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A 77 y/o female has suffered cardiac arrest. You can't tell if the rhythm is asystole or v-fib. What do you do?: treat as if its v-fib
Define subendocardial MI.: inner wall of ventricle involved.
called non-Q-wave infarction
What is myocardial infarction?: death of some mass of the heart muscle due to inadequate blood supply
What is a quick look?: Method quickly used to determine a patient's heart rhythm by applying defibrillator paddles
What are the signs and symptoms of pulmonary congestion.: dyspnea
cyanosis
tachypnea
frothy sputum
labored respirations
jugular venous distension
What is the correct energy setting for an unstable patient in atrial fibrillation?: 50-100-200-300-360 joules
What are the contraindications for transcutaneous pacing?: flail chest
chest trauma
cervical spine injury
weight <33lbs unless you have pediatric pads
Define transmural MI.: entire thickness of myocardium is destroyed
often called Q-wave infarction
What is an AED?: Automated External Defibrillator- senses and records rhythms and if indicated shocks the patient
Why is pain relief a high priority in the management of acute myocardial infarction?: decreases:
anxiety & pain
myocardial O2 demand
risk of dysrhythmias
may decrease heart rate and BP
What are 2 disadvanteges of AED?: display screen not as readable as conventional defibrillators
lowest energy setting is 200J which is high for patients less than 110lbs.
not recommended for children
Why is hypertension potentially harmfull in acute MI?: may increase myocardial O2 demand
may exacerbate myocardial ischemia or infarction
What complications can occur with transcutaneous pacing?: coughing
skin burns
inability to capture
sharp pain or burning sensation with pacing
interference from movement
What are the advantages of transcutaneous pacing?: safety
ease of application
lack of significant pain
least invasive pacing technique available
can be used effectively by non-medical providers with proper training
Why is tachycardia often associated with right sided heart failure?: body trys to maintain cardiac output by increasing heart rate
What does cocaine due to the cardiovascular system?: tachycardia
increased myocardial contractility
increased blood pressure
These are sympathomimetic effects that may cause
-hypertension
-MI
-cardiac dysrhythmias
-precipiation of angina
-coronary artery vasospasm
What are the four components of the chain of survival?: early access
early CPR
early defib
early ACLS
When is the greatest risk of death from MI?: within 1st two hours of symptom onset
What are the AHA's classification of therapeutic intervention?: I definitely helpful
IIa probably helpful
IIb possibly helpful
III not indicated, may be harmful
You have a 72 y/o male c/o chest pain and weakness x 3hrs. Pain is a 10. He is pale and diaphoretic. BP 62/40. He has sinus rhythm at 90bpm without ectopy. What do you do?: he most likely has an acute MI and cardiogenic shock.
O2, IV, fluid challenge of 250ml NS.
If response is inadequate, give norepi infusion and titrate till systolic is 70-100mm Hg.
Then switch to dopamine infusion 2.5-20 mcg/kg/min
What are the non-modifiable risk factors for myocardial infarction?: age
race
heredity
male gender
Why would calcium channel blockers be useful in the management of angina or acute MI?: dilates coronary arteries increasing blood flow
relaxes vascular smooth muscles causing vasodilation which increases afterload
decreases myocardial O2 demand
What are the modifiable risk factors of MI?: stress
obesity
diabetes
HTN
lack of exercise
cigarette smoking
elevated cholesterol
elevated triglycerides
What is the purpose of defibrillation?: to produce temporary asystole
your hoping the natural pacemakers will take over pacing
Describe the characteristics of unstable angina.: angina at rest
new onset precipitated by minimal exertion
progressive increase in severity, frequency, and/or duration of anginal attacks in a patient with a previously stable pattern of anginal pain
Why is nitro administered to patients with acute pulmonary edema who have a systolic BP >100mm Hg?: to increase venous pooling, which reduces preload and afterload
The ambulance responds to a a 58 y/o male in cardiac arrest. Once confirmed to be pulseless and apneic an AED is applied. It delivers 3 sequential shocks without conversion of the rhythm. By the time they get back to the clinic it has delivered a second: begin ACLS ventricular fib sequence (remember the nemonic Please Shock Shock Shock...?)
cont CPR, intubate, IV access,
epi, vasopressin...
