cardiovascular emergencies 2017 cen review - ky …€¦ · cardiovascular emergencies 2017 cen...
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Cardiovascular Emergencies 2017 CEN Review
CENExamContent
As of July 6, 2016
* Primary Disease States include: * dysrhythmias (e.g., PEA) * angina * arrest (e.g., cardiac/pulmonary arrest * medications via ET tube * contusion * dissection (aortic), including other injuries to great vessels * aneurysm (aortic) * hypertension * infarction * CHF – congestive heart failure/pulmonary edema * endocarditis * pericarditis * tamponade * thromboembolic disease * PVD – peripheral vascular disease (e.g., arterial, venous)
Cardiovascular (21 items)
* With any patient entering the ED, the nurse must always complete the primary and secondary assessments and document the findings
Cardiovascular Emergencies
* KnownewACLSguidelines!* Knowyournewdrugsanddosages!* Ventricularfibrillation* VentricularTachycardia* Asystole* HeartBlocks* SVT* Bradyarrhythmias
Dysrhythmias
* A55yearoldfemalepresentstotheEDwithintermittentchestpainof4hoursduration.Sheispainfreeatthetimeofadmission.Sheisonhormonereplacementtherapyandstoppedsmoking2weeksagoaftera30packyearhistory.Themostappropriatetriageandmanagementforthispatientwouldbe:
* 1.Emergent;cardiacworkup
* 2.Nonemergent;admissiontochestpainunit
* 3.Urgent;clinicreferral
* 4.Nonemergent;senthome
* A55yearoldfemalepresentstotheEDwithintermittentchestpainof4hoursduration.Sheispainfreeatthetimeofadmission.Sheisonhormonereplacementtherapyandstoppedsmoking2weeksagoaftera30packyearhistory.Themostappropriatetriageandmanagementforthispatientwouldbe:
* 1.Emergent;cardiacworkup
* 2.Nonemergent;admissiontochestpainunit
* 3.Urgent;clinicreferral
* 4.Nonemergent;senthome
Whichofthefollowingistheexpectedoutcomeforapatienttreatedforacutecoronarysyndrome?* 1.Reducedfatigue
* 2.Reliefofchestpainorangina
* 3.Muffledheartsounds
* 4.IncreasedJVD
Whichofthefollowingistheexpectedoutcomeforapatienttreatedforacutecoronarysyndrome?* 1.Reducedfatigue
* 2.Reliefofchestpainorangina
* 3.Muffledheartsounds
* 4.IncreasedJVD
* Acollectionofbloodinthepericardialsac* Life-threateningcardiacinjury* Inhibitsorcompromisesventricularfilling* Decreasesstrokevolume* Decreasescardiacoutput
* SignsandSymptoms* Dyspnea* Penetratingchestwound* Fractureofleft3rd,4th,or5thribs* Cyanosis* Beck’striad* Distendedneckveins* Hypotension* Muffledheartsounds
* Signsofshock* ProgressivedecreasedvoltageofEKGcomplexes
PericardialTamponade
Ofthefollowingstructureswhichismostpronetotheeffectsofdecelerationforces?* 1.Brainstem
* 2.Inferiorvenacavaattheiliacroots
* 3.Spinalcordinthethoracicspine
* 4.Theaortaneartheligamentumarteriosum
Ofthefollowingstructureswhichismostpronetotheeffectsofdecelerationforces?
* 1.Brainstem
* 2.Inferiorvenacavaattheiliacroots
* 3.Spinalcordinthethoracicspine
* 4.Theaortaneartheligamentumarteriosum
* 1.Pericardialtamponade
* 2.Lacerationontheperonealartery
* 3.Liverlaceration
* 4.Diaphragmatichernia
A22yearoldfemalewasfoundunconsciouswithapenetratingstabwoundtotheleftchestatthelevelofthe5thribfromanicepick.TheEDnurseshouldsuspectwhich
ofthefollowinginjuries?
