en route, you should maintain a compression-to-ventilation ratio of 30:2, analyzing the heart rhythm whenever the AED advises, and not overventilate the patient.
In general, there are two types of AEDs: fully automated and semi-automated. Semi-automated AEDs: A. automatically charge up and deliver the appropriate electrical shock. B. have only one operational button. C. indicate to the operator when a shock is advised so he can push another button to deliver the shock. D. allow the operator to attach the device to the patient, push a button to turn on the power, and let the device do the rest.
indicate to the operator when a shock is advised so he can push another button to deliver the shock. (428) The benefit of semi-automated AEDs is that they require the operator to push a shock button after ensuring that everyone is clear and no longer in contact with the patient. The semi-automated AED will have more than one button for operation (often a power button and a shock button), and both semi-automated and fully automated AEDs will charge automatically if indicated.
You are on the scene of a 58-year-old male patient who collapsed in the bathroom at a local restaurant. Bystanders determined that he was in sudden cardiac arrest so they started CPR. After delivering your first shock with an AED, if the patient is still pulseless, you should NEXT: A. deliver three more stacked shocks. B. perform 2 minutes of CPR and reassess. C. immediately transport, continuing CPR. D. contact medical direction.
perform 2 minutes of CPR and reassess. (431-434) pulseless (429-430) If the AED's analysis determines that a shock is appropriate, it provides a "Deliver Shock" message. In that case, proceed with defibrillation by depressing the shock or defibrillation button. If the AED's analysis determines a non-shockable rhythm, it gives a "No Shock" message. In that case, immediately resume CPR, beginning with chest compressions.
If the AED gives you a "no shock indicated" message and your patient is still in cardiac arrest, you should: A. contact medical direction for permission to discontinue resuscitation. B. resume CPR immediately for 2 minutes and then reassess. C. contact medical direction for permission to override the AED and defibrillate the patient. D. continue to have the AED reassess the rhythm until a shockable rhythm is detected.
resume CPR immediately for 2 minutes and then reassess. If the AED's analysis determines that a shock is appropriate, it provides a "Deliver Shock" message. In that case, proceed with defibrillation by depressing the shock or defibrillation button. If the AED's analysis determines a non-shockable rhythm, it gives a "No Shock" message. In that case, immediately resume CPR, beginning with chest compressions.
What should you do if a patient who goes into and out of cardiac arrest while you are on scene? A. Summon ALS. B. Ventilate the patient faster. C. Constantly perform CPR. D. Contact medical control for termination of efforts.
summon ALS As an EMT, you can operate an AED without advanced life support personnel on scene. With cases of cardiac arrest, however, you should keep the American Hospital Association's Chain of Survival in mind. The fourth link of that chain is effective advanced cardiac life support (ACLS). It would make sense that an ALS provider may be able to provide other therapies such as medications to prevent the patient from deteriorating back into arrest.
Your partner is doing CPR compressions, and you are about to deploy the AED. Your FIRST step should be to: A. apply the defibrillation pads to the patient. B. complete 2 minutes of CPR before applying the AED. C. administer two breaths before using the AED. D. turn on the AED and follow the voice prompts.
turn on the AED and follow the voice prompts. (432-434) If compressions are ongoing, as soon as the AED is available, apply it while chest compressions are being performed. When the AED is ready to start the rhythm analysis, stop chest compressions and proceed with the AED protocol. If bystanders or First Responders are already performing CPR when you arrive, instruct them to continue while you prepare to apply the AED.
Instead of organized contractions, the heart may show uncoordinated twitching known as: A. pulseless electrical activity. B. ventricular tachycardia. C. ventricular fibrillation. D. asystole.
ventricular fibrillation. (428) Ventricular fibrillation (VF or V-fib) is a disorganized cardiac rhythm that produces no pulse or cardiac output. It is commonly associated with advanced coronary artery disease, though it may have other causes. Somewhere between 50 and 60 percent of cardiac arrest patients will be in ventricular fibrillation during the first 8 minutes after becoming pulseless. V-fib is most commonly the rhythm that the AED defibrillates. In pulseless electrical activity, there is coordinated electrical activity in the heart but no mechanical contraction. Ventricular tachycardia is a dysrhythmia to the ventricles, and asystole is an absence of all electrical activity.
What type of AED will provide the BEST safety from being accidently shocked during a defibrillation attempt? A. Biphasic B. Monophasic C. Semi-automatic D. Fully automatic
Semi-automatic (428) The semi-automated AED requires more involvement by the operator. The operator attaches the AED to the patient in the normal manner, pushes a button to turn on the power, and initiates the heart rhythm analysis. After AED analysis is complete, a computer voice synthesizer and/or display message indicates to the operator when a shock is advised. The operator must then push another button to deliver the shock after clearing the patient. This type of AED offers another layer of safety, since the operator can ensure that everyone is clear from the patient. "Monophasic" and "biphasic" are terms that refer to how the energy is delivered, not an indication that one is any safer than the other.
When assessing the patient whom you suspect has hypoperfusion, the early effects of norepinephrine can be seen as: A. increased urine output. B. pupillary constriction. C. tachycardia. D. pale, cool skin.
pale, cool skin. (Physical exam 422-424) When a patient is in shock, exhibiting signs of hypoperfusion, the adrenal glands release epinephrine and norepinephrine into the bloodstream. The norepinephrine will initially cause pale, cool skin from vasoconstriction. Other effects of norepinephrine include pupillary dilation and stimulation of the sweat glands. During early shock, however, there is not an increase in urine output (if anything, it would decrease). The pupils would dilate, not become constricted. Finally, tachycardia is from the release of epinephrine, not norepinephrine.