keep AED attached unless there is no rhythm display screen
What does pulseless electrical activity mean?: when there is an organized rhythm with rate on the cardiac monitor but no pulse is palpated
After delivering the first shock in a patient with v-fib, should CPR be resumed?: no
What are the qualifying criteria for administration of thrombolytic therapy in acute MI?: <70
ST elevation = or > than 1mm in 2 or more contiguous leads
(II,III,aVF; I,AVL; V1 toV6)
history of new onset chest pain unreleived by sublingual nitroglycerin lasting at least 30 minutes
seen within 6 hours of symptom onset
no absolute contraindications to thrombolytic therapy
What are the goals of thrombolytic therapy?: decrease mortality
improve myocardial oxygenation
limit zones of myocardial ischemia
improve perfusion to infarct related artery
improving left ventricular function and cardiac output
reducing incidence of dysrhythmias associated with myocardial ischemia
What meds may be useful in the setting of acute MI with HTN?: morphine or sublingual nitro to relieve pain/anxiety
furosemide if pulmonary congestion present
non-responsive to initial therapy consider IV nitro (esp with CHF) or beta-blockers in tachycardia and high cardiac output
IV nitroprusside when ischemia is absent
What are the effects of parasympathetic stimulation of the heart?: slows discharge rate of SA node
decreases conduction through AV node
which decreases heart rate
Tachycardia, jugular venous distention, dyspnea, diphoresis, and dependent edema are all signs and symptoms of ____ heart failure.: right
What chemical is released with parasympathetic stimulation of the heart?: acetylcholine
What are the signs and symptoms of cardiogenic shock?: Hypotension
cool, clammy skin
S&sx of acute MI
sinus tach
altered LOC- inc. reslessness,confusion or unconsciousness
What type of MI is associated with a higher mortality rate?: anterior MI
What are the causes of cardiac arrest?: CAD
trauma
hypoxia
drowning
electrocution
hypothermia
drug overdose
acid base imbalance
electrolyte imbalance
Describe the pain pattern typically associated with chronic stable angina.: predictable and consistent
usually relieved by rest or withing 5-45 minutes of nitro administration
precipitating factors are exertion, cold weather, emotional stress
What type of MI causes a greater risk of CHF and cardiogenic shock?: anterior MI
What is the difference between the fully automated and the semi-automated external defibrillator?: automated: pads attached to patient, machine turned on. analyzes rhythm. if vf or vt(above a preset rate) is present delivers a shock
semiautomated: operator presses "analyze" button that initiates rhythm analysis & press "shock" button to deliver shock. never enters analysis mode unless activated by operator. final decision to shock made by operator
If defibrillation is necessary when transcutaneous pacing electrodes have been applied to the chest, where should the defibrillator paddles be placed?: 2-3 cm from the pacemaker electrodes. Prevents arcing
What are the complications of carotid sinus pressure?: AV block
asystole
ventricular dysrhythmias
syncope, seizures, or CVA
What is Prinzmetal's angina?: spontaneous anginal pain thought to be due to coronary artery spasm typically associated with st segment elevation on the ECG
usually occurs 12-8 am
relieved with nitro
can be accompanied by acute MI
What is the most common complication in the 1st few hours of acute MI?: cardiac dysrhythmia
How does defibrillation differ from synchronized counter shock?: defib (unsynchronized) has no relation to cardiac cycle
synchronized reduces the potential for delivery during relative refractory period of T wave
What are the branches of the right coronary artery?: marginal artery
posterior descending artery
Where is the pulse generater of an automatic implantable cardioverter defibrillator implanted?: left upper quadrant of abdomen
Describe how carotid sinus pressure is performed?: while monitoring ECG and IV c atropine and lidocaine immediately available
turn patients head, firm pressure to right carotid bifurcation near jaw (brief)
if fails repeat "massage it" for 5-10 seconds
Anterior or lateral wall infarctions are most often due to occlusion of the ____ coronary artery?: left
How do you manage an elderly patient with acute pulmonary edema and a BP of 80/48 and pulse of 110?: O2, IV, prepare dopamine infusion (DOC c a systolic BP between 70-100)
start at 2.5-5mcg/kg/minute
titrate prn to 20mcg/kg/minute
What are the absolute contraindications for thrombolytic therapy?: nemonic- CAB CRAPS 2HI
CNS arteriovenous malformation or tumor
Aortic Dissection
BP > 200/120
Cardiogenic shock if PTCA available within 60 minutes
Recent head trauma
Allergy to agent
Pregnancy
Surgery <2months CNS and <2weeks major surgery
History of intracranial hemorrhage
Hemophilia
Internal bleeding
What are the causes of flat line on an EKG?: asystole
isoelectric VF/VT
no power
loose leads
no connection to patient and/or monitor
Why is routine shocking of asystole not recommended?: produces sympathetic discharge
might eliminate return of spontaneous cardiac activity
What do you have to find out in a patient with shock or hypotension?: Do they have a rate, pump, or volume problem?
