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=== CARDIOLOGY 121

=== 1/121 cardiology


When assessing a patient's pulse, you note that it is fast and has an irregularl
y irregular pattern. On the basis of these
findings, which of the following cardiac rhythms would MOST likely be seen on th
e cardiac monitor?
A: Supraventricular tachycardia
B: Second-degree AV block type 1
C: Uncontrolled atrial fibrillation
D: Ventricular tachycardia
Reason:
Of the cardiac rhythms listed, atrial fibrillation (A-Fib) is the only one that
is irregularly irregular. In fact, A-Fib is never seen as a regular rhythm. At a
rate of less than 100 beats/min, A-Fib is said to be controlled. Uncontrolled A
-Fib, or A-Fib with a rapid ventricular rate (RVR), occurs when the ventricular
rate exceeds 100 beats/min. Second-degree AV block type I has a pattern that is
regularly irregular; the P-R interval progressively lengthens until a P wave is
blocked. Ventricular tachycardia (V-Tach) and supraventricular tachycardia (SVT)
are typically regular rhythms.
Answer is C
==== 2/121 cardiology
You are treating a 68-year-old woman with chest pressure and shortness of breath
that started 2 days ago. Her BP is 76/52 mm Hg and her pulse is 130 beats/min a
nd weak. The cardiac monitor reveals sinus tachycardia with occasional PVCs and
auscultation of her lungs reveals diffuse coarse crackles. Which of the followin
g treatment interventions is MOST appropriate for this patient?
A: Nitroglycerin, 10 to 20 g/min.
B: Amiodarone, 150 mg over 10 min.
C: Dopamine, 2 to 20 g/kg/min.
D: Normal saline, 20 mL/kg rapid bolus.
Reason:
Your patient's history and clinical presentation is consistent with cardiogenic
shock. She has had chest pressure and shortness of breath for 2 days and is now
significantly hypotensive with weak pulses. Because of its positive inotropic ef
fect of increasing myocardial contractility, dopamine is the drug of choice for
non-hypovolemic shock (eg, cardiogenic shock) and may improve perfusion. Typical
ly, dopamine for cardiogenic shock is started at 2 g/kg/min and titrated upwards
as needed to improve blood pressure and perfusion. At doses of greater than 10 g/
kg/min, dopamine acts predominantly as a vasopressor, which results in systemic
vasoconstriction. Clearly, nitroglycerin is contraindicated in any patient with
shock; its potent vasodilatory effects would further lower the patient's blood p
ressure and worsen her condition. Amiodarone is not the drug of choice for this
patient; it is given in a dose of 150 mg over 10 minutes for hemodynamically sta
ble patients with wide or narrow-complex tachycardias that exceed 150 beats/min.
Caution must be used if you consider giving a normal saline bolus; the coarse c
rackles in her lungs indicate pulmonary edema, which could easily be exacerbated
by large fluid boluses. Her problem is heart failure, not hypovolemia.
Answer is C
==== 3/121 cardiology
You should interpret the following cardiac rhythm as:
(MOBITZ I)
A: type II second-degree AV block.
B: type I second-degree AV block.
C: wandering atrial pacemaker.
D: complete AV dissociation.
Reason:
The progressive lengthening of the PR interval until a P wave is blocked (not fo
llowed by a QRS complex) makes this cardiac rhythm a type I second-degree AV blo
ck, also referred to as Wenckebach. This type of AV heart block represents a progr
essive delay at the AV node/junction until an electrical impulse is completely b
locked from entering the ventricles. A type II second-degree AV block is charact
erized by more P waves than QRS complexes; however, the P-R intervals of the con
ducted complexes are consistent. In complete AV dissociation (ie, third-degree A
V block), there are more P waves than QRS complexes, and no relationship exists
between a given P wave and QRS complex. A wandering atrial pacemaker is characte
rized by varying morphologies of P waves.
Answer is B
==== 4/121 cardiology
A 59-year-old woman presents with a regular, narrow-complex tachycardia at a rat
e of 180 beats/min. She is conscious and alert, but complains of chest discomfor
t and has a blood pressure of 86/56 mm Hg. In addition to giving her supplementa
l oxygen, you should:
A: administer 150 mg of amiodarone over 10 min.
B: give her up to 3 sublingual doses of nitroglycerin.
C: administer 12 mg of adenosine rapid IV push.
D: have her chew and swallow 325 mg of aspirin.
A regular, narrow complex tachycardia at a rate greater than 150 beats/min is co
nsistent with supraventricular tachycardia (SVT). Although the patient is consci
ous and alert, she is complaining of chest discomfort and is hypotensive. Since
she could be experiencing an acute coronary syndrome (ACS), you should instruct
her to chew and swallow up to 325 mg of aspirin. Aspirin should be given to any
patient suspected of experiencing an ACS, provided there are no contraindication
s (eg, allergy); it will not affect her blood pressure. Nitroglycerin, however,
may exacerbate her hypotension and should be avoided. You can consider administe
ring adenosine; however, the initial dose is 6 mg rapid IV push. Amiodarone, in
a dose of 150 mg over 10 minutes, is appropriate for patients with hemodynamical
ly stable wide-complex tachycardias (ie, V-Tach). Closely monitor this patient a
nd be prepared to perform synchronized cardioversion.
Answer is D
==== 5/121 cardiology
A 44-year-old man presents with the rhythm shown below. He complains of nausea,
but denies vomiting. He is conscious and alert with a BP of 122/62 mm Hg, a puls
e rate of 98 beats/min, and respirations of 16 breaths/min and unlabored. Treatm
ent for this patient would MOST likely include:
(AFLUTTER)
A: diltiazem, 0.25 mg/kg.
B: ondansetron, 4 mg.
C: cardioversion.
D: amiodarone, 150 mg.
Reason:
Unless associated with a fast rate (> 100 beats/min) and hemodynamic compromise
(eg, hypotension, altered mental status, pulmonary edema), treatment for atrial
flutter is usually not necessary in the prehospital setting. Administer suppleme
ntal oxygen if indicated, transport, and monitor the patient's hemodynamic statu
s en route. For this patient, you should treat his nausea with an antiemetic, su
ch as ondansetron (Zofran), 4 mg; or promethazine (Phenergan), 12.5 to 25 mg.
Answer is B
==== 6/121 cardiology
Assessment and treatment of a responsive adult with a suspected acute coronary s
yndrome (ACS) might include all of the following, EXCEPT:
A: administering lidocaine at a dose of 1.5 mg/kg.
B: obtaining a 12-lead electrocardiogram.
C: administering 2 to 5 mg of morphine sulfate.
D: asking the patient if she has a cardiac history.
Reason:
Lidocaine is not given prophylactically to patients suspected of experiencing an
acute coronary syndrome (ACS). In addition to assessing the responsive patient'
s ABCs and vital signs, you should obtain a 12-lead ECG as early as possible and
promptly notify the receiving facility of your findings. Obtaining a SAMPLE his
tory may provide you with additional information that may affect your treatment.
Treatment includes supplemental oxygen (maintain an SpO2 of greater than or equ
al to 94%), 160 to 325 mg of baby aspirin, IV access, up to three doses of nitro
glycerin (if the systolic BP is greater than 90 mm Hg), and 2 to 5 mg of morphin
e sulfate if nitroglycerin fails to completely relieve the patient's chest pain
or discomfort and his or her systolic BP remains above 90 mm Hg. Transport the p
atient as soon as possible, obtain additional 12-lead tracings en route to the h
ospital, and monitor his or her vital signs and level of pain.
Answer is A
==== 7/121 cardiology
You should interpret the following cardiac rhythm as:
(3RD DEGREE BLOCK)
A: second-degree AV block type I.
B: third-degree AV block.
C: first-degree AV block.
D: second-degree AV block type II.
Reason:
The rhythm is regular, with a ventricular rate of approximately 40 to 50 beats/m
in. It has wide (greater than 120 ms [0.12 sec]) QRS complexes and more P waves
than QRS complexes. Because there is no relationship between any one P wave to a
given QRS complex, this is a third-degree AV block, also called complete heart
block. First-degree AV block is characterized by P-R intervals that exceed 200 m
s (0.20 seconds [5 small boxes]), although there is a consistent 1:1 P-to-QRS ra
tio; unless ectopic compexes are present, it is usually a regular rhythm. Second
-degree AV block type I is characterized by P-R intervals that progressively len
gthen until a P wave is blocked (not followed by a QRS complex); it is an irregu
lar rhythm. Second-degree AV block type II, which may be regular or irregular, i
s characterized by more P waves than QRS complexes; however, the P-R intervals o
f the conducted complexes are the same.
Answer is B
==== 8/121 cardiology
You should interpret the following cardiac rhythm as:
(AFLUTTER REGULAR RR)
A: atrial flutter with a variable block.
B: second-degree AV block type II.
C: atrial flutter with a fixed block.
D: uncontrolled atrial fibrillation.
Reason:
Because of the typical sawtooth flutter (F) waves, this rhythm is interpreted as a
trial flutter (A-Flutter). The block is fixed in that the ratio of F waves to QR
S complexes is consistent (2:1). A-Flutter with a variable block occurs when the
ratio of F waves to QRS complexes is different. Atrial fibrillation (A-Fib) is
characterized by an irregularly irregular rhythm with no identifiable P waves. A
type II second-degree AV block is characterized by a rhythm in which some P wav
es are blocked (eg, they are not followed by QRS complexes).
Answer is C
==== 9/121 cardiology
You arrive approximately 8 minutes after a 51-year-old male collapsed at a famil
y event. After determining that he is unresponsive and apneic, you should:
A: immediately assess the patient's cardiac rhythm.
B: assess for a carotid pulse for 5 to 10 seconds.
C: begin CPR, starting with chest compressions.
D: give 2 rescue breaths and check for a pulse.
Reason:
After determining that an adult patient is unresponsive and apneic, you should a
ssess for a carotid pulse for at least 5 seconds but no more than 10 seconds. If
the patient has a pulse, open the airway and provide rescue breathing. If the p
atient does not have a pulse, begin CPR (starting with chest compressions), then
open the airway and give 2 rescue breaths. Assess the patient's cardiac rhythm
as soon as a monitor/defibrillator is available.
Answer is B
==== 10/121 cardiology
When administering a sympathomimetic medication, you must be alert for:
A: acute hypotension.
B: severe bradycardia.
C: acute respiratory failure.
D: cardiac arrhythmias.
Reason:
Sympathomimetic medications, such as epinephrine and norepinephrine, cause incre
ases in myocardial oxygen demand and consumption. If given to patients with hypo
xemia or acute coronary syndrome (eg, unstable angina, acute myocardial infarcti
on), this effect can result in cardiac arrhythmias. Therefore, you should monito
r the cardiac rhythm of any patient who receives a sympathomimetic drug. Sympath
omimetic drugs cause an increase in heart rate, not a decrease. Hypotension and
respiratory failure are not common following the administration of a sympathomim
etic drug.
Answer is D
==== 11/121 cardiology
A 70-year-old man presents with the cardiac rhythm shown below. He is confused,
is slow to answer your questions, and is profusely diaphoretic. His blood pressu
re is 76/54 mm Hg, his pulse is rapid and weak, and his respirations are 22 brea
ths/min and labored. He is receiving high-flow oxygen and your partner has estab
lished a patent IV line. You should:
(VTACH)
A: Administer a 500-mL normal saline bolus and reassess
B: Administer 150 mg of amiodarone over 10 minutes
C: Consider sedation and then cardiovert with 100 joules
D: Attempt vagal maneuvers and then consider adenosine
Reason:
This patient is in ventricular tachycardia (V-Tach). Furthermore, he is hemodyna
mically unstable as evidenced by his confusion, hypotension, and labored breathi
ng. Therefore, he requires prompt synchronized cardioversion, starting with 100
joules. Consider sedation with midazolam (Versed) or diazepam (Valium), but do n
ot allow this to delay cardioversion. Amiodarone would be an appropriate interve
ntion if the patient was hemodynamically stable. Vagal maneuvers and adenosine a
re appropriate for stable patients with narrow complex tachycardias (eg, SVT). F
luid boluses will likely not improve the patient's blood pressure; his hypotensi
on is the result of inadequate ventricular filling and decreased cardiac output
due to his cardiac rhythmnot hypovolemia.
Answer is C
==== 12/121 cardiology
Which of the following statements regarding the use of vasopressin in cardiac ar
rest is correct?
A: Vasopressin can be used to replace the first or second dose of epinephrine
B: Vasopressin should be given every 3 to 5 minutes throughout the arrest
C: Vasopressin is highly effective in treating pediatric cardiac arrest patients

D: Vasopressin is superior to epinephrine and should be used when possible
Reason:
According to the 2010 guidelines for CPR and emergency cardiac care (ECC), vasop
ressin, in a one-time dose of 40 units, can be given to replace the first OR sec
ond dose of epinephrine for adult patients in cardiac arrest. There are no defin
itive data to support superiority of vasopressin over epinephrine. There are ins
ufficient data to make a recommendation for or against the use of vasopressin in
pediatric cardiac arrest.
Answer is A
==== 13/121 cardiology
What are the therapeutic effects of aspirin when given to patients experiencing
an acute coronary syndrome?
A: Dilates the coronary arteries
B: Prevents platelet aggregation
C: Direct blood-thinning effect
D: Increases platelet production
Aspirin (acetylsalicylic acid [ASA]) blocks the formation of thromboxane A2, thu
s minimizing local coronary vasoconstriction and preventing platelet aggregation
. Therefore, aspirin helps prevent an existing clot from getting any larger. Asp
irin has clearly been shown to reduce mortality and morbidity from acute coronar
y syndrome (ACS), and should be given as soon as possible. Examples of blood thi
nners (anticoagulants) include warfarin sodium (Coumadin) and heparin. Aspirin i
s not an anticoagulant, nor does it dilate the coronary arteries; nitroglycerin
(NTG) does this.
Reason:
Aspirin (acetylsalicylic acid [ASA]) blocks the formation of thromboxane A2, thu
s minimizing local coronary vasoconstriction and preventing platelet aggregation
. Therefore, aspirin helps prevent an existing clot from getting any larger. Asp
irin has clearly been shown to reduce mortality and morbidity from acute coronar
y syndrome (ACS), and should be given as soon as possible. Examples of blood thi
nners (anticoagulants) include warfarin sodium (Coumadin) and heparin. Aspirin i
s not an anticoagulant, nor does it dilate the coronary arteries; nitroglycerin
(NTG) does this.
Answer is B
==== 14/121 cardiology
While assessing a middle-aged man who complains of nausea and weakness, he sudde
nly becomes unresponsive. The cardiac monitor displays the rhythm shown below. A
fter determining that he is apneic and pulseless, you should:
(COARSE VFIB)
A: perform synchronized cardioversion.
B: start CPR and prepare to defibrillate.
C: start an IV and give 300 mg of amiodarone.
D: perform CPR for 2 minutes and defibrillate.
Reason:
You witnessed your patient's deterioration to cardiac arrest, and he is now in v
entricular fibrillation (V-Fib). You should immediately start CPR and defibrilla
te as soon as possible. Deliver a single shock with 360 monophasic joules or the
equivalent biphasic setting, and immediately resume CPR (starting with chest co
mpressions). Perform 5 cycles (about 2 minutes) of CPR and then reassess his car
diac rhythm. If V-Fib persists, defibrillate again and immediately resume CPR, s
tarting with chest compressions. During CPR, establish vascular access (if not a
lready done), and give 1 mg of epinephrine 1:10,000. After 2 minutes of CPR, rea
ssess the patient's cardiac rhythm. If V-Fib persists, defibrillate again and im
mediately resume CPR, starting with chest compressions. It would then be appropr
iate to administer 300 mg of amiodarone. Synchronized cardioversion is indicated
for patients with narrow or wide-complex tachycardias who are hemodynamically u
nstable but have a pulse.
Answer is B
==== 15/121 cardiology
The MOST appropriate initial action for a 54-year-old man who presents with the
following cardiac rhythm should consist of:
(SINUS BRADY)
A: quickly establishing vascular access.
B: assessing the patients clinical status.
C: administering 0.5 mg of atropine sulfate.
D: preparing for transcutaneous pacing.
Reason:
When assessing the cardiac rhythm of any patient, you must interpret it in the c
ontext of his or her clinical status. Before you reach for atropine or a pacemak
er, determine if the bradycardia is causing hemodynamic compromise (ie, hypotens
ion, altered mental status, chest pressure or discomfort, pulmonary edema). If t
he patient is hemodynamically unstable, treat according to established ACLS guid
elines (ie, atropine, pacing, etc.). However, if the patient is hemodynamically
stable, simply monitor his or her clinical status and transport to the hospital.
Answer is B
=== 16/121 cardiology
Side effects of atropine sulfate may include:
A: pupillary constriction.
B: hypotension.
C: acute urinary retention.
D: hypersalivation.
Reason:
Side effects of atropine sulfate may include thirst, dry mouth, pupillary dilati
on (mydriasis), tachycardia, hypertension, and urinary retention. Acute urinary
retention is especially common in older men with benign prostatic hyperplasia (B
PH), also known as an enlarged prostate gland.
Answer is C
==== 17/121 cardiology
Sudden cardiac arrest in the adult population is MOST often secondary to:
A: accidental electrocution.
B: respiratory failure.
C: a cardiac dysrhythmia.
D: massive hypovolemia.
Reason:
Most cases of sudden cardiac arrest (SCA) in the adult population are secondary
to a cardiac dysrhythmia, usually ventricular fibrillation (V-Fib). This fact un
derscores the criticality of early defibrillation. Respiratory failure is the mo
st common cause of cardiac arrest in the pediatric population.
Answer is C
==== 18/121 cardiology
Which of the following pain descriptions is MOST consistent with a cardiac probl
em?