When the heart fails to pump blood or the cardiac output is completely ineffective, the patient may go into: A. shock. B. hypothermia. C. cardiac arrest. D. respiratory failure
Cardiac Arrest (424-425) Cardiac arrest, the worst manifestation of cardiac compromise from an acute coronary event, occurs when the ventricles of the heart, for any of a variety of reasons, are not contracting or when the cardiac output is completely ineffective and no pulses can be felt. Shock is a state of hypoperfusion to the organs and tissues of the body, hypothermia is a lowered body temperature, and respiratory failure is said to occur when the pulmonary system fails to adequately supply oxygen to and remove carbon dioxide from the lungs.
Your patient is in shock after suffering a massive heart attack that damaged a large portion of the left ventricle. Which type of shock is the patient MOST likely to experience? A. Distributive B. Hypovolemic C. Metabolic D. Cardiogenic
Cardiogenic (416)
Which type of shock results from cardiac insufficiency, that is, the inability of the heart to pump an adequate amount of blood? A. Cardiogenic B. Distributive C. Circulatory D. Obstructive
Cardiogenic (416) When the heart fails to adequately pump blood to the body, it is known as cardiogenic shock (or pump failure). Obstructive shock occurs when the heart cannot pump the blood forward because of a mechanical obstruction to the movement of blood, distributive shock results from vasodilation, and circulatory shock is a fictitious term.
If a patient has suffered a heart attack, what kind of shock could this produce? A. Distributive B. Obstructive C. Hypovolemic D. Cardiogenic
Cardiogenic Cardiogenic shock occurs when the pumping ability of the heart is diminished, causing poor forward movement of blood and poor peripheral perfusion. This is often seen by the EMT during a heart attack. Hypovolemic shock occurs when the body loses intravascular volume, distributive shock occurs from peripheral vasodilation, and obstructive shock occurs when there is a blockage of forward blood flow.
You are assessing a patient that has a heart rate of 110/min, a blood pressure of 108/88, and respirations of about 14/min. If this patient also has lost blood from a traumatic event, what stage of shock would this be categorized as? A. Compensated B. Irreversible C. Progressive D. Decompensated
Compensated (419-421) Compensated shock is hallmarked by maximized feedback loops. Typically, the EMT will find tachycardia, a narrow pulse pressure, tachypnea, and a slightly anxious patient, but the systolic pressure will still be normal. In decompensated shock, the heart rate is typically >120/min, the respirations are >30/min, and the blood pressure drops.
During what stage of shock do the baroreceptors initially detect the change and initiate the compensatory mechanisms? A. Progressive B. Compensatory C. Decompensatory D. Irreversible
Compensatory (419-421) Rationale When the pressure in the aorta and carotid bodies decreases, the arterial wall tension is reduced, which triggers the baroreceptors to send decreased signals to the hypothalamus. This is an indication that the pressure is falling in the large arteries. In response, the hypothalamus activates a whole cascade of organ and gland stimulation and hormone releases in an attempt to increase the blood pressure to restore the arterial wall tension. This process is compensation, also known as compensatory shock or compensated shock, in which the body is able to maintain a near normal blood pressure and perfusion of the vital organs.
Which of the following disturbances in the body would cause the greatest change in perfusion? A. Loss of blood volume B. Elevation of the heart rate C. Elevation of the respiratory rate D. Elevation in the blood pressure
Loss of blood volume (411) To ensure adequate perfusion to the body, there must be an adequate volume of blood, sufficient pumping of the heart, and a vascular container that is in proportion with the amount of blood and pumping function of the heart. An elevation of the heart rate would increase perfusion by increasing cardiac output, an increase in the respiratory rate would be assumed to increase available oxygen, and an elevation in the blood pressure would promote better perfusion.
The loss of what component of the blood could cause shock but not necessarily a drop in the ability of the blood to carry oxygen? A. Loss of platelets B. Loss of plasma C. Loss of white blood cells (WBC) D. Loss of electrolytes
Loss of plasma Rationale A patient who loses whole blood has lost fluid (plasma) and red blood cells, meaning that the patient may not be able to maintain perfusion or proper oxygenation, since the body is also missing red blood cells. On the other hand, consider a patient who is in shock from fluid depletion resulting from excessive diarrhea. No red blood cells were lost in the diarrhea, only large amounts of water and some electrolytes. The patient has enough red blood cells and hemoglobin available to carry oxygen; however, the depleted fluid volume has decreased the blood pressure and ability of the blood to deliver the oxygen to the cells.
What structures within the cell, after becoming released as a result of failure of the sodium/potassium pump, start to autodigest the cell? A. ATP B. Sodium molecules C. Lysozymes D. Carbon dioxide
Lysozymes When cells become ischemic, there will be a shift from aerobic metabolism to anaerobic metabolism. Thus, there is insufficient energy (ATP) production to maintain the sodium/potassium pump. The sodium then collects inside the cell and attracts water. As a result, the cell swells and eventually ruptures and dies. The acid that has been liberated causes the failure of enzyme systems and the release of lysozymes. The lysozymes begin to autodigest the cell, leading to cell death and eventual organ death. Carbon dioxide levels do not autodigest cells, nor do sodium molecules.
What is the overall goal for the EMT in managing a shock patient? A. Keep the pulse ox reading greater than 94%. B. Keep the heart rate less than 100/min. C. Provide adequate ventilations. D. Maintain adequate perfusion to the core and peripheral tissues.
Maintain adequate perfusion to the core and peripheral tissues. The overall goal during the management of shock is to improve the adequate perfusion of blood to core and peripheral tissues. Normal perfusion is inclusive of normally oxygenated blood, not deoxygenated blood. The steps are to keep the heart rate within a physiological range, ensure adequate ventilations, and maintain the pulse ox greater than 94 percent.