* 1.Pericardialtamponade
* 2.Lacerationontheperonealartery
* 3.Liverlaceration
* 4.Diaphragmatichernia
A22yearoldfemalewasfoundunconsciouswithapenetratingstabwoundtotheleftchestatthelevelofthe5thribfromanicepick.TheEDnurseshould
suspectwhichofthefollowinginjuries?
* Formallycalled“cardiaccontusionorconcussion”* ShouldbesuspectedfollowinganassociatedMOIorinpatients
thatexhibitanabnormallypoorcardiovascularresponsetotheirinjury
* MostcommonlyassociatedwithMVC* Directimpactofchestwithsteeringwheelorfallsfromheights
* Symptoms* EKGabnormalities
* PVCs,AVblocks(mostcommon)* STandTwavechanges
* ChestPain* ChestWallecchymosis
BluntCardiacInjury
* Excruciating,abruptpaindescribedasripping,knifeliketearingsensationthatradiatestotheback,
abdomen,extremities,oranteriorchest* Hypertension,althoughthepatientmaylookshocky,with
diaphoresis* Severeapprehension* Decreasedordiminishedpulses* Unequalpulses* BPdifferentinarms* Decreasedurineoutput* Mentalstatuschanges* Chestpain
Aorticdissections
* Patientsappearill* Diastolicpressuregreaterthan130mmhg* Chestpain* Severeheadache* Dyspnea* Blurringofvision* Acuteuremicsyndrome* Markedretinalchanges* Linearhemorrhages* Hardexudates
* Papilledema* BUNandcreatelevated* Rapidlyproducesrenalfailure,cardiacfailure,andcerebral
damage
Aorticdissections
* WidenedmediastinumonCXR* Deviationoftrachea* Aorticcalcification,abnormalitiesoftheaorticknob* Labsareofnovaluefordiagnosing* CTscanusedtoevaluatesizeandposition* Arteriographycanidentifyoriginofthedissectionandstatusofrenalbloodflow
DiagnosticFindings
* Weakeningofthearterialwall* Defectisthedestructionoftheelasticfibersinthemediallayer,whichpermitstheremainingfibroustissuetostretchandincreaseindiameter,whichraiseswalltension
AorticAneurysm
* Pain:mostcommonpresentingsymptom* Lowpainbackthatradiatestotheflankorgroin* Abdominalbruit* Dulltoseveresteadyepigastricpain* Sensationoffullness* Claudication* Scapularpain* LowGIbleed* Dysphagia* Hoarseness* Trachealdisplacement* Dyspnea
ClinicalManifestations
* Thegoaloftreatmentistopreventruptureoftheaneurysm.Generally,yourtreatmentoptionsaretowatchandwaitortohavesurgery.Yourdecisiondependsonthesizeoftheaorticaneurysmandhowfastit'sgrowing.
* Therapeuticinterventions:* High-Fowler’sposition* Oxygen* Large-boreIVs* LR* Maintainingbloodpressurecontrol(Nipride)* WhataboutCardene?