An elderly patient is complaining of difficulty breathing. BP 166/94, irregular pulse 90-120bpm, respirations 32. auscultation reveals bilateral crackles and pedal pitting edemais present. Cardiac monitor shows a-fib. How do you treat her?: acute pulmonary edema:
sit her up legs dependent
O2, IV
furosemide 0.5-1.0mg/kg
sublingual nitro
consider morphine
Would reversing the paddle position reduce effectiveness of defibrillation?: No, but reading rhythms may be affected (eg. a sinus rhythm would appear to be junctional)
How is a precordial thump delivered?: center of sternum using hypothenar fist no >12in high
reassess
What is afterload?: the force or resistance against which the heart must pump to eject blood
What types of vagal maneuvers can be used?: coughing
breath holding
eyeball pressure
carotid sinus pressure
bearing down (valsalva)
stimulation of gag reflex
face in ice water
When is a Precordial thump contraindicated ?: When the patient is a child
You have a patient with a full thickness MI. What do you call it?: transmural infarction or
q-wave infarction
What are the second line meds used in the treatment of acute pulmonary edema?: IV nitro (if systolic >100)
nitroprusside (if systolic >100)
dopamine (if systolic >100)
dobutamine (if normotensive)
You have an elderly patient complaining of severe chest pain x40 minutes unrelieved with rest. BP 66/40 cardiac monitor shows sinus bradycardia with occ. uniform PVC's. What is the treatment?: O2, IV
atropine 0.5-1.0 rapid IV bolus
reassess
no pain relief meds until systolic > 100mm Hg
What are the signs and symptoms of pulmonary edema?: tachycardia
diaphoresis
pink, foamy sputum
severe respiratory distress
severe agitation/confusion
rales, rhonchi, maybe wheezing
hyper or hypo tension maybe
chest pain maybe
How percentage of the left ventricle is involved when cardiogenic shock is present?: approximately 40%
Give indications for the delivery of unsynchronized countershock: v-fib
torsade de Pointes
pulsless v-tach
v-tach c a pulse if there is delay in synchronization or patient is critical
What are the metabolic causes of cardiac arrest?: antidysrhythmic drug treatment
hypokalemia
hypothermia
hypomagnesemia
toxic reactions to cocaine, phenothiazines, and cyclic antidepressants
Inferior wall myocardial infarction is usually the result of occlusion of the ____ coronary artery.: right
How far should defib paddles be placed from a patient who has a pacemaker?: 5 inches
A patient presents with a narrow QRS v-tach at 220bpm. You begin synchronized countershocks at 50 joules. Reassessment reveals patient is pulseless, apneic, and a course wavy line on ECG? What do you do?: Turn synchronizer switch off
d-fib 200 joules
reassess
When is the use of an automatic implanter cardioverter-defibrillator (AICD)indicated?: for patients at risk of sudden cardiac arrest:
will have survived at least one episode of VT or VF not associated with an MI or
have recurrent VT that does not respond to conventional antidysrhthmic drug therapy
One of your patients presents with dizziness and palpitations. She is taking Procanbid for heart problems. You put her on a monitor and discover Torsades de Pointes. What do you do?: Stop Procanbid!!! (procainamide aggravates atypical v-tach)
12 lead ECG
lab studies- esp mag and potassium
admin mag sulfate 1-2gm IV over 1-2 minutes. repeat as needed or cont IV therapy.