A: Intermittent
B: Sharp
C: Tearing
D: Crushing
Reason:
Chest pain of cardiac origin is most often described as crushing, dull, pressure
, or as a feeling of heaviness or discomfort. The pain is typically constant, no
t intermittent, and is usually not palliated or exacerbated by movement. Bear i
n mind that these are typical pain descriptions. The paramedic should not rule o
ut a cardiac problem if the patient describes the pain differently. Sharp (pleur
itic) pain is often associated with conditions such as pleurisy, pulmonary embol
ism, or spontaneous pneumothorax. A tearing sensation should alert you to the po
ssibility of acute aortic dissection.
Answer is D
==== 19/121 cardiology
You are assessing a 59-year-old woman who complains of chest pressure. When you
are looking at her list of medications, you note that she takes Vasotec. What ty
pe of medication is this?
A: Parasympathetic blocker
B: ACE inhibitor
C: Calcium channel blocker
D: Beta-blocker
Reason:
Enalapril maleate (Vasotec) is an ACE (angiotensin converting enzyme) inhibitor
that is used to treat hypertension. Angiotensin II, a potent chemical produced b
y the kidneys that causes vasoconstriction, is formed from angiotensin I in the
blood by the angiotensin converting enzyme. ACE inhibitors inhibit the activity
of this enzyme, which decreases the production of angiotensin II. As a result, t
he blood vessels dilate and blood pressure is reduced. Beta blockers, which are
also used to treat hypertension, include drugs such as metoprolol (Lopressor), p
ropranolol (Inderal), and atenolol (Tenormin), among others. Calcium channel blo
ckers are also used to treat hypertension, and include drugs such as diltiazem (
Cardizem), verapamil (Calan; Isoptin), and amlodipine (Norvasc), among others. A
tropine sulfate is a parasympathetic blocker (vagolytic) that is used to treat p
atients with hemodynamically unstable bradycardia.
Answer is B
==== 20/121 cardiology
A patient with acute chest discomfort displays the cardiac rhythm shown below. W
hich of the following is the MOST detrimental effect that this rhythm can have o
n the patient?
(SINUS TACH)
A: Increased myocardial oxygen demand
B: Increased nervousness and anxiety
C: Decreased myocardial irritability
D: Decreased myocardial contractility
Reason:
The rhythm shown is sinus tachycardia. Any increase in cardiac workload, such as
an increase in heart rate, contractility, or blood pressure, will increase the
amount of oxygen that the myocardium demands and consumes. In patients experienc
ing an acute coronary syndrome (ie, unstable angina [UA], acute myocardial infar
ction [AMI]), this could extend the area of ischemia or infarction.
Answer is A
==== 21/121 cardiology
During resuscitation of a 60-year-old man with ventricular fibrillation, you res
tore spontaneous circulation following CPR, defibrillation, two doses of epineph
rine, and one dose of amiodarone. The patient remains unresponsive and apneic. W
hich of the following represents the MOST appropriate post-arrest care for this
patient?
A: Ventilate at a rate of 10 to 12 breaths/min, support blood pressure, and cons
ider therapeutic hypothermia
B: Ventilate at a rate of 8 to 10 breaths/min, support blood pressure, and give
150 mg of amiodarone over 10 minutes
C: Ventilate at a rate of 20 breaths/min, begin an epinephrine infusion to maint
ain perfusion, and keep the patient warm
D: Hyperventilate the patient, administer a normal saline bolus, and begin an am
iodarone infusion at 0.5 mg/min
Reason:
The 2010 guidelines for CPR and emergency cardiac care (ECC) have added a fifth
link to the chain of survival, integrated post-arrest care. In addition to suppo
rting the patient's airway and ventilatory status and supporting his or her bloo
d pressure with IV fluid boluses or an inotropic agent (ie, dopamine), you shoul
d assess for and correct any glucose abnormalities. If the patient is unable to
follow verbal commands or remains comatose following return of spontaneous circu
lation (ROSC), therapeutic hypothermia (89.6F to 93.2F [32C to 34C]) has been shown
to improve neurologic recovery and should be considered (follow your local proto
cols regarding therapeutic hypothermia). Once ROSC has been established, you sho
uld continue to ventilate the adult patient at a rate of 10 to 12 breaths/min (o
ne breath every 5 to 6 seconds) if he or she remains apneic. DO NOT hyperventila
te the patient as this may impair venous return to the heart and compromise card
iac output. If the patient is able to follow verbal commands following ROSC, obt
ain a 12-lead ECG tracing and assess for signs of acute MI (ie, ST elevation). D
epending on your transport time, you may consider starting a maintenance infusio
n of the antidysrhythmic drug that was administered during the arrest, which in
this case, would be amiodarone (1 mg/min).
Answer is A
==== 22/121 cardiology
Which of the following interventions has the greatest impact on patient survival
from sudden cardiac arrest?
A: Cardiac medication administration
B: Identifying the cause
C: Early CPR and defibrillation
D: Advanced airway control
Reason:
Early CPR and defibrillation are the two interventions that will have the greate
st impact on patient survival from sudden cardiac arrest (SCA). Early, effective
CPR maintains perfusion to the body's vital organs until defibrillation can be
provided. The most common initial cardiac rhythm observed during SCA is ventricu
lar fibrillation (V-Fib). Early defibrillation, in conjunction with early CPR, g
reatly enhances the chance of establishing return of spontaneous circulation (RO
SC). The probability of successful defibrillation decreases over time, especiall
y if CPR is delayed. For each minute that V-Fib persists, the patient's chance o
f survival decreases by approximately 7% to 10%.
Answer is C
==== 23/121 cardiology
You are assessing a 50-year-old man with acute chest pressure, diaphoresis, and
nausea. The 12-lead ECG tracing reveals 3-mm ST segment elevation in leads V3 th
rough V6. This indicates:
A: inferior injury.
B: anterolateral injury.
C: lateral ischemia.
D: anteroseptal ischemia.
Reason:
Leads V1 and V2 view the interventricular septum. Leads V3 and V4 view the anter
ior wall of the left ventricle. Leads I, aVL, V5 and V6 view the lateral wall of
the left ventricle. Leads II, III, and aVF view the inferior wall of the left v
entricle. Myocardial ischemia manifests on the 12-lead ECG with ST segment depre
ssion and/or T-wave inversion, whereas myocardial injury manifests with ST segme
nt elevation that is equal to or greater than 1-mm in two or more contiguous lea
ds. Therefore, 3-mm ST segment elevation in leads V3 through V6 indicates injury
to the anterior and lateral wall of the left ventricle (anterolateral injury).
Answer is B
==== 24/121 cardiology
A 66-year-old woman is diagnosed with cardiomyopathy. What does this indicate?
A: An occluded coronary artery
B: An enlarged myocardium
C: Strengthening of the ventricles
D: Progressive cardiac weakening
Reason:
Cardiomyopathy is a progressive weakening of the myocardium. This condition is c
ommonly the result of chronic hypertension or a history of multiple myocardial i
nfarctions. An enlarged myocardium is called cardiomegaly.
Answer is D
==== 25/121 cardiology
Which of the following 12-lead ECG findings signifies a left bundle branch block
?
A: QRS duration of 124 ms; terminal S wave in lead V1
B: QRS duration of 122 ms; terminal S wave in lead V6
C: QRS duration of 126 ms; terminal S wave in lead aVL
D: QRS duration of 128 ms; terminal R wave in lead V1
Reason:
A QRS duration of greater than 120 ms (0.12 seconds [3 small boxes]) signifies a
n intraventricular conduction delay (IVCD), such as a bundle branch block. A lef
t bundle branch block (LBBB) is characterized by a QRS duration of greater than
120 ms and a terminal S wave in lead V1 (the second half of the QRS complex term
inates in an S wave); terminal R waves are seen in leads I, aVL, and V6. A right
bundle branch block (RBBB) is characterized by a QRS duration of greater than 1
20 ms and a terminal R wave in lead V1 (the second half of the QRS complex termi
nates in an R wave); terminal S waves are seen in leads I, aVL, and V6.
Answer is A
==== 26/121 cardiology
An elderly man is apneic and pulseless. The ECG shows the following rhythm, whic
h you should interpret as:
(SINUS TACH)
A: sinus bradycardia.
B: first-degree AV block.
C: normal sinus rhythm.
D: sinus tachycardia.
Reason:
The rhythm shown is sinus tachycardia at a rate of approximately 100 to 110 beat
s/min. First-degree AV block is characterized by a PR interval that is greater t
han 0.20 seconds, the normal being 0.12 to 0.20 seconds (120 to 200 milliseconds
). The fact that the patient does not have a pulse indicates pulseless electrica
l activity (PEA). PEA is not a specific rhythm; it is a condition in which a pul
seless, apneic patient presents with an organized cardiac rhythm (except for pul
seless V-Tach).
Answer is D
==== 27/121 cardiology
After determining that an elderly man is pulseless and apneic, you and your team
begin CPR and briefly pause to assess his cardiac rhythm, which is shown below.
After resuming CPR, you should:
(SINUS TACH)
A: give 1 mEq of sodium bicarbonate to rule out acidosis.
B: insert an advanced airway as CPR is briefly paused.
C: prepare to cardiovert the patient at 50 to 100 joules.
D: establish vascular access and give 1 mg of epinephrine.
Reason:
After determining that a patient is in pulseless electrical activity (PEA), you
should resume CPR, establish vascular access (IV or IO), and administer 1 mg of
epinephrine 1:10,000. Consider inserting an advanced airway (ie, ET tube, multil
umen airway, supraglottic airway), but DO NOT interrupt CPR to do this. Focus on
ruling out potentially reversible causes (Hs and Ts). Routine administration of
sodium bicarbonate during cardiac arrest is not recommended; its administration
should be guided by arterial blood gas (ABG) values. Synchronized cardioversion
is indicated for hemodynamically unstable patients with wide and narrow complex
tachycardias, not PEA.
Answer is D
==== 28/121 cardiology
Appropriate treatment for asystole includes:
A: transcutaneous cardiac pacing and epinephrine 1:10,000.
B: vasopressin every 3 to 5 minutes and tracheal intubation.
C: supraglottic airway placement and antidysrhythmic therapy.
D: epinephrine 1:10,000 and advanced airway management.
Reason:
Appropriate treatment for a patient in asystole includes high-quality CPR with m
inimal interruptions, vascular access, 1 mg of epinephrine 1:10,000 every 3 to 5
minutes, advanced airway management (eg, ET tube, multilumen airway, supraglott
ic airway), and assessing for and ruling out potentially reversible causes (Hs a
nd Ts). Vasopressin may be given in a one-time dose of 40 units to replace the f
irst or second dose of epinephrine, but not both. Transcutaneous cardiac pacing
(TCP) has not shown to be beneficial for patients in asystole and is not recomme
nded. Antidysrhythmic drugs, such as amiodarone and lidocaine, are indicated for
patients with ventricular fibrillation or pulseless ventricular tachycardia; th
ey are not given to patients with asystole.
Answer is D
==== 29/121 cardiology
A 56-year-old man presents with the cardiac rhythm shown below. He complains of
chest discomfort, shortness of breath, and is profusely diaphoretic. His blood p
ressure is 84/64 mm Hg and his radial pulses are barely palpable. You should:
(Regular, T and P waves visible.150-300)
A: give 150 mg of amiodarone over 10 minutes.
B: defibrillate with 200 biphasic joules.
C: consider sedation and perform cardioversion.
D: prepare for immediate cardiac pacing.
Reason:
Your patient has a narrow-complex tachycardia, probably supraventricular tachyca
rdia (SVT). Furthermore, he is hemodynamically unstable as evidenced by his hypo
tension, respiratory distress, and chest discomfort. Heart rates greater than 15
0 beats/min often cause hemodynamic compromise because they impair ventricular f
illing and subsequent cardiac output. Patients with unstable tachycardias requir
e synchronized cardioversion. For the patient with a regular narrow-complex tach
ycardia (ie, SVT), start with 50 to 100 joules. Consider sedating the patient pr
ior to cardioversion only if doing so does not delay the procedure. If the initi
al cardioversion attempt is unsuccessful, repeat the cardioversion, increasing t
he energy setting in a stepwise fashion, and search for potentially reversible u
nderlying causes. Defibrillation is indicated for patients with V-Fib and pulsel
ess V-Tach. Transcutaneous cardiac pacing (TCP) is indicated for patients with h
emodynamically unstable bradycardia. Amiodarone, in a dose of 150 mg over 10 min
utes, is indicated for patients with stable narrow or wide-complex tachycardias.
Answer is C
==== 30/121 cardiology
A 70-year-old woman was suddenly awakened with the feeling that she was suffocat
ing. She is anxious, is laboring to breathe, and has dried blood on her lips. Th
e ECG shows the cardiac rhythm below. Which of the following pathophysiologies B
EST explains her clinical presentation?
(SINUS TACH over 150)
A: Increased stroke volume with right heart failure
B: Decreased preload with right heart failure
C: Decreased stroke volume with left heart failure
D: Increased preload with left heart failure
Reason:
Paroxysmal nocturnal dyspnea (PND), the sudden awakening from sleep with the fee
ling of being suffocated, along with the dried blood around the patient's lips (
likely due to coughing up blood-tinged sputum), are classic indicators of left-s
ided congestive heart failure (CHF). In left-sided CHF, stroke volume (the amoun
t of blood ejected from the ventricle per contraction) is decreased secondary to
a weakened or damaged myocardium. Decreased stroke volume causes blood to regur
gitate into the upper chamber of the heart and ultimately backs up into the lung
s and causes pulmonary edema.
Answer is C
==== 31/121 cardiology
You have defibrillated a patient who presented with ventricular fibrillation. Af
ter 2 minutes of CPR, you reassess the patient's cardiac rhythm and see a wide-c
omplex tachycardia. You should:
A: administer 300 mg of amiodarone via rapid IV or IO push.
B: check for a carotid pulse and defibrillate if a pulse is absent.
C: cardiovert with the energy setting you used to defibrillate.
D: defibrillate and then immediately resume chest compressions.
Reason:
Cardiac rhythm checks should be performed after every 2 minutes of CPR. If you n
ote a change in the patient's cardiac rhythm after 2 minutes, especially if it i
s an organized rhythm, you should check for a carotid pulse for 5 to 10 seconds.
In this case, the patient has converted from V-Fib to a wide-complex tachycardi
a, which is probably V-Tach. If the patient has a pulse, perform synchronized ca
rdioversion with the same energy setting that you used for defibrillation. If th
e patient is pulseless, however, you should defibrillate and immediately resume
CPR, starting with chest compressions. During the 2-minute period of CPR, you ca
n adminster epinephrine, if 3 to 5 minutes have passed, or 300 mg of amiodarone
via rapid IV or IO push.
Answer is B
==== 32/121 cardiology
A 65-year-old man with difficulty breathing and palpitations presents with the c
ardiac rhythm shown below, which you should interpret as:
(Regular, narrow , Ts and Ps, 150-300)
A: uncontrolled atrial fibrillation.
B: supraventricular tachycardia.
C: ventricular tachycardia.
D: atrial flutter with a fixed block.
Reason:
Since this rhythm has narrow (less than 0.12 seconds) QRS complexes and a rate g
reater than 150 beats/min, it should be interpreted as supraventricular tachycar
dia (SVT), which means that its site of origin is above (supra) the level of the
ventricles. SVT can be either atrial or junctional in origin. Atrial fibrillati
on is characterized by an irregularly irregular rhythm and no discernable P wave
s. Atrial flutter is characterized by flutter (F) waves that resemble a saw toot
h. Ventricular tachycardia (V-Tach), in contrast to SVT, is characterized by wid
e (greater than 0.12 seconds) QRS complexes and no visible P waves.
Answer is B
==== 33/121 cardiology
On the 12-lead ECG, the high lateral wall of the left ventricle is viewed by lea
ds:
A: V1 and V2.
B: III and aVF.
C: I and aVL.
D: V5 and V6.
Reason:
Leads V1 and V2 view the interventricular septum. Leads V3 and V4 view the anter
ior wall of the left ventricle. Leads V5 and V6 view the low lateral wall of the
left ventricle. Leads I and aVL view the high lateral wall of the left ventricl
e. Leads II, III, and aVF view the inferior wall of the left ventricle. Lead V4R
views the right ventricle.
Answer is C
==== 34/121 cardiology
An older man is suddenly awakened in the middle of the night, gasping for air. H
e is extremely restless and pale, and is coughing up blood. His clinical present
ation is MOST consistent with:
A: right side heart failure.
B: unstable angina.
C: left side heart failure.
D: gastrointestinal bleed.
Reason:
Waking up in the middle of the night with severe difficulty breathing (paroxysma
l nocturnal dyspnea [PND]) and coughing up blood or blood-tinged sputum (hemopty
sis) are consistent with left-sided heart failure and pulmonary edema. Right-sid
ed heart failure typically does not present with respiratory distress; it common
ly manifests with jugular venous distention and peripheral edema. Shortness of b
reath and hemoptysis are not consistent with a gastrointestinal (GI) bleed; sign
s of a GI bleed include abdominal pain, vomiting up blood (hematemesis), which m
ay be bright red or have a coffee-ground appearance; dark, tarry stools (melena)
; or bright red blood in the stool (hematochezia). Because left-sided heart fail
ure can be caused by other factors, such as a long history of poorly-controlled
hypertension, angina may or may not be present.
Answer is C
==== 35/121 cardiology
A patient experiencing a right ventricular infarction would be expected to prese
nt with:
A: ST elevation in leads II, III, and aVF.
B: severe pulmonary edema and hemoptysis.
C: greater than 2-mm ST depression in lead V1.
D: hypertension and tachycardia.