* Ifhypovolemicshock—ABCs,fluidresuscitation,prepareforemergencysurgery
Treatment
* Resultofpenetratingorblunttrauma* Usualsiteofdamagetothedescendingaortaisattheaorticisthmusdistaltotheligamentumarteriosumandthetakeoffoftheleftsubclavianarterywheretheaortaisrelativelyfixed* Ascendingaorticinjuriesareimmediatelyfatalinmostcases
AorticInjuries
* Hypotension* DecreasedLOC* Hypertensioninupperextremities* Decreasedqualityoffemoralpulsescomparedtoupperextremitiespulses* Loudsystolicmurmur* Chestpain* Chestwallecchymosis* WidenedmediastinumonCXR* paraplegia
SignsandSymptoms
* Sinus Node * AV Node * bundle of His * Right and Left bundles
* Purkinje fibers
The Electrical Conduction
* Left coronary artery * Left main * Left anterior descending * Diagonal
* Circumflex * Obtuse marginal
* Right coronary artery * PDA: posterior descending artery
Coronary Circulation
* Normal heart sounds * First heart sound—closure of the mitral and tricuspid
valves * Second heart sound—closure of the aortic and pulmonic
valves * Extra diastolic sounds * Gallops—S 3 an S 4 * Diastolic filling sounds * S 3 heard with LV heart failure, primary pulmonary
hypertension, and core pulmonale * S 4 heard with MI, LV hypertrophy, hypertension, aortic
stenosis
Heart Sounds
* Murmurs * Produced in the heart or great vessels by turbulent
blood flow * Turbulent flow can be produced by: * Increased rate of flow across a normal valve * Flow across a partial obstruction * Flow across an irregularity without obstruction * Flow into a dilated vessel * Backward flow across an incompetent valve or through a
septal defect
Heart Sounds
* Pericardial Friction Rubs * Characteristic of pericarditis * Rub occurs with heart movement
Heart Sounds
* Assessmentdataareobtainedfrom:* patient’shistory* physicalexamination* diagnoses
Assessment
* Myocardialhypertrophy* TheLVwall25%thickeratage80thanatage30
* Decreasenumberofpacemakercells* Vesseldiametertendstoincreaseandtheintimalandmediallayerstendtothicken* Arterialwallsarelessdistensibleandlesscompliantwithaging
Agerelatedchanges
* LiverChanges* Decreaseinsizeofliver* Decreasebloodflow* Declineindrugclearance* “Goslow,staylow”whentreatingelderlypatientswithmedications
* 1.ThepainpatternofMIfrequentlyisdescribedas:
A.Tearing,radiatingtothebackB.Sudden,sharp,increasingwithachangeofpositionC.Sudden,crushing,radiatingtothejawandneck
D.Sudden,sharpoverthelungfields,increasingwithinspiration
* 1.ThepainpatternofMIfrequentlyisdescribedas:
A.Tearing,radiatingtothebackB.Sudden,sharp,increasingwithachangeofposition
C.Sudden,crushing,radiatingtothejawandneck
D.Sudden,sharpoverthelungfields,increasingwithinspiration
* Fibrinolytictherapyisbeingconsideredforthispatient.Allofthefollowingshouldbeconsideredasinitialindicatorsforfibrinolytictherapyexcept:
A.SerumcardiacenzymeslevelsB.A12LeadEKGwithsignificantSTelevationC.AhistoryofCVdiseaseanddiabetesD.Onsetofchestpaingreaterthan6hours
* Fibrinolytictherapyisbeingconsideredforthispatient.Allofthefollowingshouldbeconsideredasinitialindicatorsforfibrinolytictherapyexcept:
A.SerumcardiacenzymeslevelsB.A12LeadEKGwithsignificantSTelevationC.AhistoryofCVdiseaseanddiabetesD.Onsetofchestpaingreaterthan6hours
* STelevationona12LeadEKGindicates:
* A.Infarction
* B.Ischemia
* C.Dysrhythmia
* D.Injury
* STelevationona12LeadEKGindicates:
* A.Infarction(PathologicQwaves)* B.Ischemia(Twaveinversion)
* C.Dysrhythmia
* D.Injury
A.AnteriorwallMIB.InferiorwallMIC.PosteriorwallMID.LateralwallMI
TheEDnurseobtainsa12LeadEKG.ThereisSTelevationgreaterthan2cminleadsV2,V3,andV4.Thepatientis
havinganacute:
A.AnteriorwallMIB.InferiorwallMI(leads2,3andAVF)C.PosteriorwallMI(leadsshowingwavechangesinV1andV2,a
tall,broadRwave,STsegmentdepressionandatalluprightTwave)
D.LateralwallMI(lead1,V5,V6andAVL)
TheEDnurseobtainsa12LeadEKG.ThereisSTelevationgreaterthan2cminleadsV2,V3,andV4.Thepatientis
havinganacute:
A.PlaceanexternalpacemakeronthepatientB.Drawallinitialbloodstudiesbeforeadministratingthe
drugC.Administerplateletstothepatienttopreventthe
possibilityofbleedingD.Startadopamineordobutaminedriptoprevent
hypotension.