overdrive pacing if no response
if torsade is sustained may have to give unsynchronized countershocks (200, 200-300, 360J)
What factors affect transthoracic resistance?: -electrode size and/or pressure
-phase of patients ventilation
-interelectrode distance
-number and time interval of previous shocks
-use of interface (gel, disoposable pads)
What are the signs of pericardial tamponade?: hypotension
pulsus paradoxus
distended neck veins
muffled heart sounds
narrowing pulse pressure
What are the indications for emergent transcuataneous pacing?: hemodynamic comprimising brady- bp<80 systolic, change in mental status, myo-ischemia, pulm edema
brady c malignant escape rhythms- unresponsive to pharm therapy
overdrive pacing of refractory tach- SVT or VT refactory to pharm therapy or countershock
asystolic cardiac arrest
What is the difference between the AICD and the PCD?: AICD cardioverts VT or VF
PCD trys to correct VT with pacing. If fails goes to low energy cardioversion (if fails go to high energy. can also give auto programmed ventricular pacing for asystole, intermittent ventricular contraction, or post-shock bradycardia
What is the purpose of vagal maneuver?: Increase parasympathetic tone which slows conductin through the AV node
A patient presents with 2nd degree AV block type II with ECG evidence of an anterior MI (relieved by O2 and nitro). What should be done now?: Patient needs a transvenous pacemaker as the block could progress to 3rd degree without warning.
High levels of creatine kinase are common following resuscitation. What causes this?q: skeletal muscle trauma secondary to chest compression during CPR and to cardiac ischemia during arrest and attempted resuscitation
What is meant by the term reperfusion dysrhythmias?: refers to abnormal rhythms seen once blood flow is reestablished to ischemic heart muscle
What are the main branches of the left coronary artery?: circumflex
anterior descending
Why is it important to look for and remove transdermal patches from patints's chest before delivering a countershock?: patch has aluminum backing which can lead to electric arcing. ie it might burn the patient
What are the proper energy settings for an unstable patient with paroxysmal supraventicular tachycardia?: 50-100-200-300-360 joules
What chamber of the heart is most often involved in acute MI?: left ventricle
What are the correct energy setting for management of the unstable patient in monomorphic ventricular tachycardia?: AHA recommendations are
100, 200, 300, 360 joules
A 63 y/o woman has complaint of chest pain and severe headache. BP is 240/146, pulse 110, respirations 18-20. Nifedipine is ordered. Why and what is this drug?: Also known as Procardia or Adalat it's a calcium channel blocker used for hypertensive emergencies & in patients with ischemic chest pain unresponsive to or who cannot tolerate nitro.
It's used because it causes vasodilation of the peripheral vasculature and coronary arteries reducing afterload
What types of dysrhythmias are particularly common with an inferior wall MI?: sinus bradycardia
1st degree AV block
2nd degree AV block type I
3rd degree AV block c a junctional escape rhythm
What are the primary mechanisms of out-of-hospital cardiac arrest?: v-fib
v-tach
asystole
PEA
SVT's
How do you confirm that asystole is present in another lead?: rotate the paddles 90 degrees which simulates placement for lead I or III
What is the placement of defibrillator paddles?: sternum- right of upper sternum below clavicle
apex- left of (L)nipple mid-axillary line
Anterior-Post placement:
left lower sternal border
on back behind heart below left scapula
What ECG changes are seen in acute MI?: T-wave inversion (ischemia)
ST segment elevation (Injury)
abnormal Q waves (necrosis)
What causes T-wave inversion in acute MI?: altered tissue repolarization at the zone of ischemia
What are the correct energy settings for an unstable patient in a-fib?: AHA recommendations
100-200-300-360 joules
What causes abnormal Q waves from MI?: lack of depolarization of necrotic tissue
What causes ST segment elevation in acute MI?: abnormal repolarization at the zone of injury
How is nifedipine administered?: Usually breaking capsule and putting under the tongue or biting the capsule
What are the advantages of the AED?: easy use
reliable performance
"hands-free" defibrillation
easy to train on
speed of operation faster than conventional use
What complications can occur from MI?: dysrhythmias
pericarditis
thromboembolism
cardiogenic shock
congestive heart failure
rupture of vent wall or papillary muscle
ventricular aneurysm

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