Reason:
A right ventricular infarction (RVI) should be suspected when a patient presents
with ECG changes indicative of an inferior wall injury pattern (equal to or gre
ater than 1-mm ST elevation in leads II, III, and aVF; reciprocol ST depression
and T wave inversion in leads I and aVL) AND has equal to or greater than 1-mm S
T elevation in lead V4R when a right-sided 12-lead ECG is obtained. Patients exp
eriencing an RVI are preload dependent and often present with hypotension; there
fore, vasodilators (eg, nitroglycerin, morphine) should be avoided. Instead, IV
fluid boluses should be given to maintain adequate perfusion. Other signs of an
RVI include jugular venous distention and peripheral edema. Pulmonary edema and
coughing up blood (hemoptysis) are indicative of left ventricular failure.
Answer is A
==== 36/121 cardiology
A 56-year-old man has had chest pain for the past 2 days, but refused to go to t
he hospital. His wife called EMS when she noticed that he was not acting right.
He is conscious, but confused, and is diaphoretic. His BP is 80/40 mm Hg and his
pulse is rapid and weak. The patient's history and your assessment findings are
MOST consistent with:
A: acute ischemic stroke.
B: cardiogenic hypoperfusion.
C: acute myocardial infarction.
D: unstable angina pectoris.
Reason:
The patient most likely experienced an acute myocardial infarction (AMI); howeve
r, since he did not receive timely treatment, extensive myocardial damage has re
sulted in pump failure. His low BP; weak, rapid pulses; and altered mental statu
s indicate that he is systemically hypoperfused. Hypoperfusion (shock) secondar
y to a cardiac etiology (ie, pump failure, fast or slow heart rate) is called ca
rdiogenic shock. True cardiogenic shock, which occurs when the myocardium is ext
ensively and permanently damaged and can no longer meet the metabolic needs of t
he body, has a high mortality rate.
Answer is B
==== 37/121 cardiology
You are called to a local supermarket where a customer collapsed. When you arriv
e, two bystanders are performing CPR on the patient. You should:
A: verify the effectiveness of the bystanders CPR.
B: assess the patient to confirm pulselessness and apnea.
C: perform a precordial thump and assess for a carotid pulse.
D: immediately assess the patient's cardiac rhythm.
Reason:
When you arrive at a scene and find bystanders performing CPR, you should briefl
y pause and confirm that the patient is pulseless and apneic. In some cases, you
will find CPR being performed on patients who do not require it. Once cardiac a
rrest is confirmed, resume high-quality CPR and assess the patient's cardiac rhy
thm as soon as possible. According to the 2010 guidelines for CPR and emergency
cardiac care (ECC), the precordial thump should not be used for unwitnessed out-
of-hospital cardiac arrest. However, it may be considered for patients with witn
essed, monitored unstable ventricular tachycardia, including pulseless ventricul
ar tachycardia, if a defibrillator is not immediately ready for use.
Answer is B
==== 38/121 cardiology
What are the therapeutic effects of morphine sulfate when administered to a pati
ent with cardiogenic pulmonary edema?
A: Increased cardiac inotropy and increased cardiac output
B: Systemic venous pooling of blood and increased afterload
C: Increased venous capacitance and decreased preload
D: Decreased venous capacitance and increased inotropy
Reason:
In patients with cardiogenic pulmonary edema (ie, congestive heart failure [CHF]
), morphine sulfate causes systemic pooling of blood, which increases venous cap
acitance and decreases preload (the volume of blood returned to the heart). The
net effect is to minimize the volume of fluid that accumulates in the lungs. Not
e that morphine is not a diuretic and will not remove fluid from the body. This
is accomplished by administering furosemide (Lasix), which may be considered for
patients with CHF and pulmonary edema.
Answer is C
==== 39/121 cardiology
You are preparing to defibrillate a patient in cardiac arrest with a manual biph
asic defibrillator, but are unsure of the appropriate initial energy setting. Wh
at should you do?
A: Continue CPR and shock with 360 joules in 2 minutes.
B: Contact medical control for further guidance.
C: Deliver one shock with 200 joules and resume CPR.
D: Deliver three sequential shocks with 120 joules.
Reason
Energy settings for manual biphasic defibrillators are device-specifictypically 1
20 joules (rectilinear) or 150 joules (truncated). However, if the appropriate i
nitial energy setting is unknown, you should defibrillate with 200 joules. For s
ubsequent shocks, use the same or higher energy setting. Whether you are using a
monophasic or biphasic defibrillator, you should only perform 1 shock, followed
immediately by CPR (starting with chest compressions).
Answer is C
==== 40/121 cardiology
During your SAMPLE history of an elderly man, he tells you that his cardiologist
told him that he has an irregular heartbeat. His medications include warfarin sod
ium and digoxin. On the basis of this information, what underlying cardiac rhyth
m should you suspect?
A: AV heart block
B: Sinus dysrhythmia
C: Atrial tachycardia
D: Atrial fibrillation
Reason:
Patients with atrial fibrillation (A-Fib) are commonly prescribed digoxin (a dig
italis preparation) and warfarin sodium (Coumadin), which is a blood thinner. As
the atria fibrillate, blood has a tendency to stagnate and form microemboli tha
t can be ejected from the heart and occlude a pulmonary, cerebral, or coronary a
rtery.
Answer D
==== 41/121 cardiology
Which of the following represents the MOST appropriate initial drug and dose tha
t is given to all adult patients in cardiac arrest?
A: 1 mg of epinephrine 1:1,000 every 3 to 5 minutes
B: 10 mL of epinephrine 1:10,000 every 3 to 5 minutes
C: 40 units of vasopressin every 3 to 5 minutes
D: 0.1 mg/kg of epinephrine every 3 to 5 minutes
Reason
Once vascular access has been obtained (IV or IO), the first drug and dose given
to all patients in cardiac arrestregardless of the rhythm on the cardiac monitori
s epinephrine 1 mg (10 mL) of a 1:10,000 solution, repeated every 3 to 5 minutes
. You may consider a one-time dose of vasopressin (40 units) to replace the firs
t or second dose of epinephrine, but not both. Higher doses of epinephrine may b
e necessary if special circumstances exist (ie, severe beta-blocker toxicity). C
onsult with medical control as needed.
Answer is B
==== 42/121 cardiology
Which of the following represents the correct medication sequence when treating
a patient with a suspected acute coronary syndrome?
A: Oxygen, aspirin, nitroglycerin, and morphine
B: Oxygen, aspirin, morphine, and nitroglycerin
C: Oxygen, morphine, aspirin, and nitroglycerin
D: Oxygen, nitroglycerin, aspirin, and morphine
Reason:
The mnemonic MONA is used to help remember the medications given to patients who a
re experiencing an acute coronary syndrome (ACS). Although it does not represent
the correct sequence in which the medications should be given, it is a useful m
nemonic to remember. The appropriate sequence of medications is oxygen (as neede
d to maintain an SpO2 of greater than 94%), aspirin (160 to 325 mg), nitrogylcer
in (0.4 mg up to 3 times), and morphine (2 to 4 mg) if the nitroglycerin does no
t relieve the chest pain. Pain relief is very important in patients experiencing
ACS (eg, unstable angina or AMI) because it reduces anxiety and subsequent oxyg
en consumption and demand.
Answer is A
==== 43/121 cardiology
A middle-aged man presents with chest discomfort, shortness of breath, and nause
a. You give him supplemental oxygen and continue your assessment. As your partne
r is attaching the ECG leads, you should:
A: administer 2 to 4 mg of morphine IM.
B: establish vascular access.
C: administer 0.4 mg of nitroglycerin.
D: administer up to 325 mg of aspirin.
Reason:
Since oxygen has already been administered to this patient and your partner is a
ttaching the ECG leads, you should administer aspirin (160 to 325 mg, non-enteri
c-coated). Early administration of aspirin has clearly been shown to reduce mort
ality and morbidity in patients experiencing an acute coronary syndrome (ACS). A
fter establishing vascular access, you should assess his vital signs and then ad
minister 0.4 mg of nitroglycerin (up to 3 doses, 5 minutes apart), provided that
his systolic BP is greater than 90 mm Hg. If 3 doses of nitroglycerin fail to c
ompletely relieve his chest discomfort, consider administering 2 to 4 mg of morp
hine IV, provided that his systolic BP remains above 90 mm Hg.
Answer is D
==== 44/121 cardiology
What are the physiologic effects of nitroglycerin when given to patients with ca
rdiac-related chest pain, pressure, or discomfort?
A: Increased afterload and vascular constriction
B: Smooth muscle relaxation and decreased preload
C: Increased venous return to the right side of the heart
D: Analgesia, vasoconstriction, and increased preload
Reason:
Nitroglycerin (NTG) is a vasodilator. It relaxes the smooth muscle of the vascul
ar walls, which promotes systemic venous pooling of blood. As a result, venous r
eturn to the right atrium (preload) is decreased; this decreases the cardiac wor
kload. The amount of resistance that the left ventricle must contract against (a
fterload) is also decreased secondary to vasodilation. By dilating the coronary
arteries, NTG increases blood supply to ischemic myocardium and may relieve the
chest pain, pressure, or discomfort associated with acute coronary syndrome (ACS
). Nitroglycerin is not an analgesic; if it relieves the patient's pain, it is b
ecause myocardial oxygen supply and demand have been rebalanced.
Answer is B
==== 45/121 cardiology
What is the correct initial dose and rate of administration of amiodarone for a
patient with refractory ventricular fibrillation?
A: 300 mg via rapid IV or IO push
B: 150 mg given over 10 minutes
C: 150 mg via rapid IV or IO push
D: 300 mg given over 10 minutes
Reason:
The correct initial dose and rate of administration of amiodarone for a patient
with refractory ventricular fibrillation or pulseless ventricular tachycardia is
300 mg rapid IV or IO push. You may repeat amiodarone one time in 5 minutes at
a dose of 150 mg rapid IV or IO push. For patients with hemodynamically stable n
arrow or wide-complex tachycardias, the correct dose and rate of administration
for amiodarone is 150 mg given over 10 minutes.
Answer is A
==== 46/121 cardiology
When assessing a patient with suspected cardiac-related chest pain, which of the
following questions would be MOST appropriate to ask?
A: Is the pain crushing or dull in nature?
B: Can you describe the quality of the pain?
C: Does the pain move to your arms?
D: Were you at rest when the pain began?
Reason:
Patient assessment involves simple questioning techniques. You should ask open-e
nded questions, whenever possible; this is especially true when determining the
onset and quality of a patient's pain. Asking a leading question, such as Do you
have sharp chest pain? will often lead the patient to say yes, even though that is
not the true quality of his or her pain. Allow the patient to use his or her own
words when describing symptoms.
Answer is B
==== 47/121 cardiology
Which of the following findings is MOST suggestive of right-sided heart failure?
A: Persistent orthopnea
B: Engorged jugular veins
C: Blood-tinged sputum
D: Nocturnal dyspnea
Reason:
As the right side of the heart fails, blood is not effectively ejected into the
pulmonary circulation; therefore, it backs up beyond the right atrium and into t
he systemic venous system. This is most noticeable by the presence of engorged o
r distended jugular veins. Orthopnea, nocturnal dyspnea, and coughing up blood-t
inged sputum are indicators of left-sided heart failure as they all indicate flu
id in the lungs.
Answer is B
==== 48/121 cardiology
A clinically unstable patient presents with an irregular narrow-complex tachycar
dia at a rate of 170 per minute. What is the recommended initial energy setting
for synchronized cardioversion?
A: 320 to 360 joules
B: 50 to 100 joules
C: 200 to 300 joules
D: 120 to 200 joules
Reason:
If a patient has a heart rate that is greater than 150 per minute, and he or she
is clinically unstable because of the cardiac rhythm, synchronized cardioversio
n should be performed. The following initial energy settings are recommended by
current emergency cardiac care (ECC) guidelines: narrow and regular, 50 to 100 j
oules (biphasic or monophasic); narrow and irregular, 120 to 200 joules biphasic
(200 joules monophasic); wide and regular, 100 joules (biphasic or monophasic);
wide and irregular, defibrillation dose (NOT synchronized). If the initial ener
gy dose is unsuccessful, increase in a stepwise fashion.
Answer is D
==== 49/121 cardiology
Immediately following return of spontaneous circulation, the paramedic should:
A: reassess the patients ventilatory status.
B: induce therapeutic hypothermia.
C: provide a bolus of normal saline solution.
D: assess the patients blood pressure.
Reason:
Immediately following return of spontaneous circulation (ROSC), as evidenced by
the presence of a pulse, the paramedic should reassess the patients ventilatory s
tatus and continue to treat accordingly. Remember, if an advanced airway is plac
ed during cardiac arrest, ventilations are given at a rate of one breath every 6
to 8 seconds (8 to 10 breaths/min) with continuous chest compressions. However,
if ROSC occurs and the patient remains apneic, you should deliver one breath ev
ery 5 to 6 seconds (10 to 12 breaths/min) for the adult, or one breath every 3 t
o 5 seconds (12 to 20 breaths/min) for infants and children. Next, assess the pa
tient's BP and use crystalloid fluid boluses or an inotropic drug (eg, dopamine)
to treat hypotension and maintain adequate perfusion. If the patient remains co
matose following ROSC, therapeutic hypothermia should be considered. Follow your
local protocols.
Answer is A
==== 50/121 cardiology
A 30-year-old man complains of nausea and one episode of vomiting. He is conscio
us and alert and states that he has a slight headache. He denies chest pain or s
hortness of breath, and his skin is pink, warm, and dry. His BP is 136/88 mm Hg,
pulse is 44 beats/min and strong, and respirations are 14 breaths/min and unlab
ored. The cardiac monitor reveals sinus bradycardia. Treatment for this patient
should include:
A: supportive care and transport to the hospital.
B: 2 to 10 g/min of epinephrine via IV infusion.
C: high-flow oxygen and 0.5 mg atropine IV push.
D: high-flow oxygen and a 20 mL/kg fluid bolus.
Reason:
Although the patient's heart rate is slow, he is hemodyamically stable; therefor
e, pharmacological or electrical intervention aimed at increasing his heart rate
is not indicated at this point. Provide supportive care (ie, oxygen as needed,
IV set to a KVO/TKO rate) and transport him to the hospital. Consider administer
ing an antiemetic drug, such as ondansetron (Zofran) or promethazine (Phenergan)
. If his clinical status deteriorates (ie, chest pain, dyspnea, altered mental s
tatus, hypotension), atropine sulfate (0.5 mg) or transcutaneous cardiac pacing
(TCP) will be necessary. IV fluid boluses are not indicated at this point becaus
e there is no evidence of hypovolemia.
Answer is A
==== 51/121 cardiology
You and your team are attempting to resuscitate a 66-year-old man in cardiac arr
est. The cardiac monitor reveals a slow, wide-complex rhythm. The patient has be
en successfully intubated and an IV line has been established. As CPR is ongoing
, you should:
A: ventilate the patient at a rate of 24 breaths/min.
B: administer 10 mL of epinephrine 1:10,000 IV.
C: attempt transcutaneous pacing to increase the heart rate.
D: give 40 units of vasopressin every 3 to 5 minutes.
Reason:
The first drug given to any patient in cardiac arrest is epinephrine in a dose o
f 1 mg (10 mL of a 1:10,000 solution) via the IV or IO route. This dose should b
e repeated every 3 to 5 minutes. Alternatively, a one-time dose of vasopressin (
40 units) can be given to replace the first or second dose of epinephrine, but n
ot both. Do NOT hyperventilate the patient as doing so increases intrathoracic p
ressure and can impair venous return (preload) and cardiac output, which would d
ecrease the effectiveness of chest compressions. After an advanced airway has be
en placed during cardiac arrest, deliver one breath every 6 to 8 seconds (8 to 1
0 breaths/min) and ensure that chest compressions are uninterrupted. There is pr
esently no evidence to support the efficacy of transcutaneous cardiac pacing (TC
P) in patients with bradycardic PEA or asystole.
Answer is B
==== 52/121 cardiology
A middle-aged man is found unresponsive, pulseless, and apneic. His cardiac arre
st was not witnessed, although his skin is still warm to the touch. You should:
A: assess his need for defibrillation.
B: insert an advanced airway device.
C: begin immediate high-quality CPR.
D: administer a precordial thump.
Reason:
The first and most crucial intervention for any patient in cardiac arrest is imm
ediate high-quality CPR. With CPR ongoing, you or your partner can apply the def
ibrillation pads and assess the patient's cardiac rhythm. If a shock is indicate
d, deliver it and immediately resume CPR, starting with chest compressions. Duri
ng the 2-minute cycles of CPR, vascular access can be obtained, cardiac drugs ca
n be administered, and the patient's airway can be secured with an advanced devi
ce if necessary. It is absolutely critical to minimize interruptions in chest co
mpressions; if you must interrupt compressions, do so for no longer than 10 seco
nds. The precordial thump is not indicated for unwitnessed cardiac arrest; it ma
y be considered for patients with witnessed V-Tach, however, but has a low succe
ss rate.
Answer is C
==== 53/121 cardiology
You are evaluating a regular cardiac rhythm in lead II. The rate is 90 beats/min
, the QRS complexes consistently measure 0.16 seconds, and inverted P waves are
seen immediately following each QRS complex. The rhythm described is MOST charac
teristic of a/an:
A: accelerated junctional rhythm with ventricular aberrancy.
B: wandering atrial pacemaker with a bundle branch block.
C: second-degree AV block with abnormal ventricular conduction.
D: ectopic atrial rhythm with a ventricular conduction delay.
Reason:
A junctional rhythm is characterized by inverted P waves in lead II. If seen, th
e inverted P waves precede or follow the QRS complex. At a rate of 90 beats/min,
the rhythm is further defined as an accelerated junctional rhythm. QRS complexe
s greater than 0.12 seconds (120 ms) indicate aberrant (abnormal) ventricular co
nduction (ie, bundle branch block). A wandering atrial pacemaker is characterize
d by P waves that precede each QRS complex, but vary in morphology. An ectopic a
trial rhythm is also characterized by P waves of varying morphologies as well as
varying PR intervals. A second- or third-degree AV block should be suspected wh
en there are more P waves than QRS complexes.