t-PAisordered.Inpreparationforadministration,theEDnursemay:
A.PlaceanexternalpacemakeronthepatientB.Drawallinitialbloodstudiesbeforeadministratingthe
drugC.Administerplateletstothepatienttopreventthe
possibilityofbleedingD.Startadopamineordobutaminedriptoprevent
hypotension.
t-PAisordered.Inpreparationforadministration,theEDnursemay:
A.PurgetheIVtubingtogetallofthedrugB.DrawaCBCandanABGC.InsertafoleycathetertomonitorforhematuriaD.DrawaPTandPTTtomonitorclottingtime
Afterthet-PAhasbeeninfused,theEDnurseshould:
A.PurgetheIVtubingtogetallofthedrugB.DrawaCBCandanABGC.InsertafoleycathetertomonitorforhematuriaD.DrawaPTandPTTtomonitorclottingtime
Afterthet-PAhasbeeninfused,theEDnurseshould:
* 1.BolusplusinfusionIV
* 2.Infusedover60minutes
* 3.Singlebolusgivenover5secondsIV
* 4.TwoIVbolusgiven30minutesapart
The physician changes his mind and wants tenecteplase (TNKase) administered, how would
the drug be administered?
A.ChangeallIVfluidstoNSB.PlacebloodtubingononeoftheIVlinesC.BringalongadefibrillatorandACLSdrugsD.Placeapulseoximeteronthepatient
Thepatientistobetransportedtothecardiaccathlab.Inpreparationfortransport,theEDnurse
should:
A.ChangeallIVfluidstoNSB.PlacebloodtubingononeoftheIVlinesC.BringalongadefibrillatorandACLSdrugsD.Placeapulseoximeteronthepatient
Thepatientistobetransportedtothecardiaccathlab.Inpreparationfortransport,theEDnurse
should:
A.VentricularfibrillationB.CompleteHeartBlockC.AcceleratedidioventricularrhythmD.Asystole
Acommondysrhythmiaassociatedwithreperfusionis:
A.VentricularfibrillationB.CompleteHeartBlockC.AcceleratedidioventricularrhythmD.Asystole
Acommondysrhythmiaassociatedwithreperfusionis:
A.DysrhythmiaB.BleedingC.ThrombosisD.Hypocalcemia
Themostcommoncomplicationoffibrinolytictherapyis:
A.DysrhythmiaB.BleedingC.ThrombosisD.Hypocalcemia
Themostcommoncomplicationoffibrinolytictherapyis:
A.ElderlypatientswithahistoryofheadachesB.WomenbeingtreatedwithfibrinolyticsforMIC.MenwhohavehadpreviousinfarctionsD.Menwhohaveahistoryofheadaches
Whichgroupofpatientsisatgreaterriskofhavingastrokeaftertreatmentwithfibrinolytictherapy?
A.ElderlypatientswithahistoryofheadachesB.WomenbeingtreatedwithfibrinolyticsforMIC.MenwhohavehadpreviousinfarctionsD.Menwhohaveahistoryofheadaches
Whichgroupofpatientsisatgreaterriskofhavingastrokeaftertreatmentwithfibrinolytictherapy?