Answer is A
==== 54/121 cardiology
A 50-year-old woman is pulseless and apneic. Your partner and an emergency medic
al responder are performing well-coordinated CPR. After 2 minutes of CPR, the ca
rdiac monitor reveals coarse ventricular fibrillation. You should:
A: deliver a single shock and immediately resume CPR.
B: assess for a carotid pulse for no longer than 10 seconds.
C: defibrillate at once and then reassess the rhythm and pulse.
D: shock the patient three times with 360 monophasic joules.
Reason:
A single shock (360 monophasic joules or the biphasic equivalent) should be admi
nistered to the patient with V-Fib or pulseless V-Tach cardiac arrest. Immediate
ly following this single shock, begin or resume CPR, starting with chest compres
sions. Assessing the patients cardiac rhythm and pulse immediately following defi
brillation causes an unnecessary delay in CPR, and delays in CPR have been direc
tly linked to poor patient outcomes. Most patients who are defibrillatedespeciall
y if their arrest interval is prolongedremain in V-Fib/pulseless V-Tach or conver
t to another non-perfusing rhythm (ie, asystole, PEA). Either way, the patient i
s still in cardiac arrest and needs immediate CPR. After 2 minutes of CPR, reass
ess the patients rhythm, and if necessary, a pulse (if an organized cardiac rhyth
m appears), and repeat defibrillation (single shock) if indicated, followed imme
diately by CPR.
Answer is A
==== 55/121 cardiology
The appropriate second dose and method of administration of amiodarone for a pat
ient with refractory ventricular fibrillation is:
A: 300 mg given over 10 minutes.
B: 150 mg given over 10 minutes.
C: 150 mg via rapid IV/IO push.
D: 300 mg via rapid IV/IO push.
Reason:
The initial dose of amiodarone for a patient with refractory ventricular fibrill
ation or pulseless ventricular tachycardia is 300 mg via rapid IV or IO push. A
second dose of 150 mg via rapid IV or IO push may be repeated one time in 5 minu
tes. For supraventricular tachycardia or ventricular tachycardia with a pulse, a
miodarone should be given in a dose of 150 mg over 10 minutes; this same dose ma
y be repeated as needed.
Answer is C
==== 56/121 cardiology
Which of the following signs or symptoms occurs more commonly in patients with s
table angina than in those with unstable angina?
A: ST segment elevation on the 12-lead ECG
B: Chest pain that begins during exertion
C: Chest pressure, tightness, or discomfort
D: Pain that lasts more than 15 minutes
Reason:
Angina pectoris occurs when the heart's demand for oxygen exceeds it's available
supply (ischemia) and is a sign of coronary artery disease (CAD). Angina is cla
ssified as being stable or unstable. Stable angina typically follows a predictab
le pattern (ie, chest pain, pressure, or discomfort induced by exertion), lasts
less than 15 minutes, and is usually relieved with rest and/or nitroglycerin. Wh
ile unstable angina (preinfarction angina) can also occur during exertion, it mo
re commonly occurs when the patient otherwise would not expect it to, such as wh
en he or she is asleep or is otherwise resting. Furthermore, unstable angina is
often not relieved by rest and/or nitroglycerin and typically lasts longer than
15 minutes. Chest pressure, tightness, or discomfort occurs in patients with bot
h stable and unstable angina. If a patient is experiencing angina, you would exp
ect to see ST segment depression and/or T wave inversion on the 12-lead ECG as t
hese are indicators of myocardial ischemia. ST segment elevation indicates myoca
rdial injury (eg, acute MI in progress).
Answer is B
==== 57/121 cardiology
A 145-pound man requires a dopamine infusion at 15 g/kg/min for severe hypotensio
n. You have a premixed bag containing 800 mg of dopamine in 500 mL of normal sal
ine. If you are using a microdrip administration set (60 gtts/mL), how many drop
s per minute should you deliver to achieve the required dose?
A: 30
B: 48
C: 42
D: 36
Reason:
First, convert the patient's weight from pounds to kilograms: 145 2.2 = 66 kg. N
ext, determine the desired dose: 15 g/kg/min 66 kg = 990 g/min. The next step is t
o determine the concentration of dopamine on hand: 800 mg 500 mL = 1.6 mg/mL (1,
600 g/mL [1.6 1,000 = 1,600]). Now, you must determine the number of mL to be del
ivered per minute: 990 g/min [desired dose] 1,600 g/mL [concentration on hand] = 0
.6 mL/min. The final step is to determine the number of drops per minute that yo
u must set your IV flow rate at: 0.6 mL/min 60 gtts/mL (drop factor of the micro
drip) 1 (total infusion time in minutes) = 36 gtts/min.
Answer is D
==== 58/121 cardiology
You are transporting a 60-year-old woman with chest discomfort and diaphoresis.
The 12-lead ECG indicates an acute anterior wall MI. The patient is receiving ox
ygen and an IV has been established. You have administered 324 mg of aspirin, 3
sublingual nitroglycerin, and 5 mg of morphine. Which of the following should co
ncern you the MOST during transport?
A: Severe hypotension
B: Completely relieving her pain
C: An acute cardiac dysrhythmia
D: Respiratory depression
Reason:
More than 500,000 deaths occur each year as the result of acute myocardial infar
ction (AMI). Sixty to seventy percent of these deaths occur outside the hospital
, usually during the first few hours after the onset of symptoms. Of all deaths
from AMI, 90% are due to dysrhythmiasusually ventricular fibrillationwhich typical
ly occur during the early hours of the infarct; this should be your primary conc
ern. Many patients experiencing an anterior wall MI are hyperdynamicthat is, they
are hypertensive and tachycardic; hypotension is not as common. Depression of t
he CNS (respiratory depression, bradycardia, and hypotension) should be a concer
n any time you administer a narcotic analgesic (ie, morphine); however, most pat
ients do not experience significant CNS depression with 5 mg of morphine. Pain r
elief is an important aspect in the management of the patient with AMI; minimizi
ng pain minimizes anxiety, which can limit the size of the infarct.
Answer is C
==== 59/121 cardiology
The initial dose of diltiazem for a 165-pound patient is approximately:
A: 25 mg.
B: 17 mg.
C: 22 mg.
D: 19 mg.
Reason:
Diltiazem hydrochloride (Cardizem) is a calcium channel blocking drug that is us
ed to treat rapid ventricular rates associated with atrial fibrillation or atria
l flutter. It can also be used after adenosine to treat refractory reentry supra
ventricular tachycardia in hemodynamically stable patients. The initial dose of
diltiazem is 0.25 mg/kg IV over 2 minutes; the average initial dose is 15 to 20
mg. It may be repeated in 15 minutes in a dose of 0.35 mg/kg IV over 2 minutes;
the average second dose is 20 to 25 mg. A 165-pound patient weighs 75 kg. Theref
ore, the initial dose of diltiazem for a patient of this weight would be 18.75 m
g (approximately 19 mg), and the second dose would be 26.25 mg (approximately 26
mg).
Answer is D
==== 60/121 cardiology
When assessing lead II in a patient with a heart rate of 70 beats/min, the Q-T i
nterval is considered prolonged if it is:
A: twice the width of the QRS complex.
B: three times the length of the P-R interval.
C: greater than one half of the R-R interval.
D: consistently greater than 0.20 seconds.
Reason:
The Q-T interval represents the time from the beginning of ventricular depolariz
ation to the end of ventricular repolarization, and is measured from the start o
f the QRS complex to the end of the T wave. In a patient with a heart rate betwe
en 60 and 100 beats/min, the Q-T interval in lead II is considered to be prolong
ed if it is greater than one half the distance between any two R waves (R-R inte
rval). If the Q-T interval is prolonged, the patient is at increased risk for de
veloping a lethal dysrhythmia; an electrical impulse may fire during the relativ
e refractory period (downslope of the T-wave), resulting in monomorphic or polym
orphic ventricular tachycardia (with or without a pulse) or ventricular fibrilla
tion. If lead II suggests Q-T prolongation, a 12-lead ECG should be obtained to
quantify this finding. In a normocardic patient (heart rate of 60 to 100 beats/m
in), the corrected Q-T interval (QTc) should range between 0.36 and 0.44 seconds
(360 to 440 milliseconds) on the 12-lead ECG. The Q-T interval is corrected bas
ed on the patients heart rate. The faster the heart rate, the narrower the Q-T in
terval; the slower the heart rate, the wider the Q-T interval.
Answer is C
==== 61/121 cardiology
You are treating a patient with ventricular fibrillation. As the defibrillator i
s charging, you should:
A: ask your partner to ventilate the patient at 20 breaths/min.
B: ensure that CPR is continuing until the defibrillator is charged.
C: visually confirm that nobody is touching the patient.
D: check the defibrillator to ensure the synchronizer is activated.
Reason
A major emphasis is placed on minimizing interruptions in CPR. Evidence has show
n that even a brief pause in chest compressions can result in a significant decr
ease in coronary and cerebral perfusion. Therefore, CPR should be continuingeven
as the defibrillator is charging. When the defibrillator is charged, ensure (vis
ually and verbally) that nobody is touching the patient, and then deliver the sh
ock. When defibrillating a patient with V-Fib, you must ensure that the synchron
izer is off; the synchronizer will not be able to identify an R wave in V-Fib du
e to the chaotic nature of the dysrhythmia. Cardiac arrest patients (adults, chi
ldren, and infants) should be ventilated at a rate of 8 to 10 breaths/min after
an advanced airway device has been placed (eg, ET tube, multilumen airway, supra
glottic airway). Excessive ventilation rates should be avoided; they cause incre
ased intrathoracic pressure, which may impair venous return and cardiac output.
Answer is B
==== 62/121 cardiology
When administering epinephrine to a patient in cardiac arrest, the MAIN desired
effect is:
A: bronchodilation, which facilitates positive-pressure ventilation.
B: beta-1 receptor stimulation, which increases cardiac contractility.
C: vasoconstriction, which improves coronary and cerebral perfusion.
D: coronary artery dilation, which decreases the myocardial workload.
Reason:
Epinephrine stimulates alpha and beta receptors. However, it is used during card
iac arrest because of its vasopressor effects that result from stimulation of al
pha-1 receptors. In conjunction with high-quality CPR, epinephrines vasoconstrict
ive effects improve coronary and cerebral perfusion, thus keeping these organs v
iable until the underlying cardiac dysrhythmia can be terminated.
Answer is C
==== 63/121 cardiology
Which of the following represents the correct adult dosing regimen for adenosine
?
A: 6 mg, followed by 12 mg in 2 minutes if needed
B: 12 mg, followed by 12 mg in 2 minutes if needed
C: 36 mg, divided in 12 mg increments 2 minutes apart
D: 6 mg, followed by 6 mg in 2 minutes if needed
Reason
According to the 2010 guidelines for CPR and emergency cardiac care (ECC), the c
orrect dosing regimen of adenosine for a hemodynamically stable patient with a n
arrow-complex tachycardia is 6 mg via rapid (over 1 to 3 seconds) IV push. If ne
eded, adenosine can be repeated in 1 to 2 minutes in a dose of 12 mg rapid IV pu
sh.
Answer is A
==== 64/121 cardiology
Which of the following causes of pulseless electrical activity (PEA) would be th
e MOST likely to respond to immediate treatment in the prehospital setting?
A: Drug overdose
B: Hypovolemia
C: Hypokalemia
D: Lactic acidosis
Reason
Hypovolemia is the most easily correctable cause of PEA, provided that immediate
treatment is given in the prehospital setting. In addition to CPR, airway manag
ement, and epinephrine, fluid boluses are repeatedly given, followed by a reasse
ssment of the patients condition. Remember, myocardial contraction is dependent o
n electricity and pressure. This pressure is caused as blood fills the heart. If
there is no blood, the heart will not pump, even though electrical activity con
tinues. Drug overdose is the underlying cause of asystole that would most likely
respond to immediate prehospital treatment, especially in younger patients. Hyp
okalemia is treated with potassium chloride, which is not administered in the pr
ehospital setting. Lactic acidosis is treated with effective ventilation first,
and then sodium bicarbonate if local protocol permits. While sodium bicarbonate
can be given in the prehospital setting, paramedics do not have the ability to q
uantify the pH or bicarbonate level of the patient's blood; this requires arteri
al blood gas analysis.
Answer is B
==== 65/121 cardiology
In which of the following situations is transcutaneous cardiac pacing (TCP) clea
rly indicated?
A: Third-degree AV block in a patient with pulmonary edema.
B: First-degree AV block in a patient with abdominal pain.
C: Asystole, but only after 10 minutes of adequate CPR.
D: Pulseless electrical activity at a rate of 50 beats/min.
Reason
Because third-degree AV block (complete heart block)an inherently slow cardiac dy
srhythmiarepresents total atrioventricular dissociation, it is associated with he
modynamic compromise in most cases and should be treated with immediate transcut
aneous cardiac pacing (TCP). Signs of hemodynamic compromise include ongoing che
st pain, pulmonary edema, decreased level of consciousness, shortness of breath,
and hypotension. First-degree AV block is typically a benign rhythm and is not
commonly associated with hemodynamic compromise. Evidence has shown TCP to be of
little or no benefit to patients with PEA or asystole, and it is clearly of no
benefit to patients with prolonged asystole.
Answer is A
==== 66/121 cardiology
When obtaining a 12-lead ECG, lead V1 should be placed:
A: in the second intercostal space just inferior to the second rib.
B: on the upper right shoulder just above the clavicle.
C: in the fourth intercostal space just to the right of the sternum.
D: approximately 1 inch to the right of the angle of Louis.
Reason
Correct lead placement is critical in obtaining an accurate 12-lead ECG tracing.
Lead V1the first precordial (chest) leadis placed in the fourth intercostal space
, just to the right of the sternum. Lead V2 is placed in the fourth intercostal
space, just to the left of the sternum.
Answer is C
==== 67/121 cardiology
A 54-year-old man presents with chest pressure, confusion, and profuse diaphores
is. As your partner administers supplemental oxygen, you apply the cardiac monit
or. In lead II, you observe a wide QRS complex rhythm with dissociated P waves a
nd a ventricular rate of 35 beats/min. You should:
A: start an IV and give 0.5 mg of atropine.
B: immediately obtain a 12-lead ECG.
C: begin transcutaneous pacing at once.
D: obtain a complete set of vital signs.
Reason:
The patient in this scenario is in a third-degree (complete) AV block, which is
causing his signs and symptoms. Complete heart block should be treated with imme
diate transcutaneous cardiac pacing (TCP). Given the patients clinical presentati
on, it is clear that he is hemodynamically unstable; obtaining a complete set of
vital signs will yield very little, if any, additional information. A 12-lead E
CG should be obtained, but not before addressing the most immediate problem of h
emodynamic compromise. Atropine should be avoided in patients with high-grade AV
heart blocks (eg, second-degree AV block type II and third-degree AV block). At
ropine may worsen the patients conditionespecially in cases of third-degree AV blo
ckby increasing sinus node discharge without any effect on the ventricles. Rememb
er, if the rhythm is perfusing, but is slow and wide, begin TCP without delay.
Answer is C
==== 68/121 cardiology
If a patient was experiencing acute injury involving the interventricular septum
and anterior wall of the left ventricle, you would expect the 12-lead ECG to re
veal:
A: ST segment elevation in leads V5, V6, I, and aVL.
B: Inverted T waves in all of the precordial leads.
C: ST segment elevation in leads V1 through V4.
D: ST segment depression in leads II, III, and aVF.
Reason:
ST segment elevation that is equal to or greater than 1-mm in two or more contig
uous leads indicates myocardial injury (eg, an acute MI in progress). ST segment
depression and/or dynamic T wave inversion indicates myocardial ischemia. Leads
V1 and V2 view the interventricular septum; leads V3 and V4 view the anterior w
all of the left ventricle; leads V5, V6, I, and aVL view the lateral wall of the
left ventricle; and leads II, III, and aVF view the inferior wall of the left v
entricle. Therefore, if a patient is experiencing acute injury involving the int
erventricular septum and anterior wall of the left ventricle (anteroseptal injur
y), you would expect the 12-lead ECG tracing to reveal ST segment elevation is l
eads V1 through V4. It is important to note, however, that an absence of ST elev
ation does not definitively rule out acute myocardial infarction.
Answer is C
==== 69/121 cardiology
A patients medication regimen includes fluoxetine, Toprol, Proscar, lansoprazole,
and Klonopin. Which of these medications is used to treat cardiovascular disord
ers?
A: Toprol
B: fluoxetine
C: lansoprazole
D: Proscar
Reason:
Toprol (metaprolol) is a commonly prescribed beta-blocker used to treat various
cardiovascular conditions, including hypertension and tachydysrhythmias. Proscar
(finasteride) is used to treat benign prostatic hyperplasia (BPH). Fluoxetine (
Prozac) is a selective serotonin reuptake inhibitor (SSRI) antidepressant. It is
used to treat conditions such as depression, generalized anxiety disorder, and
obsessive-compulsive disorder (OCD). Lansoprazole (Prevacid)a proton pump inhibit
oris used to treat conditions such as heartburn, acid reflux disease, and ulcers.
Clonazepam (Klonopin) is a benzodiazepine sedative-hypnotic; it is used to trea
t anxiety.
Answer is A
==== 70/121 cardiology
In addition to CPR, the recommended treatment sequence for an unresponsive, apne
ic, and pulseless patient with a regular, wide-complex cardiac rhythm at a rate
of 40 beats/min includes:
A: 40 units of vasopressin every 10 minutes and treating reversible causes.
B: 1 mg of epinephrine every 3 to 5 minutes and 1 gram of calcium chloride.
C: 1 mg of epinephrine every 3 to 5 minutes and treating reversible causes.
D: transcutaneous cardiac pacing and 1 mg of epinephrine every 3 to 5 minutes.
Reason:
Pulseless electrical activity (PEA) exists when an unresponsive, apneic, pulsele
ss patient presents with a regular cardiac rhythm. Treatment for PEA includes im
mediate high-quality CPR with minimal interruptions, obtaining vascular access (
IV or IO), 1 mg of epinephrine every 3 to 5 minutes, advanced airway management
(ie, ET tube, multilumen or supraglottic airway), and assessing for and treating
reversible causes (Hs and Ts). Vasopressin, in a one-time dose of 40 units, can
be given to replace the first or second dose of epinephrine, but not both. Ther
e are insufficient data to recommend transcutaneous pacing (TCP) for patients wi
th bradycardic PEA or asystole, and the routine use of calcium chloride during c
ardiac arrest is not recommended.
Answer is C
==== 71/121 cardiology
You are transporting a 44-year-old man with shortness of breath. He is conscious
alert and is receiving supplemental oxygen. A patent IV line has been establish
ed. Suddenly, he develops the rhythm shown below. He is now responsive to pain o
nly; is profusely diaphoretic; and has weak radial pulses. You should:
(VTACH)
A: give 6 mg of adenosine rapid IV push and reassess.
B: give 150 mg of amiodarone IV over 10 minutes.
C: perform synchronized cardioversion with 100 joules.
D: assess his BP to determine if he is clinically unstable.
Reason:
The patient is in monomorphic ventricular tachycardia with a pulse. He is clinic
ally unstable, as evidenced by his decreased level of consciousness, profuse dia
phoresis, and weak radial pulses. Assessing his BP will yield little additional
information; therefore, you should perform synchronized cardioversion with 100 j
oules. Consider sedating the patient, but do not delay cardioversion. Amiodarone
, 150 mg IV over 10 minutes, would be an appropriate intervention if the patient
was clinically stable. Adenosine is used for clinically stable patients with na
rrow-complex tachycardias and can be considered for clinically stable patients w
ith wide-complex monomorphic tachycardias.
Answer is C
==== 72/121 cardiology
After performing synchronized cardioversion on an unstable patient with a wide-c
omplex tachycardia, you look at the monitor and see coarse ventricular fibrillat
ion. The patient is unresponsive, apneic, and pulseless. You should:
A: perform CPR for 2 minutes and then cardiovert with 100 joules.
B: prepare to intubate the patient as your partner begins CPR.
C: begin CPR, establish vascular access, and give amiodarone.
D: start CPR, ensure the synchronize mode is off, and defibrillate.
Reason:
If a patient develops ventricular fibrillation (V-Fib) or pulseless ventricular
tachycardia (V-Tach) following synchronized cardioversion, immediately begin CPR
(even if it's just for a short period of time), ensure that the monitor/defibri
llator is not in synchronize mode, and defibrillate as soon as possible. CPR sho
uld be ongoing as the defibrillator is charging in order to avoid unnecessary de
lays in performing chest compressions. The synchronize mode must be turned off
prior to defibrillation or the device will not deliver a shock; this is because
there are no R waves to synchronize with in V-Fib. Vascular access (IV or IO), a
dvanced airway management, and pharmacologic therapy should be performed during
the 2-minute cycles of CPR; they are not an immediate priority during early card
iac arrest.
Answe is D
==== 73/121 cardiology
Unlike a second-degree AV block type I, a second-degree AV block type II is char
acterized by:
A: consistent P-R intervals following conducted P waves.
B: a progressive lengthening of the P-R interval.
C: dissociation of the P waves and QRS complexes.
D: a ventricular rate that is less than 50 beats/min.
Reason:
A second-degree AV block Mobitz Type II (classic second-degree AV block) is char
acterized by more P waves than QRS complexes. However, the P-R intervals of the
conducted complexes (P waves that are followed by a QRS complex)whether shortened
, normal, or prolongedare consistent. By contrast, a second-degree AV block Mobit
z Type I (Wenkebach) is characterized by a progressive lengthening of the P-R in
terval until a P wave is blocked (not followed by a QRS complex). The ventricula
r rate of a second-degree AV block may be normal or slow. Dissociation of the P
waves and QRS complexes is characteristic of a third-degree (complete) AV block.
Answer is A
==== 74/121 cardiology
A 49-year-old male complains of generalized weakness that began about a week ago
. He is conscious and alert and is breathing adequately. His blood pressure is 1
38/78 mm Hg, pulse is 130 beats/min and irregular, and respirations are 14 breat
hs/min. You administer supplemental oxygen and apply the cardiac monitor, which
reveals atrial fibrillation; a 12-lead ECG tracing reveals the same. The patient
denies any significant medical problems and takes no medications. After establi
shing IV access, you should:
A: administer 0.25 mg/kg of diltiazem and transport for evaluation.
B: give 150 mg of amiodarone over 10 minutes and transport.
C: attempt vagal maneuvers and then give 6 mg of adenosine IV push.
D: sedate with midazolam and perform synchronized cardioversion.
Reason:
In the absence of any significant medical history, this patients weakness probabl
y signaled the onset of his atrial fibrillation (A-Fib). New-onset A-Fib of grea
ter than 48 hours duration should not be treated with synchronized cardioversion
until the patient is adequately anticoagulated first (ie, Coumadin). Blood can s
tagnate in the fibrillating atria, which increases the risk of clot formation; c
ardioversion may dislodge these clots, resulting in a stroke, pulmonary embolism
, or myocardial infarction. Furthermore, this patient is hemodynamically stable
and is not in need of electrical therapy. Appropriate treatment for a patient wi
th A-Fib or atrial flutter (A-Flutter) with a rapid ventricular rate (RVR) invol
ves controlling the ventricular rate with a calcium-channel blocker. Diltiazem (
Cardizem) is the most common drug used for this purpose. The initial dose is 0.2
5 mg/kg, which may be repeated in 15 minutes in a dose of 0.35 mg/kg. Amiodarone
may be used to terminate new-onset A-Fib or A-Flutter, but is uncommonly given
for this purpose in the prehospital setting. Vagal maneuvers and adenosine are i
ndicated for narrow-complex tachycardias in an attempt to slow the ventricular r
ate so you can identify the underlying rhythm. You have already identified this
patients rhythm.
Answer is A
==== 75/121 cardiology
You are assessing a man with a acute chest pain. As you are inquiring about the
quality of his pain, he clenches his fist. This is called __________ sign and no
nverbally conveys a feeling of:
A: Cullens, dullness.
B: Grey-Turners, fluttering.
C: Levines, pressure.
D: Becks, impending doom.
Reason:
Patients with an acute coronary syndrome (ACS)that is, unstable angina or acute m
yocardial infarctionoften clench their fist when describing the quality of their
chest pain or discomfort. This is called Levines sign, and it conveys a feeling o
f pressure in the chest. The pain associated with ACS may also be described as a
dull or aching sensation or as a feeling of heaviness. An ACS patient who compl
ains of fluttering in the chest should make you suspicious for a cardiac dysrhyt
hmia (ie, SVT, V-Tach). Cullens sign is characterized by periumbilical bruising a
nd indicates blood in the peritoneal space. Grey-Turners signbruising to the flank
areaalso indicates blood in the peritoneal space. Beck's triad is a trio of clin
ical findings that indicates a cardiac tamponade; it includes jugular venous dis
tention, muffled or distant heart sounds, and a narrowing pulse pressure.
Answer is C
==== 76/121 cardiology
A 60-year-old man presents with chest discomfort, diaphoresis, and dyspnea. The
12-lead ECG reveals 4-mm ST segment elevation in leads V1 through V4. You should
suspect:
A: inferoseptal ischemia.
B: anteroseptal injury.
C: anterolateral infarct.
D: anterolateral injury.
Reason
The precordial (chest) leads view the following aspects of the heart: V1 and V2,
interventricular septum; V3 and V4, anterior wall; V5 and V6, lateral wall. ST
segment depression and/or T wave inversion in two or more contiguous leads indic
ates ischemia. ST segment that is equal to or greater than 1-mm in two or more c
ontiguous leads indicates injury. A developing Q wave may be seen in conjunction
with ST segment elevation associated with myocardial injury. Therefore, 4-mm ST
segment elevation in leads V1 through V4 indicates an anteroseptal injury patte
rn (acute MI in progress). Infarcted (dead [necrotic]) myocardium is characteriz
ed by poor R wave progression in the precordial leads and/or the presence of a p
athologic Q wave in two or more contiguous leads. By definition, a pathologic Q
wave is wider than 0.04 seconds (40 ms) or deeper than one third the height of t
he R wave that follows it.
Answer is B
==== 77/121 cardiology
In the context of an acute coronary syndrome, the presence of dyspnea should mak
e you MOST suspicious for:
A: cor pulmonale.
B: severe anxiety.
C: pulmonary congestion.
D: diffuse bronchospasm.
Reason:
Dyspnea that occurs in the context of an acute coronary syndrome (ACS)that is, un
stable angina or acute myocardial infarctionshould be assumed to be the result of
left side congestive heart failure with resultant pulmonary congestion/edema. T
he majority of myocardial infarctions involve the left ventricle. The damage may
be so extensive that myocardial contractility is impaired and blood backs up in
to the lungs. Cor pulmonaleacute right heart failure secondary to pulmonary hyper
tensiontypically presents with systemic venous congestion (ie, JVD, peripheral ed
ema), not pulmonary congestion. Anxiety is very common with ACS, and can potenti
ally exacerbate the patients condition due to increases in myocardial oxygen cons
umption and demand. In the interest of the patient, however, assume that any com
plaint of dyspnea in conjunction with ACS is the result of the worst case scenar
iopulmonary edema and impaired oxygenation.
Answer is C
==== 78/121 cardiology
A 59-year-old male with a monomorphic wide-complex tachycardia at a rate of 220/
min, a blood pressure of 80/50 mm Hg, and a decreased level of consciousness, sh
ould be treated with:
A: 2 g of magnesium sulfate.
B: 150 mg of amiodarone IV.
C: monophasic defibrillation.
D: synchronized cardioversion.
Reason:
The patient in this scenario is likely in ventricular tachycardia (V-Tach). Appr
oximately 90% of wide-complex tachycardias are ventricular in origin. Furthermor
e, he is hypotensive and has a decreased level of consciousnesssigns of hemodynam
ic compromise. To prevent his condition from deteriorating further, immediate sy
nchronized cardioversion, starting with 100 joules, is indicated. Monophasic (or
biphasic equivalent) defibrillation is indicated for patients with pulseless V-
Tach and ventricular fibrillation (V-Fib). Amiodarone (150 mg over 10 minutes) i
s indicated for patients with V-Tach who have a pulse, but are hemodynamically s
table; it may also be used as an adjunct for patients with unstable V-Tach when
cardioversion alone is not effective. Magnesium sulfate (1 to 2 g) is indicated
for patients with torsade de pointesa variant of polymorphic V-Tach.
Answer is D
==== 79/121 cardiology
Where is the point of maximal impulse (PMI) located in most people?
A: Left anterior chest, in the midclavicular line, at the fifth intercostal spac
e
B: Directly over the sternum, approximately 1 to the left of the angle of Louis
C: Left anterolateral chest, in the midaxillary line, at the fifth intercostal s
pace
D: Left anterior chest, on the left sternal border, at the fourth intercostal sp
ace
Reason:
On visualization of the chest, you may be able to see the apical thrust, or poin
t of maximal impulse (PMI). The PMI is normally located on the left anterior par
t of the chest, in the midclavicular line, at the fifth intercostal space. This
thrust occurs when the apex of the heart rotates forward during systole, gently
beating against the chest wall and producing a visible pulsation.
Answer is A
==== 80/121 cardiology
A 35-year-old female experienced a syncopal episode shortly after complaining of
palpitations. She was reportedly unconscious for less than 10 seconds. Upon you
r arrival, she is conscious and alert, denies any injuries, and states that she
feels fine. She further denies any significant medical history. Her vital signs
are stable and the cardiac monitor reveals a sinus rhythm with frequent prematur
e atrial complexes. On the basis of this information, what MOST likely caused he
r syncopal episode?
A: Paroxysmal supraventricular tachycardia
B: Aberrant conduction through the ventricles
C: A sudden increase in cardiac output
D: A brief episode of ventricular tachycardia
Reason:
Syncope (fainting) of cardiac origin is caused by a sudden decrease in cerebral
perfusion secondary to a decrease in cardiac output. This is usually the result
of an acute bradydysrhythmia or tachydysrhythmia. In this particular patient, th
e presence of frequent premature atrial complexes (PACs), which indicates atrial
irritability, suggests paroxysmal supraventricular tachycardia (PSVT) as the un
derlying dysrhythmia that caused her syncopal episode. In PSVT, the heart is bea
ting so fast that ventricular filling and cardiac output decrease, which results
in a transient decrease in cerebral perfusion. Not all patients with PSVT exper
ience syncope. Many experience an acute onset of palpitations and/or lightheaded
ness that spontaneously resolves.
Answer is A
==== 81/121 cardiology
A 27-year-old female complains of palpitations. The cardiac monitor reveals a na
rrow-complex tachycardia at 180/min. She denies any other symptoms, and states t
hat this has happened to her before, but it typically resolves on its own. Her b
lood pressure is 126/66 mm Hg, pulse is 180 beats/min, and respirations are 16 b
reaths/min. After attempting vagal maneuvers and giving two doses of adenosine,
her cardiac rhythm and vital signs remain unchanged. You should:
A: administer 0.35 mg/kg of diltiazem over 2 minutes and then reassess her hemod
ynamic status.
B: administer 5 mg of midazolam and perform synchronized cardioversion starting
with 50 joules.
C: infuse 150 mg of amiodarone over 10 minutes, reassess her, and repeat the ami
odarone if needed.
D: transport at once, reassess her frequently, and perform synchronized cardiove
rsion if necessary.
Reason:
Although the patient is in supraventricular tachycardia (SVT), she remains stabl
e following your initial efforts to slow her heart rate with vagal maneuvers and
adenosine. Her failure to respond to initial treatment does not automatically m
ake her unstable. Simply transport her, closely monitor her en route, and be pre
pared to cardiovert her if she does become unstable (ie, hypotension, altered me
ntal status, chest pain). Unless specified in your local protocols, pharmacologi
c therapy beyond adenosine (ie, calcium channel blockers, amiodarone) is typical
ly not indicated in the field for stable patients with SVT, although these medic
ations may be given in the emergency department. However, if your protocols or m
edical control call for the administration of diltiazem (Cardizem), the initial
dose is 0.25 mg/kg.
Answer is D
==== 82/121 cardiology
Which of the following clinical presentations is MOST consistent with an acute i
schemic stroke involving the left cerebral hemisphere?
A: Decerebrate posturing, asymmetric pupils, hypertension, bradycardia
B: Aphasia, lethargy, right side hemiparalysis, right side facial droop
C: Dysarthria, confusion, right side hemiparesis, left side facial droop
D: Dysphasia, confusion, left side hemiparesis, right side facial droop
Reason:
Acute ischemic strokes represent approximately 75% of all strokes. Each cerebral
hemisphere controls functions on the contralateral (opposite) side of the body;
therefore, sensory and motor deficits (ie, hemiparesis, hemiparalysis) are obse
rved on the side of the body opposite the stroke. However, because the facial ne
rves do not decussate (cross as they leave the cerebral cortex, move through the
brainstem, and arrive at the spinal cord), facial droop is typically observed o
n the ipsilateral (same) side as the stroke. Pupillary changes, if present, will
also occur on the same side as the stroke because of optic nerve crossover in t
he brain. Other common signs of acute ischemic stroke include dysarthria (slurre
d speech), dysphasia (difficulty speaking or understanding), aphasia (inability
to speak or understand), and mental status changes. In contrast to acute ischemi
c stroke, acute hemorrhagic stroke (caused by a ruptured cerebral artery) typica
lly presents with more ominous signs, which include a sudden, severe headache th
at is followed by a rapid decline in level of consciousness. Because bleeding is
occurring within the brain, intracranial pressure increases, resulting in signs
such as decorticate (flexor) or decerebrate (extensor) posturing, asymmetric or
bilaterally dilated pupils, and Cushings triad (hypertension, bradycardia, abnor
mal respiratory pattern).
Answer is C
==== 83/121 cardiology
A 70-year-old man presents with an acute onset of confusion, slurred speech, and
left side weakness. According to his daughter, he has high blood pressure and h
as had several "small strokes" over the past 6 months. Your partner applies supp
lemental oxygen; assesses his vital signs, which are stable; and assesses his bl
ood glucose level, which reads 35 mg/dL. You attempt to perform the Cincinnati P
rehospital Stroke test, but the patient is unable to understand your instruction
s. After establishing IV access, you should:
A: administer 50% dextrose, monitor his cardiac rhythm, protect his impaired ext
remities, and transport.
B: administer oral glucose, place him in a semi-sitting position, monitor his ca
rdiac rhythm, and transport.
C: monitor his cardiac rhythm, withhold glucose in case he is having a hemorrhag
ic stroke, and transport.
D: give 324 mg of baby aspirin, place him in a supine position, monitor his card
iac rhythm, and transport.
Reason:
This patients clinical presentation and his history of hypertension and transient
ischemic attacks (TIAs) suggest acute ischemic stroke. However, his blood gluco
se level (BGL) is significantly low and must be treated. Untreated hypoglycemia
may cause irreversible brain damage or death. Appropriate treatment for this pat
ient involves administering 50% dextrose (consider giving 12.5 g) and then reass
essing his BGL to determine the need for additional glucose. Because the patient
is confused, and because some patients with acute ischemic stroke lose protecti
ve airway reflexes, oral glucose should be avoided. He may not be able to swallo
w it, which may result in aspiration. Further treatment includes protecting his
impaired extremities from injury, monitoring his cardiac rhythm, and transportin
g him to the hospital. Notify the receiving facility early. Aspirin should be av
oided in the prehospital setting for patients with signs and symptoms of a strok
e. A CT scan of the head must be performed first to rule out intracranial hemorr
hage.