A.ThepresenceofpetechiaeB.ChangesinLOCC.BloodintheurineD.Feverandchills
Becauseofthepossibilityofanintracerebralhemorrhageoccurringastheresultoffibrinolyticadministration,theED
nurseshouldevaluatethepatientfor:
A.ThepresenceofpetechiaeB.ChangesinLOCC.BloodintheurineD.Feverandchills
Becauseofthepossibilityofanintracerebralhemorrhageoccurringastheresultoffibrinolyticadministration,theED
nurseshouldevaluatethepatientfor:
* Majorpublichealthproblemworldwide* Mostfrequentcauseofhospitalizationinpatientsolderthan65years* FourthleadingcauseofadulthospitalizationinUS
CongestiveHeartFailure
* PulmonaryEdemaistheresultof:
* 1.Leftsidedheartfailure
* 2.Rightsidedheartfailure
HeartFailureandPulmonaryEdema
* PulmonaryEdemaistheresultof:
* 1.Leftsidedheartfailure
* 2.Rightsidedheartfailure
CHFistheinabilityofthehearttomaintainanadequateoutputtomeetthedemandsofthebody.* 1.True
* 2.False
CHFistheinabilityofthehearttomaintainanadequateoutputtomeetthedemandsofthebody.* 1.True
* 2.False
* Right-sidedheartfailure Left-sidedheartfailure
Elevated pulmonary venous pressure Decreased cardiac output Breathlessness Weakness, fatigue, dizziness Confusion,pulmonary congestion Hypotension and death
Increased systemic venous pressure JVD Hepatomegaly Dependent peripheral edema Ascites
* Endocarditisisaninflammationoftheinsideliningoftheheartchambersandheartvalves(endocardium)* Endocarditiscaninvolvetheheartmuscle,heartvalves,or
liningoftheheart.* Injectiondruguse,recentdentalsurgery,permanent
centralvenousaccesslines,priorvalvesurgery,andweakenedvalvesareriskfactorsfordevelopingendocarditis.* Bacterialinfectionisthemostcommonsourceof
endocarditis.However,itcanalsobecausedbyfungi.Insomecases,nocausativeorganismcanbeidentified.
Endocarditis
* fatigue* weakness* fever* chills* nightsweats,maybesevere* weightloss* muscleachesandpains* heartmurmur* shortnessofbreathwithactivity* swellingoffeet,legs,abdomen* bloodintheurine* sweating,excessive* redpainlessskinspots,locatedonthepalmsandsoles(calledJanewaylesions)* red,painfulnodesinthepadsofthefingersandtoes(calledOsler'snodes)* paleness* nailabnormalities(splinterhemorrhagesunderthenails)* jointpain* abnormalurinecolorNote:Endocarditissymptomsmaydevelopslowly(subacute)orsuddenly(acute).
Symptomsofendocarditis
* Long-termantibiotictherapyisrequiredtoeliminatethebacteriafromtheheartchambersandvalve
Endocarditis
* Inflammationofthepericardialsaccausedby:* AMI* Trauma* Infection* Neoplasms
* Symptoms* Frictionrub* Chestpainthatincreaseswithinspirationandincreaseactivity* Fever* Chills* Dyspnea* EKG* STsegmentelevationinallleadsexceptAVRandVI
* Treatment* Oxygen,sedation,analgesia,bedrest,* Anti-inflammatoryagentsandsteroidsmaybeused
Pericarditis
PulmonaryEmbolism
* CommonEKGfindings* Sinustachycardia* T-waveinversioninleadV1-V4* New-onsetRBBB* Rightaxisdeviation* Classicfindings:* SwaveinleadI* QwavewithinvertedTwaveinleadIII
* 1.AAMI
* 2.Pericarditis
* 3.Myocardialischemia
* 4.Cardiactamponade
WhichofthefollowingconditionswouldberepresentedbyanelevatedSTsegmentinallleadsexceptAVRandV1?
* 1.AAMI
* 2.Pericarditis
* 3.Myocardialischemia(STdepression)
* 4.Cardiactamponade(noSTelevation)
WhichofthefollowingconditionswouldberepresentedbyanelevatedSTsegmentinallleadsexceptAVRandV1?