Answer is A
==== 84/121 cardiology
Cardioversion involves delivering a shock that is synchronized to occur during t
he:
A: R wave.
B: P wave.
C: upslope of the T wave.
D: downslope of the T wave.
Reason:
Cardioversion involves delivering a shock that is synchronized to occur during t
he R wave, which is when the heart is absolutely refractory. This prevents the s
hock from occurring during the relative refractory period (the downslope of the
T wave). Depolarization that occurs during the relative refractory period may in
duce a non-perfusing ventricular dysrhythmia, such as pulseless V-Tach or V-Fib.
Synchronized cardioversion is indicated for patients with supraventricular or v
entricular tachycardia who have a pulse, but are hemodynamically unstable.
Answer is A
==== 85/121 cardiology *REPEAT*
In contrast to unstable angina, stable angina occurs when a patient:
A: needs more than two nitroglycerin treatments to relieve his or her chest pain
.
B: experiences chest discomfort after a certain, predictable amount of exertion.

C: complains of chest pain at the same time of the day for more than 2 weeks.
D: presents with chest pain or discomfort during periods of low oxygen demand.
Reason:
Angina pectoris is a sign of coronary artery disease (CAD), and is the result of
an imbalance in myocardial oxygen supply and demand. Stable angina occurs when
the patient experiences chest pain or discomfort after a certain, predictable am
ount of exertion. Furthermore, the patient with stable angina typically knows wh
at actions to take to relieve the pain (ie, rest, nitroglycerin). By contrast, u
nstable angina is characterized by noticeable changes in the frequency, severity
, and degree of chest pain or discomfort. The patient experiences symptoms, whic
h are often not relieved with rest and/or nitroglycerin, when myocardial oxygen
demand is otherwise low (ie, sleep, rest). Unstable angina indicates advanced CA
D; it is commonly referred to as preinfarction angina.
Answer is B
==== 86/121 cardiology
In older adults, an S3 heart sound:
A: indicates mitral valve closure.
B: is generally very pronounced.
C: signifies moderate heart failure.
D: is considered a normal variant.
Reason:
The S3 or third heart sound is a soft, low-pitched sound that is caused by vibra
tions of the ventricular walls, resulting from the rapid filling period of the v
entricle during the beginning of diastole. An S3 sound should occur 120 to 170 m
illiseconds after S2, if it is heard at all. An S3 sound may be a normal clinica
l finding in children and young adults, although a cardiac evaluation should be
performed to determine this. When it is heard in older adults, however, it signi
fies moderate to severe heart failure. S1 is heard near the beginning of ventric
ular contraction (systole), when the tricuspid and mitral valves close. S2 is he
ard near the beginning of ventricular relaxation (diastole), when the pulmonic a
nd aortic valves close.
Answer is C
==== 87/121 cardiology
You respond to a residence for a 68-year-old male with nausea, vomiting, and blu
rred vision. As you are assessing him, he tells you that he has congestive heart
failure and atrial fibrillation, and takes numerous medications. The cardiac mo
nitor reveals atrial fibrillation with a ventricular rate of 50 beats/min. Which
of the following medications is MOST likely responsible for this patient's clin
ical presentation?
A: Vasotec
B: Furosemide
C: Digoxin
D: Warfarin
Reason:
This patient has classic signs of digitalis toxicity. Digoxin is commonly prescr
ibed to patients with congestive heart failure and atrial fibrillation (A-Fib) o
r atrial flutter (A-Flutter). Its positive inotropic effects increase cardiac co
ntractility and maintain cardiac output, while its negative chronotropic effects
control the ventricular rate of the A-Fib or A-Flutter. Digitalis preparations
(ie, Lanoxin, Digoxin) have a narrow therapeutic indexthat is, there is a fine li
ne between a therapeutic and toxic dose. You should suspect digitalis toxicity i
n any patient who takes Digoxin or Lanoxin and presents with complaints such as
nausea, vomiting, abdominal pain, anorexia, or blurred/yellow vision. Additional
ly, virtually any cardiac dysrhythmia can be caused by the toxic effects of digi
talis. Treatment involves the administration of Digibind, which is given at the
hospital.
Answer is C
==== 88/121 cardiology
What occurs at the beginning of ventricular contraction?
A: The pulmonic and aortic valves close and the tricuspid and mitral valves open
.
B: Increased ventricular pressure causes the ventricular walls to stretch.
C: Additional blood fills the ventricles secondary to atrial kick.
D: The atrioventricular valves close and the semilunar valves are forced open.
Reason:
As ventricular contraction begins, the atrioventricular valves (tricuspid and mi
tral) close and the semilunar valves (pulmonic and aortic) are forced open. As a
result, blood moves from the right ventricle through the pulmonary arteries and
from the left ventricle through the aorta and into the systemic circulation. Th
e majority of ventricular filling occurs by gravity. Atrial kick is the volume o
f blood that the atria contribute to ventricular filling; this occurs before ven
tricular contraction. Increased pressure within the myocardium (ie, increased bl
ood volume) causes stretching of the myocardial walls, thus increasing the force
of its contraction (Starling effect); this process precedes ventricular contrac
tion.
Answer is D

==== 89/121 cardiology
Ventricular ejection fraction is defined as the:
A: amount of blood pumped from either ventricle each minute.
B: amount of blood pumped out from either ventricle per contraction.
C: percentage of blood in the ventricle pumped out during a contraction.
D: volume of blood pumped into the left ventricle from the left atrium.
Reason:
Ejection fraction (EF) is the percentage of blood that is pumped from the ventri
cle per contraction. The total volume of blood pumped out of the ventricle per c
ontraction is called the stroke volume (SV). If the ventricle contains 100 mL of
blood before a contraction, but only ejects 55 mL when it contracts (SV), the e
jection fraction is 55% (100 mL 0.55 = 55 mL). Ejection fraction should be at le
ast 65% in the adult. Cardiac output (CO) is the volume of blood ejected from th
e left ventricle each minute, and is calculated by multiplying the stroke volume
by the heart rate; in the adult, this is typically 5 to 6 L/min.
Answer is C
==== 90/121 cardiology
Which of the following electrolytes moves slowly into the cardiac cell and maint
ains the depolarized state of the cell membrane?
A: Magnesium
B: Sodium
C: Potassium
D: Calcium
Reason:
The process of depolarization begins as sodium ions rush into the cell. At the s
ame time, calcium ions enter the cellalbeit more slowly and through specialized c
hannelsto help maintain the depolarized state of the cell membrane and to supply
calcium ions for contraction of cardiac muscle tissue. During repolarization, th
e sodium and calcium channels close, thus stopping the rapid influx of these ion
s. Then, special potassium channels open, allowing potassium ions to rapidly exi
t the cell. This helps restore the inside of the cell to its negative charge; th
e proper electrolyte distribution is then reestablished by pumping sodium ions o
ut of the cell and potassium ions back in. After the potassium channels close, t
he sodium-potassium pump helps move sodium and potassium ions back to their resp
ective locations. For every three sodium ions the pump moves out of the cell, it
moves two potassium ions into the cell, thereby maintaining the polarity of the
cell membrane
Answer is D
==== 91/121 cardiology
Which of the following ECG findings indicates a pathologic delay at the AV node?
A: P-R interval of 0.28 seconds
B: P waves of varying morphologies
C: P-R interval less than 0.12 seconds
D: QRS complex of 0.16 seconds
Reason:
Normally, there is a physiologic delay of an impulse at the AV node that allows
the atria to empty into the ventricles. On the ECG, this manifests as a P-R inte
rvalthe period of time that includes atrial depolarization and the delay at the A
V nodethat is between 0.12 and 0.20 seconds (120 to 200 ms). A pathologic delay a
t the AV node, such as what occurs with a first-degree AV block, would manifest
with a P-R interval that is greater than 0.12 seconds (120 ms) in duration. By c
ontrast, A P-R interval that is less than 0.12 seconds indicates that an impulse
is traversing the AV node too fast or is bypassing it altogether, such as what
occurs with Wolff-Parkinson-White (WPW) syndrome, a preexcitation syndrome in wh
ich the electrical impulse follows accessory pathways around the AV node (bundle
of Kent) and prematurely depolarizes the ventricles. A wide (> 0.12 seconds [1
20 ms]) QRS complex indicates an intraventricular conduction delay, such as a bu
ndle branch block. P waves that vary in morphology (appearance) indicate more th
an one atrial pacemaker site; an example of this is an ectopic atrial rhythm.
Answer is A
==== 92/121 cardiology
The main purpose of listening to heart sounds is to:
A: determine if the cardiac valves are functioning properly.
B: assess for an S4 sound, which indicates a weak left ventricle.
C: evaluate the location of the point of maximal impulse (PMI).
D: assess the rate, regularity, and quality of the heartbeat.
Reason
In general patient assessment, the main purpose of listening to heart sounds is
to identify the lub-dub that indicates the cardiac valves are functioning properly
. S1 (lub) occurs near the beginning of ventricular contraction, when the tricus
pid and mitral valves close. S2 (dub) occurs near the end of the ventricular con
traction, when the pulmonary and aortic valves close. Although cardiac rate and
regularity can be assessed by listening to heart sounds (apical pulse), the qual
ity of the heartbeat can only be assessed by palpating the pulse. The point of m
aximal impulse (PMI)also called the apical thrustis not heard, but rather seen. Th
e PMI, which is normally located on the left anterior part of the chest in the m
idclavicular line at the fifth intercostal space, occurs when the hearts apex rot
ates forward with systole and gently beats against the chest wall, producing a v
isible pulsation.
Answer is A
==== 93/121 cardiology
Occlusion of the right coronary artery would MOST likely result in:
A: sudden cardiac arrest.
B: an increase in atrial kick.
C: ectopic ventricular complexes.
D: sinoatrial node failure.
Reason:
The sinoatrial (SA) node is the dominant cardiac pacemaker; it sets the inherent
rate at which the heart beats. The SA node receives blood from the right corona
ry artery (RCA); therefore, if the RCA is occluded (ie, acute myocardial infarct
ion), the SA node will become ischemic and may cease functioning. If this occurs
, the atrioventricular (AV) node would likely assume the role of the primary pac
emaker, although at an inherently slower rate. If the SA node fails, the flow of
electricity throughout the atria would likely suffer as well; this would result
in a decrease in atrial kickthe volume of blood (about 20%) that is ejected from
the atria to the ventricles (the other 80% fills the ventricles by gravity). Su
dden cardiac arrest is more likely to occur following occlusion of the left main
coronary artery. Ectopic ventricular complexes (eg, PVCs), although benign in m
any cases, may indicate irritability in the ventricles.
Answer is D
==== 94/121 cardiology *REPEAT*
Immediately after establishing a return of spontaneous circulation in a woman wi
th ventricular fibrillation of short duration, you should:
A: assess her ventilatory status and treat accordingly.
B: assess her blood pressure and treat if needed.
C: obtain a 12-lead ECG to assess for cardiac damage.
D: establish vascular access and give amiodarone.
Reason:
Your first action after establishing return of spontaneous circulation (ROSC) in
a patientregardless of his or her arrest rhythm and durationis to assess the pati
ent's ventilatory status. If the patient is not breathing or is breathing inadeq
uately, provide ventilatory support. After assessing and managing airway and bre
athing, assess the patients blood pressure and stabilize it if it is low. Airway
and circulatory support are critical following ROSC; inadequate ventilation and/
or hypotension following cardiac arrest may lead to a recurrence of cardiac arre
st. Depending on your local protocols, IV amiodarone may be given following ROSC
. After assessing and maintaining respiratory and circulatory functions, obtain
a 12-lead ECG if time allows. If the patient remains comatose following ROSC, co
nsider inducing therapeutic hypothermia.
Answer is A
==== 95/121 cardiology
Atropine sulfate exerts its therapeutic effect by:
A: opposing the vagus nerve.
B: blocking sympathetic activity.
C: increasing cardiac contractility.
D: stimulating alpha receptors.
Reason:
Atropine sulfate is a parasympathetic blocker (parasympatholytic, vagolytic). It
is used to increase the heart rate by opposing the vagus nerve when excessive p
arasympathetic (vagal) tone causes symptomatic bradycardia. Alpha adrenergic ago
nists, such as norepinephrine (Levophed), primarily stimulate alpha-1 receptors
and cause vasoconstriction. Drugs such as propranolol (Inderal) and prazosin (Mi
nipress) block sympathetic nervous system activity by binding to beta and alpha
receptors, respectively. Beta receptor blockade causes a decrease in heart rate
(negative chronotropy), a decrease in contractility (negative inotropy), and a d
ecrease in electrical conduction velocity (negative dromotropy). Alpha receptor
blockade causes vasodilation, and a subsequent decrease in blood pressure. Drugs
that increase cardiac contractility, such as dopamine (Intropin), do so through
their positive inotropic effects.
Answer is A
==== 96/121 cardiology
Which of the following ECG lead configurations is correct?
A: To assess lead III, place the negative lead on the right arm and the positive
lead on the left leg.
B: To assess lead II, place the negative lead on the right arm and the positive
lead on the left leg.
C: To assess lead III, place the negative lead on the left leg and the positive
lead on the right arm.
D: To assess lead I, place the positive lead on the right arm and the negative l
ead on the left arm.
Reason:
According to the Einthoven triangle, lead I is assessed by placing the negative
(white) lead on the right arm and the positive (red) lead on the left arm. Lead
II is assessed by placing the negative lead on the right arm and the positive le
ad on the left leg. Lead III is assessed by placing the negative lead on the lef
t arm and the positive lead on the left leg.
Answer is B
==== 97/121 cardiology
You are assessing a middle-aged female who complains of chest discomfort. She is
conscious, alert, and oriented. Her skin is diaphoretic. Her blood pressure is
122/72 mm Hg, her pulse rate is 120 beats/min, and her respirations are 20 breat
hs/min. On the basis of her chief complaint, which of your assessment findings i
s the MOST significant?
A: Mental status
B: Pulse rate of 120 beats/min
C: Diaphoresis
D: Elevated respiratory rate
Reason
Your patient has signs and symptoms of an acute coronary syndrome (ACS)a spectrum
of cardiac diseases that includes unstable angina pectoris and acute myocardial
infarction. In ACS, tachycardia increases myocardial oxygen consumption and dem
and, and may exacerbate myocardial ischemia or injury. Therefore, her heart rate
of 120 beats/min is the most significant clinical finding. Stimulation of the s
ympathetic nervous system increases the production of sweat, resulting in diapho
resis. Although this is a clinically significant finding, it is not detrimental
to the patient. The patients mental statusconscious, alert, and orientedindicates t
hat her brain is adequately perfused; obviously, this is a positive sign. Her re
spiratory rate of 20 breaths/min is consistent with the upper limit of normal fo
r an adult.
Answer is B
==== 98/121 cardiology
A 72-year-old male presents with an acute onset of confusion, slurred speech, an
d decreased movement of his right arm. The patients wife tells you that this bega
n about 20 minutes ago, and that he was fine before that. He has type II diabete
s, hypertension, and atrial fibrillation. Given this patients clinical presentati
on and past medical history, you should be MOST suspicious that he has:
A: an occluded cerebral artery.
B: a space-occupying intracranial lesion.
C: acute hypoglycemia.
D: an acute epidural hemorrhage.
Reason:
Acute ischemic stroke, which is caused by an occluded cerebral artery, is charac
terized by an acute onset of confusion, slurred speech, facial droop, and unilat
eral weakness (hemiparesis), among other signs. This patient has two major risk
factors for a stroke: hypertension and atrial fibrillation (A-Fib). Although hyp
ertension could be a contributing factor, it is more likely that his A-Fib resul
ted in the stroke. In A-Fib, a small blood clot can dislodge from the wall of th
e fibrillating atria, enter the systemic circulation, and occlude a cerebral art
ery. An epidural hemorrhage is unlikely; it is generally the result of blunt hea
d traumamost often to the temporal lobe. Furthermore, patients with an epidural h
emorrhage tend to deteriorate rapidly and exhibit signs of increased intracrania
l pressure. Epidural hemorrhage is most often the result of injury to the middle
meningeal artery, which bleeds rapidly. Hypoglycemia can also present with acut
e confusion and slurred speech; however, hemiparesis is a less common finding. C
learly, you should assess the blood glucose level of any patient with an altered
mental status. Patients with a space-occupying intracranial lesion (eg, brain t
umor) typically have a slow onset and insidious progression of symptomsoften over
a period of months. In some patients with a brain tumor, a seizure may be the o
nly presenting clinical manifestation.
Answer is A
==== 99/121 cardiology
You and your team are performing CPR on a 70-year-old male. The cardiac monitor
reveals a slow, organized rhythm. His wife tells you that he goes to dialysis ev
ery day, but has missed his last three treatments. She also tells you that he ha
s high blood pressure, hyperthyroidism, and has had several cardiac bypass surge
ries. Based on the patient's medical history, which of the following conditions
is the MOST likely underlying cause of his condition?
A: Hyperkalemia
B: Drug toxicity
C: Coronary thrombus
D: Hypovolemia
Reason:
Although any of the listed conditions could be causing this patients condition, t
he fact that he missed his last three dialysis treatments should make you most s
uspicious for hyperkalemia. Dialysis filters metabolic waste products from the b
lood in patients with renal insufficiency or failure. If the patient is not dial
yzed, these waste products, including potassium and other electrolytes, accumula
te to toxic levels in the blood. In addition to performing high-quality CPR, man
aging the airway, and administering epinephrine, your protocols may call for the
administration of calcium chloride and sodium bicarbonate if hyperkalemia is su
spected. Albuterol also has been shown to be effective in treating patients with
hyperkalemia becauses it causes potassium to shift back into the cells; it can
be nebulized down the ET tube or administered intravenously. Follow your local p
rotocols regarding the treatment for suspected hyperkalemia.
Answer is A
==== 100/121 cardiology
ECG indicators of Wolff-Parkinson-White (WPW) syndrome include:
A: tall P waves, QT interval prolongation, and tachycardia.
B: narrow QRS complexes and peaked T waves.
C: short PR intervals, delta waves, and QRS widening.
D: delta waves, flattened T waves, and bradycardia.
Reason
Wolff-Parkinson-White (WPW) syndrome is a condition in which accessory pathwaysca
lled the bundle of Kentbypass the atrioventricular (AV) node, causing the ventric
les to depolarize earlier than normal (preexcitation). Because the normal delay
at the AV node does not occur, the PR intervals in patients with WPW are usually
less than 0.12 seconds (120 ms). When conduction occurs down the AV node and si
multaneously along the bundle of Kent in an anterograde fashion, the two waves o
f depolarization meet (fusion). This manifests on the ECG as a delta waveslurring
or notching at the beginning of the QRS complexwhich may cause QRS widening. The
bundle of Kent is a potential site for a reentry circuit because it allows cont
inued transmission of an electrical impulse from the atria to the ventricles. Th
erefore, patients with WPW are prone to reentry tachycardiasmost notably, AV reen
try supraventricular tachycardia (SVT).
Answer is C
==== 101/121 cardiology
Which of the following cardiac rhythms is associated with bradycardia, and is ch
aracterized by regular R-R intervals and a greater ratio of P waves to QRS compl
exes?
A: Third-degree AV block
B: Second-degree AV block type I
C: First-degree AV block
D: Second-degree AV block type II
Reason:
Third-degree AV block is caused by a complete block at the AV node. The SA node
initiates impulses as usual; however, when they reach the AV node, they are bloc
ked. Resultantly, the ventricles receive no electrical stimulus from the atria,
so they initiate their own impulses, although at a much slower rate. On the ECG,
this manifests as a bradycardic rhythm with more P waves than QRS complexes. Th
e P-P intervals are regular (some P waves may not be visible because they are bu
ried in a QRS complex), as are the R-R intervals; however, no relationship exist
s between a given P wave and QRS complex. Second-degree AV block type I (Wenkeba
ch) is caused by a progressive delay at the AV node until an impulse is blocked
from entering the ventricles. On the ECG, this manifests as a progressively leng
thening P-R interval until a P wave is blocked (not followed by a QRS complex).
At this point, the R-R interval becomes irregular, and the presence of this lone
P wave increases the ratio of P waves to QRS complexes. Second-degree AV block
type I may or may not be associated with bradycardia. Second-degree AV block typ
e II is caused by an intermittent block at the AV node; it occurs when atrial im
pulses are not conducted to the ventricles. Unlike a second-degree AV block type
I, however, a type II block is characterized by consistent P-R intervals of the
P waves that are conducted. First-degree AV block is an abnormal delay at the A
V node; on the ECG, this manifests with PR intervals greater than 0.20 seconds (
120 ms) in duration. In first-degree AV block, all of the atrial impulses are co
nducted through the AV node and into the ventricles.
Answer is A
==== 102/121 cardiology
Which of the following statements regarding right ventricular failure (RVF) is c
orrect?
A: Fluid boluses are contraindicated in patients with RVF.
B: Sacral and pedal edema are common signs of RVF.
C: RVF most often leads to pulmonary hypertension.
D: Morphine is the drug of choice for patients with RVF.
Reason:
The most common cause of right ventricular failure (RVF) is left ventricular fai
lure (LVF). When the left ventricle fails, blood backs up into the lungs and eve
ntually into the pulmonary circulation, resulting in pulmonary hypertension. Bec
ause the right ventricle must work harder to overcome the increased resistance i
n the pulmonary circulation, it eventually fails as an effective forward pump. A
s a result, blood backs up into the systemic circulation, resulting in jugular v
enous distention, hepatomegaly (enlarged liver), and peripheral edemaespecially t
o dependent areas of the body (eg, extremities, the sacrum in bedridden patients
). In patients with severe RVF, total body edema (anasarca) may be present. Hypo
tension may be observed in patients with RVF, and commonly occurs as the result
of right ventricular infarction (RVI). Treat the hypotensive patient with crysta
lloid fluid boluses (250 to 500 mL), which will increase preload and may improve
contractility via the Starling effect. Vasodilators (ie, morphine, nitroglyceri
n) should not be administered to patients with RVF; they may induce or exacerbat
e hypotension.
Answer is B
==== 103/121 cardiology
A transmural myocardial infarction is defined as:
A: any area of infarcted myocardium that is caused by focal areas of acute coron
ary vasospasm.
B: an MI that occurs without gross ST segment elevation or the presence of a pat
hologic Q wave.
C: an MI that involves the entire thickness of the left ventricular wall from en
docardium to epicardium.
D: multiple areas of myocardial necrosis confined to the inner one third to one
half of the left ventricular wall.
Reason:
A transmural myocardial infarction involves the entire thickness of the left ven
tricular wall from endocardium to epicardium; it is associated with ST-segment e
levation and, eventually, the development of pathologic Q waves. A subendocardia
l infarction involves multiple areas of myocardial necrosis confined to the inne
r one third to one half of the left ventricular wall; subendocardial infarctions
are also referred to as non-Q-wave infarctions. Myocardial ischemia caused by f
ocal areas of spontaneous coronary vasospasm, which may lead to infarction, is c
alled Prinzmetals (variant) angina; the exact cause of this spontaneous coronary
vasospasm is largely unknown.
Answer is C
==== 104/121 cardiology
You are assessing the cardiac rhythm of a woman with respiratory distress. The r
hythm is irregularly irregular with a rate of 120 beats/min. The QRS complexes m
easure 0.10 seconds in duration, the P wave to QRS ratio is 1:1, and the P waves
vary in shape. This cardiac rhythm is MOST likely:
A: atrial flutter with aberrancy.
B: atrial fibrillation.
C: multifocal atrial tachycardia.
D: a wandering atrial pacemaker.
Reason:
In multifocal atrial tachycardia (MAT), the pacemaker of the heart moves within
various areas of the atria. MAT is characterized by a ventricular rate that is g
reater than 100 beats/min. MAT is irregularly irregular, with variation between
R-R intervals based on the site of the pacemaker for that particular complex. P
waves are present, upright, and precede each QRS complex; however, the shapes of
the P waves vary as an indication of their different sites of origin. The P-R i
nterval generally measures between 0.12 and 0.20 seconds, but also varies slight
ly based on the origin of the particular complex. Atrial fibrillation (A-Fib) is
also an irregularly irregular rhythm; however, there are no discernable P waves
. A wandering atrial pacemaker essentially contains all the components of MAT; u
nlike MAT, however, the ventricular rate is typically less than 100 beats/min. A
trial flutter (A-Flutter) has characteristic flutter waves (F waves) that resemb
le a saw tooth. If accompanied by aberrancy, A-flutter has QRS complexes that ar
e greater than 0.12 seconds in duration, which indicates abnormal (aberrant) ven
tricular conduction.
Answer is C
==== 105/121 cardiology
A 60-year-old female presents with confusion, shortness of breath, and diaphores
is. Her blood pressure is 70/40 mm Hg and her heart rate is 40 beats/min. The ca
rdiac monitor reveals a slow, wide complex rhythm with dissociated P waves. Afte
r applying supplemental oxygen, you should:
A: give her up to 325 mg of baby aspirin.
B: start an IV and give a rapid fluid bolus.
C: start an IV and give 0.5 mg of atropine.
D: begin immediate transcutaneous pacing.
Reason;
The cardiac rhythm described is a third-degree (complete) AV block, and the pati
ent is clinically unstable (ie, hypotension, altered mental status, shortness of
breath). Third-degree AV block is characterized by a slow ventricular rate and
no P-to-QRS relationship (AV dissociation). Patients with high-grade AV blocks (
eg, second-degree type II, third-degree) are often clinically unstable and requi
re immediate transcutaneous cardiac pacing (TCP). Atropine is an appropriate dru
g for clinically unstable patients with sinus bradycardia and bradycardia associ
ated with low-grade AV blocks (eg, first-degree, second-degree type I); it is no
t recommended for high-grade AV blocks. If TCP is unsuccessful for this patient,
consider an epinephrine infusion (2 to 10 g/min) or a dopamine infusion (5 to 10
g/kg/min), either of which may increase her heart rate and blood pressure. The p
atient's hypotension is secondary to severe bradycardia, not hypovolemia; theref
ore, a rapid IV fluid bolus is not indicated. If you have reason to suspect that
the patient is experiencing an acute coronary syndrome (ACS), aspirin should be
given.
Answer is D
==== 106/121 cardiology
A 71-year-old male presents with chest pain and shortness of breath. He is consc
ious, but confused, and is profusely diaphoretic. He has weakly palpable radial
pulses, a BP of 70/40 mm Hg, and diffuse crackles in all lung fields. You admini
ster high-flow oxygen and apply the cardiac monitor, which reveals sinus tachyca
rdia. The closest appropriate hospital is 40 miles away. Which of the following
is the MOST appropriate next action?
A: Begin an infusion of dopamine.
B: Perform a head-to-toe exam.
C: Obtain a 12-lead ECG tracing.
D: Give 20 mL/kg fluid boluses.
Reason
The patient in this scenario has likely experienced an acute myocardial infarcti
on and is now in cardiogenic shock (pump failure). Cardiogenic shock is characte
rized by general signs of shock (eg, tachycardia, diaphoresis), hypotension, alt
ered mental status, and pulmonary congestiona sign of significant left ventricula
r damage and decreased stroke volume. After ensuring airway patency and adequate
oxygenation and ventilation, your priority is to improve perfusion. Crystalloid
fluid boluses, at least not large fluid boluses (ie, 20 mL/kg), are not appropr
iate for this patient; they may exacerbate his pulmonary edema and further impai
r pulmonary respiration. Dopamine is a more appropriate intervention. In a dosin
g range of 5 to 10 g/kg/min, dopamine possesses positive inotropic effects, which
increases myocardial contractility and may improve cardiac output. Rapid transp
ort for this patient is essential; because of your extended transport time, star
t the dopamine infusion en route. Unfortunately, true cardiogenic shock has a hi
gh mortality rate.
Answer is A
==== 107/121 cardiology
According to the Los Angeles Prehospital Stroke Screen (LAPSS), the likelihood t
hat a conscious patient with an acute atraumatic neurologic complaint is experie
ncing a stroke is HIGHEST if he or she:
A: has a blood glucose level of 750 mg/dL.
B: does not have a history of seizures.
C: is normally bedridden or wheelchair bound.
D: has a symmetrical face upon smiling.
Reason:
The Los Angeles Prehospital Stroke Screen (LAPSS) is a useful tool for indentify
ing patients who are possibly experiencing a stroke. It requires the paramedic t
o rule out other causes of abnormal neurologic signs (eg, seizures, hypoglycemia
). There are six components to the LAPSS. If any one of these items is checked ye
s or unknown, you should notify the receiving facility as soon as possible and info
rm them that the patient is potentially experiencing a stroke. Bear in mind, how
ever, that some patients who are experiencing a stroke may have unremarkable fin
dings on the LAPSS (eg, all components of the LAPSS are checked no). Following are
the six components of the LAPSS: (1) Age > 45 years; (2) History of seizures is
absent; (3) Patient is not normally bedridden or confined to a wheelchair; (4)
Blood glucose level is between 60 and 400 mg/dL; (5) Symptom duration is < 24 ho
urs; (6) Unilateral asymmetry in any of the following categories: Facial smile/g
rimace, Grip strength, or Arm strength (eg, arm drift).
Answer is B
==== 108/121 cardiology
Which of the following is an absolute contraindication for fibrinolytic therapy?
A: Ischemic stroke within the last 6 months
B: BP of 170/100 mm Hg on presentation
C: Current use of anticoagulant medication
D: Subdural hematoma 3 years ago
Reason
According to current emergency cardiac care (ECC) guidelines, absolute contraind
ications for fibrinolytic therapy include ANY prior intracranial hemorrhage (ie,
subdural, epidural, intracerebral hematoma); known structural cerebrovascular l
esion (ie, arteriovenous malformation); known malignant intracranial tumor (prim
ary or metastatic); ischemic stroke within the past 3 months, EXCEPT for acute i
schemic stroke within the past 3 hours; suspected aortic dissection; active blee
ding or bleeding disorders (except menses); and significant closed head trauma o
r facial trauma within the past 3 months. Relative contraindications (eg, the ph
ysician may deem fibrinolytic therapy appropriate under certain circumstances) i
nclude, a history of chronic, severe, poorly-controlled hypertension; severe unc
ontrolled hypertension on presentation (SBP > 180 mm Hg or DBP > 110 mm Hg); isc
hemic stroke greater than 3 months ago; dementia; traumatic or prolonged (> 10 m
inutes) CPR or major surgery within the past 3 weeks; recent (within 2 to 4 week
s) internal bleeding; noncompressible vascular punctures; pregnancy; prior expos
ure (> 5 days ago) or prior allergic reaction to streptokinase or anistreplase;
active peptic ulcer; and current use of anticoagulants (ie, Coumadin).
Answer is D
==== 109/121 cardiology
A 39-year-old female presents with an acute onset of lightheadedness. The cardia
c monitor reveals a tachycardic rhythm at 170 beats/min with QRS complexes that
measure 0.08 seconds in duration. Despite vagal maneuvers and adenosine, her car
diac rhythm remains unchanged. She is conscious and alert, has a blood pressure
of 118/72 mm Hg, and denies shortness of breath or chest discomfort. You should:
A: transport immediately and monitor her en route.
B: administer 150 mg of amiodarone over 10 minutes.
C: perform synchronized cardioversion with 50 joules.
D: consider that her rhythm is ventricular in origin.
Reason:
The patient in this scenario is in supraventricular tachycardia (SVT); her heart
rate is 170 beats/min and her QRS complexes are narrow (< 0.12 seconds). Despit
e appropriate treatment for her rhythm (ie, vagal maneuvers, adenosine), her rhy
thm remains unchanged, although she remains hemodynamically stable. Lightheadedn
ess is common in patients with SVT, but it is not a clinical indicator of hemody
namic instability. A cardiac rhythm of ventricular origin (eg, ventricular tachy
cardia) is characterized by QRS complexes that are greater than 0.12 seconds in
duration; this patients QRS complexes are 0.08 seconds in duration. If vagal mane
uvers and adenosine are unsuccessful in converting her rhythm, transport immedia
tely without further treatment (other than oxygen); her present condition indica
tes that she is tolerating the cardiac rhythm. However, if signs of hemodynamic
instability are noted (ie, hypotension, decreased level of consciousness, chest
pain, shortness of breath), perform synchronized cardioversion at 50 to 100 joul
es without delay.
Answer is A
==== 110/121 cardiology
When treating an adult patient with a blood pressure of 60/40 mm Hg, confusion,
a heart rate of 40 beats/min, and sinus bradycardia on the cardiac monitor, you
should administer supplemental oxygen, establish vascular access, and then:
A: acquire a 12-lead ECG, which may reveal signs of acute myocardial ischemia or
injury.
B: administer 0.5 mg of atropine sulfate and consider transcutaneous cardiac pac
ing.
C: administer sequential crystalloid fluid boluses until his BP is greater than
100 mm Hg.
D: begin a dopamine infusion to increase blood pressure and improve cerebral per
fusion.
Reason:
A patient who presents with or develops symptomatic bradycardia needs to be trea
ted in a manner that will increase the heart rate, thus improving cardiac output
, blood pressure, and mental status. Altered mental status, hypotension, chest p
ain or pressure, and shortness of breath are indications for treatment of the br
adycardic patient. After ensuring adequate oxygenation and ventilation, establis
h vascular access and give 0.5 mg of atropine; this may be repeated every 3 to 5
minutes to a maximum dose of 3 mg. If the patient is severely compromised or do
es not respond to atropine, begin transcutaneous cardiac pacing (TCP) without de
lay. If the patient is in a second-degree type II or third-degree AV block, TCP
is the first-line treatment. Atropine and TCP-refractory bradycardia may require
a sympathomimetic infusion, such as epinephrine or dopamine. The bodys normal ph
ysiologic response to hypovolemia is tachycardia, not bradycardia. Therefore, fl
uid boluses are not the initial treatment for the hypotensive, bradycardic patie
nt. In fact, they may cause further harm to the patient. With a slow heart rate
and decreased cardiac output, a sudden increase in preload may result in acute p
ulmonary edema. After stabilizing the patients heart rate and improving perfusion
, obtain a 12-lead ECG to assess for signs of acute myocardial ischemia or injur
y.
Answer is B
==== 111/121 cardiology
You are assessing a 75-year-old male who experienced a sudden onset of slurred s
peech, a right-sided facial droop, and left-sided hemiparesis approximately 45 m
inutes ago. His blood pressure is 170/94 mm Hg, pulse rate is 68 beats/min and i
rregular, and respirations are 14 breaths/min and unlabored. His oxygen saturati
on is 94% on room air. The MOST appropriate treatment for this patient includes:
A: assisted ventilation with a bag-mask device, cardiac monitoring, an IV of nor
mal saline, IV dextrose if his blood glucose level is less than 80 mg/dL, and tr
ansport.
B: oxygen via nonrebreathing mask, an IV of normal saline, cardiac monitoring, 5
mg of labetalol to lower his BP, blood glucose assessment, and rapid transport.

C: supplemental oxygen via nasal cannula, cardiac monitoring, blood glucose asse
ssment, an IV of normal saline set to keep the vein open, and prompt transport.
D: 160 to 325 mg of aspirin, supplemental oxygen via nasal cannula, cardiac moni
toring, blood glucose assessment, an IV of an isotonic crystalloid, and transpor
t.
Reason
The patient is likely experiencing an acute ischemic stroke. Determining the tim
e of onset of his symptoms is critical; fibrinolytic therapy must be administere
d within the first 3 hours following a stroke in order to be of maximum benefit.
Treatment includes supplemental oxygen (a nasal cannula is appropriate, given h
is room air oxygen saturation), blood glucose assessment (hypoglycemia can mimic
certain signs of a stroke), vascular access, cardiac monitoring, and prompt tra
nsport with early notification of the receiving facility. Do not give aspirin to
suspected stroke patients in the field; it can cause further harm to the patien
t with a hemorrhagic stroke. Aspirin may be given at the hospital after a hemorr
hagic stroke is ruled out with a computed tomography (CT) scan of the brain. Ant
ihypertensive therapy should also be avoided in the field; it should be performe
d in the controlled setting of a hospital, where the patient has invasive hemody
namic monitoring. Lowering a patients BP in the field is dangerous and can have d
isastrous effects; inadvertently inducing hypotension in the stroke patient may
exacerbate cerebral ischemia.
Answer is C
==== 112/121 cardiology
A 61-year-old male presents with chest pressure that woke him up from his nap 30
minutes ago. He is diaphoretic, anxious, and rates his pain as an an 8 over 10.
His past medical history is significant for hypertension, type II diabetes, and
coronary stent placement 2 months ago. He takes lisinopril, Plavix, and Glucoph
age, and is wearing a medical alert bracelet stating "allergic to salicylates."
His blood pressure is 160/100 mm Hg, pulse is 110 beats/min, and respirations ar
e 22 breaths/min. The 12-lead ECG shows sinus tachycardia with 3-mm ST segment e
levation in leads V1 through V5. Which of the following treatment modalities is
MOST appropriate for this patient?
A: 325 mg of baby aspirin; high-flow oxygen via nonrebreathing mask; vascular ac
cess; and 1 g/kg of fentanyl to relieve his pain, treat his anxiety, and lower hi
s BP
B: Supplemental oxygen, vascular access, up to three 0.4 mg doses of nitroglycer
in, and 2 to 4 mg of morphine sulfate if his systolic BP is greater than 90 mm H
g and he is still experiencing pain
C: 325 mg of baby aspirin, supplemental oxygen, vascular access, up to three dos
es of nitroglycerin, and up to 10 mg of morphine if his systolic BP is greater t
han 120 mm Hg and he is still in pain
D: High-flow oxygen via nonrebreathing mask, a right-sided 12-lead ECG, vascular
access, 0.25 mg/kg of diltiazem, and application of pacing pads in case he beco
mes bradycardic
Reason:
The patient is experiencing an acute coronary syndrome (ACS). His 12-lead ECG in
dicates anteroseptal injury with lateral extension (ST elevation in leads V1 thr
ough V5). Appropriate treatment includes oxygen (maintain an SpO2 of greater tha
n 94%), vascular access, up to three 0.4 mg doses of nitroglycerin (NTG), and 2
to 4 mg of morphine if NTG fails to relieve his pain and his systolic BP is abov
e 90 mm Hg. Some EMS systems may use fentanyl (Sublimaze) for analgesia. Aspirin
, a salicylate, is also given to patients with ACS; however, this patient is all
ergic to salicylates. Obtain a right-sided 12-lead ECG in patients with signs of
inferior wall injury (ST elevation in leads II, III, aVF). Inferior wall infarc
tions may involve the right ventricle; a right-sided 12-lead ECG will help confi
rm this. Apply the multi-pads to the patient, not because he is at risk for brad
ycardia (more common with inferior infarctions), but because he is at risk for c
ardiac arrest due to V-Fib or pulseless V-Tach.
Answer is B
==== 113/121 cardiology
A 47-year-old male took two of his prescribed nitroglycerin tablets prior to cal
ling EMS. When you arrive at the scene, the patient tells you that he has a thro
bbing headache and is still experiencing chest pain. Your MOST immediate suspici
on should be that:
A: he is experiencing continued myocardial ischemia.
B: permanent myocardial damage has already occurred.
C: his chest pain is probably not of a cardiac origin.
D: his nitroglycerin is outdated or has lost its potency.
Reason:
When a patient reports taking nitroglycerin (NTG) for chest pain, you should det
ermine how many tablets or sprays he or she took, and whether or not the NTG rel
ieved his or her pain. Failure of NTG to relieve cardiac-related chest pain can
occur for one of two reasonsthe pain is of extraordinary severity, such as that a
ssociated with acute myocardial infarction, or the NTG has been open too long an
d has lost its potency. Fresh, potent NTG has certain distinct side effects, inc
luding a throbbing headache, a burning sensation under the tongue, and a bitter
taste. If the patent did not experience any of these side effects, chances are t
he drug was outdated or had lost its potency. However, if the patient experience
d any of these side effects, but is still experiencing chest pain, you should su
spect that he or she is experiencing continued myocardial ischemia and is in the
process of having an acute myocardial infarction. A 12-lead ECG and other diagn
ostic tests (ie, echocardiography) are required to determine if permanent myocar
dial damage has occurred.
Answer is A
==== 114/121 cardiology
You and your team are performing CPR on a middle-aged male who presented with as
ystole. After 2 minutes of CPR, you reassess him and note that his cardiac rhyth
m has changed to ventricular fibrillation. You should:
A: defibrillate after 2 more minutes of CPR.
B: defibrillate and then resume CPR.
C: assess for a carotid pulse for 5 seconds.
D: make sure the leads are still attached.
Reason:
CPR alone rarely, if ever, converts asystoleor any other cardiac arrest rhythmto a
perfusing rhythm. Furthermore, if one of the leads detaches from the patients ch
est, you will more likely see something that resembles massive artifact, not ven
tricular fibrillation (V-Fib). If you see V-Fib on the cardiac monitor, defibril
late one time with 360 monophasic joules (or equivalent biphasic) and then immed
iately resume CPR, starting with chest compressions. Assessing for a carotid pul
se in a patient who is clearly in V-Fib wastes time; it delays defibrillation an
d CPR. After 2 minutes of CPR, reassess the patients cardiac rhythm; if V-fib is
still present, defibrillate one time and immediately resume CPR. If you see an o
rganized cardiac rhythm, assess for a pulse for at least 5 seconds but no more t
han 10 seconds, and then resume CPR if indicated.
Answer is B
==== 115/121 cardiology
What is the therapeutic effect of aspirin when administered to a patient experie
ncing an acute coronary syndrome (ACS)?
A: Destruction of a blood clot in a coronary artery by destroying fibrin
B: Destruction of platelets by increasing thromboxane A2 production
C: Decreased thromboxane A2 production, which inhibits platelet aggregation
D: Decreased platelet production and coronary artery vasoconstriction
Reason:
Thromboxane A2 is produced by activated platelets. It is a potent vasoconstricto
r, it stimulates activation of new platelets, and it increases platelet aggregat
ion. Aspirin (acetylsalicylic acid [ASA]) blocks the production of thromboxane A
2, which inhibits vasoconstriction, inhibits activation of new platelets, and in
hibits platelet aggregation (ie, it makes the platelets less sticky). Aspirin does
not destroy a clot in a coronary arteryit prevents it from getting larger. Furth
ermore, by inhibiting local coronary vasoconstriction, it may enhance blood flow
around the clot. Fibrinolytic agents (ie, alteplase [Activase], streptokinase [
Streptase], tenecteplase [TNKase]) convert the bodys own clot-dissolving enzyme f
rom its inactive form, plasminogen, to its active form, plasmin. Plasmin then de
stroys the fibrin matrix of the clothence the term fibrinolysis.
Answer is C
==== 116/121 cardiology
You are transporting a 62-year-old male who called EMS because of nausea and dia
rrhea. His past medical history includes high cholesterol, for which he takes Li
pitor; he denies any other medical history. His blood pressure is 132/78 mm Hg,
pulse is 68 beats/min, and respirations are 16 breaths/min. He is receiving oxyg
en via nasal cannula and has a patent IV line established. He has been in a norm
al sinus rhythm, but is now experiencing occasional premature ventricular comple
xes (PVCs). After noting the PVCs, you should:
A: contact the receiving facility immediately.
B: administer 1.5 mg/kg of lidocaine.
C: give a 250500 mL normal saline bolus.
D: reassess and continue monitoring him.
Reason:
The patient in this scenario is hemodynamically stable. Premature ventricular co
mplexes (PVCs) are generally not a cause for concern unless they are frequent (>
6 per minute) or occur in the context of acute coronary syndrome (ACS) or hemod
ynamic compromise. Nonetheless, any change in the patients condition warrants rea
ssessment. Continue monitoring the ECG and his vital signs. If the PVCs become m
ore frequent, or if his condition deteriorates, an antidysrhythmic (eg, lidocain
e, amiodarone) may be indicated. The patients current vital signs are not suggest
ive of hypovolemia; therefore, a fluid bolus is not indicated at this point. Cal
l your radio report to the receiving facility as usual and report your findings
at that time; there is no need to contact them immediately.
Answer is D
==== 117/121 cardiology
When assessing a patient with sinus tachycardia at a rate of 135 beats/min, you
should recall that:
A: rate-related symptoms are uncommon in patients with a heart rate less than 15
0 beats/min.
B: a heart rate greater than 130 beats/min often causes significant hemodynamic
compromise.
C: tachycardia in a patient with cardiac ischemia is beneficial in that it impro
ves coronary perfusion.
D: the preferred treatment for tachycardia less than 150 beats/min is a calcium
channel blocker.
Reason:
Sinus tachycardia in the adultthat is, a heart rate less than 150 beats/minis usua
lly a manifestation of an underlying problem, such as hypovolemia or hypoxia. Th
erefore, the treatment for sinus tachycardia should focus on treating the underl
ying cause (ie, fluid boluses, oxygen). Rate-related hemodynamic compromise is u
ncommon in patients with a heart rate less than 150 beats/min. Tachycardia in th
e patient with myocardial ischemia is NOT good; it increases myocardial oxygen d
emand and consumption, which can exacerbate ischemia. Calcium channel blockers (
eg, diltiazem [Cardizem]) are commonly used for ventricular rate control in pati
ents with atrial fibrillation or atrial flutter. Synchronized cardioversion is i
ndicated for patients with hemodynamic compromise secondary to supraventricular
tachycardia (narrow complex; heart rate > 150 beats/min) and ventricular tachyca
rdia (wide complex; rate > 100 beats/min [often > 200 beats/min]).
Answer is A
==== 118/121 cardiology
You are attempting to resuscitate a 50-year-old man in cardiac arrest. The patie
nt has a history of congestive heart failure, hypertension, and cirrhosis of the
liver. The cardiac monitor reveals a slow, wide complex rhythm. CPR is ongoing
and the patient has been intubated. In addition to looking for potentially rever
sible causes of the patients condition, further treatment should include:
A: ventilations at a rate of 8 to 10 breaths/min and 1 mg of epinephrine 1:10,00
0 every 3 to 5 minutes.
B: one breath every 5 to 6 seconds, 40 units of vasopressin every 5 minutes, and
transcutaneous pacing.
C: hyperventilation for presumed acidosis and 1 mg of epinephrine 1:10,000 every
3 to 5 minutes.
D: one breath every 3 to 5 seconds, a 2-liter normal saline bolus, a vasopressor
, and a dopamine infusion.
Reason:
Pulseless electrical activity (PEA) refers to the presence of an organized cardi
ac rhythm (except V-Tach), despite the absence of a pulse; it can result from a
variety of conditions, such as hypovolemia, overdose, hypothermia, and trauma, a
mong others. Treatment for PEA includes high-quality CPR with minimal interrupti
ons, 1 mg of epinephrine 1:10,000 every 3 to 5 minutes, advanced airway manageme
nt, and treating potentially reversible causes. A one-time 40-unit dose of vasop
ressin can be given to replace the first or second dose of epinephrine, but not
both. After an advanced airway device is in place, perform asynchronous CPR; the
compressor delivers at least 100 compressions/min and the ventilator provides 8
to 10 breaths/min (one breath every 6 to 8 seconds). Do not hyperventilate the
patient; doing so may impair venous return to the heart and decrease cardiac out
put. A ventilation rate of 12 to 20 breaths/min is appropriate for infants and c
hildren who are apneic, but have a pulse. An apneic adult with a pulse should be
ventilated at a rate of 10 to 12 breaths/min. Dopamine is not indicated for pat
ients in cardiac arrest, and current evidence does not support the use of transc
utaneous cardiac pacing (TCP) in patients with PEA or asystole.
Answer is A
==== 119/121 cardiology
When attempting transcutaneous cardiac pacing (TCP), you will know that electric
al capture has been achieved when:
A: you see an increase in the number of narrow QRS complexes.
B: each pacemaker spike is followed by a wide QRS complex.
C: the patients inherent heart rate spontaneously increases.
D: the milliamp setting is at least 40 and the patient is in pain.
Reason:
Transcutaneous cardiac pacing (TCP) involves passing small, repetitive electrica
l currents through the patients skin (transcutaneous) across the heart between on
e externally placed pacing pad and another. The pacemaker is set at a specific r
ate, usually 60 to 80/min. The energy is then increasedusually by 10 to 20 millia
mps (mA) every few secondsuntil the heart begins to respond to the electrical sti
mulus. Electrical capture has been achieved when the stimulus depolarizes the ve
ntricles; this appears as a wide QRS complex immediately following each pacemake
r spike. If the QRS complex is not present, the pacemaker current is not depolar
izing the ventricles and electrical capture has not been achieved. Mechanical ca
pture is achieved when the patients palpated pulse rate corresponds with the pace
d rate on the ECG.
Answer is B
==== 120/121 cardiology
You are assessing a 67-year-old female with chest discomfort when she becomes un
responsive, apneic, and pulseless. The cardiac monitor reveals coarse ventricula
r fibrillation. You achieve return of spontaneous circulation after 6 minutes an
d the cardiac monitor now reveals a narrow complex rhythm. The patient is still
unresponsive, has occasional respirations, a blood pressure of 70/40 mm Hg, and
a weak pulse of 70 beats/min. The MOST appropriate postresuscitation care for th
is patient includes:
A: prompt insertion of a multilumen airway device, ventilatory assistance, vascu
lar access, 150 mg of amiodarone over 10 minutes, and 0.5 mg of atropine sulfate
.
B: high-flow oxygen via nonrebreathing mask, vascular access, a lidocaine infusi
on, and an adequate volume of normal saline solution to increase her blood press
ure.
C: insertion of an airway adjunct, assisted ventilation, vascular access, a 500-
mL crystalloid bolus, an antidysrhythmic, and consideration for induced hypother
mia.
D: preoxygenation with a bag-mask device and high-flow oxygen, endotracheal intu
bation, vascular access, 300 mg of amiodarone, and a dopamine infusion.
Reason:
If return of spontaneous circulation (ROSC) occurs, you must focus on preventing
recurrent cardiac arrest and providing optimal conditions that enhance neurolog
ic recovery. Immediately following ROSC, reassess the patients airway and breathi
ng and treat accordingly. For this patient, you should insert an airway adjunct
and assist her ventilations with a bag-mask device and high-flow oxygen. If her
breathing does not improve, and she remains unresponsive, an advanced airway dev
ice should be considered. Her heart rate (70 beats/min) does not require treatme
nt, although you must closely monitor it. Her blood pressure, however, is low an
d should be treated. Marked hypotension must be corrected in order to minimize c
erebral ischemia; this is usually accomplished initially with crystalloid fluid
boluses. If fluid boluses are unsuccessful, an inotropic drug (eg, dopamine) sho
uld be considered. Because the patient is still unresponsive, you should conside
r inducing therapeutic hypothermia, depending on your local protocols. The induc
tion of hypothermia following ROSC has been shown to improve neurologic recovery
. The postresuscitation cardiac rhythm should be stabilized to the extent possib
le. If the arrest rhythm was V-Fib or pulseless V-Tach, consider an antidysrhyth
mic bolus (eg, lidocaine, amiodarone), followed by an infusion of that same drug
.
Answer is C
==== 121/121 cardiology
Which of the following clinical presentations is MOST consistent with dissection
of the ascending aorta?
A: Gradual onset of chest pressure that increases in severity over time, hypoten
sion, tachycardia, bilaterally weak radial pulses
B: Acute tearing pain in between the scapulae, blood pressure discrepancy betwee
n arms, maximal pain severity from the onset
C: Tearing abdominal pain unrelieved by analgesia, pulse deficit in the femoral
arteries, lightheadedness, blood in the stool
D: Sudden onset of lower back pain that radiates to the groin, urge to defecate,
pain is constant and moderate in severity
Reason:
Aortic dissection occurs when the layers of the aorta undergo destructive change
s, resulting in an aneurysm (weakening and ballooning of the arterial wall). In
dissection of the ascending aorta, the patient typically experiences an acute on
set of ripping, tearing, or stabbing pain in the anterior chest or in between th
e scapulae. In some patients, it may be difficult to differentiate the pain of a
cute aortic dissection from that of acute myocardial infarction (AMI); however,
a number of distinctive features may help. The pain of an AMI is often preceded
by prodromal symptoms (eg, nausea, weakness, sweating). Although pain from an AM
I is acute, it gradually intensifies over time and is typically described as a s
queezing or pressure sensation. By contrast, the pain of aortic dissection is ac
ute, is of maximal intensity from the onset, and is usually described as a rippi
ng, tearing, or stabbing feeling. Other signs and symptoms depend on the extent
and location of the dissection. In dissections of the ascending aorta, one or mo
re of the vessels of the aortic arch may be compromised. Disruption of blood flo
w through the innominate artery, for example, is likely to produce a difference
in blood pressure between the arms. The onset and pain characteristics of abdomi
nal aortic dissection are similar to those of ascending aortic dissection; howev
er, the pain typically begins in the abdomen or lower back. Pulse deficits in th
e femoral arteries may be present, and if the aneurysm is leaking blood into the
retroperitoneal space, the patient may complain of an urge to defecate and exhi
bit signs of shock.
Answer is B