* 1.Hersensitivitytopainisdiminishedbecausesheistakingseveralantirejectionmedications
* 2.Atherosclerosis,whichcontributestocoronaryarteryclot,spasm,andchestpain,willnotdevelopfromthetransplant
* 3.Shemayneverexperiencechestpain,hearttransplantrecipientshaveadenervatedorgan
* 4.Herperceptionofpainisaffectedbyherperceptionofherheartasbelongingtosomeoneelse
A55yearoldwomaninCHFstatesthatshehadahearttransplant3yearsago.Thepatientdenieschestpain.Whichofthefollowingstatementsbestdescribeswhysheisnothavingchestpain.
* 1.Hersensitivitytopainisdiminishedbecausesheistakingseveralantiejectionmedications
* 2.Atherosclerosis,whichcontributestocoronaryarteryclot,spasm,andchestpain,willnotdevelopfromthetransplant
* 3.Shemayneverexperiencechestpain,hearttransplantrecipientshaveadenervatedorgan
* **ItisimportanttorememberthatthefirstsignofMIinthetransplantpatientisCHF
* 4.Herperceptionofpainisaffectedbyherperceptionofherheartasbelongingtosomeoneelse
A55yearoldwomaninCHFstatesthatshehadahearttransplant3yearsago.Thepatientdenieschestpain.Whichofthefollowingstatementsbestdescribeswhysheisnothavingchestpain.
* Thediagnostictestthatwouldbemostusefulindeterminingthespecificproblemis:* 1.Right-sidedEKG
* 2.Cardiacenzymesandisoenzymes
* 3.CXR
* 4.Stresstest
ApatientwithchestpainhasSTelevationinleadsII,III,andAVFonEKG.Vitalsigns:BP126/62,HR96,andrespirations22.AftersublingualNTGhasbeen
administered,vitalsignsareBP88/50,HR108,andrespirations22.
* Thediagnostictestthatwouldbemostusefulindeterminingthespecificproblemis:* 1.Right-sidedEKG
* 2.Cardiacenzymesandisoenzymes
* 3.CXR
* 4.Stresstest
ApatientwithchestpainhasSTelevationinleadsII,III,andAVFonEKG.Vitalsigns:BP126/62,HR96,andrespirations22.Aftersublingual
NTGhasbeenadministered,vitalsignsareBP88/50,HR108,andrespirations22.
* Apt.c/odizziness,feelingweakeroverthepastweekandhadasyncopalepisodethisa.m.TriagevitalsareB/P-174/92,HR-34,RR-18,T-98.6.Whatisthepriorityinterventionforthispt.?* A.AdministerO2viaNRB* B.ObtainSTATCTHead* C.Activatearapidresponseteam* D.InitiateIVaccesswithasalinelock
AdditionalReview
* A.AdministerO2viaNRB* B.ObtainSTATCTHead* C.Activatearapidresponseteam* D.InitiateIVaccesswithasalinelock* Rationale:Thept.isatriskforcardivascularcollasper/tHR-34.ProvidingO2isindicatedfortheneedtomaintainadequateoxygenation
Review
* WhatelevatedlabvaluesupportstheDxofCHF?* A-LacticAcid* B-Troponin* C-B-typenatriureticpeptide(BNP)* D-Creatinekinase(CK)
Review
* A-LacticAcid* B-Troponin* C-B-typenatriureticpeptide(BNP)* D-Creatinekinase(CK)* Rationale:BNPelevatesinresponsetoventricularvolumeexpansion,whichoccursinCHF
Review
* Theprimarysignofinstabilityassociatedwithatachydysrhythmiainthepediatricpopulationis:* A-Respiratorydistressorfailure* B-HTN* C-ST-elevationinleadsII,III,AVF* D-Hypovolemia
Review
* A-Respiratorydistressorfailure* B-HTN* C-ST-elevationinleadsII,III,AVF* D-HypovolemiaRationale:Atachydysrhythmiaisunstableifitcausessignsorsymptomsofpoortissueperfusion
Review
* WhichofthefollowingtreatmentswouldbeindicatedforanEDpt.withaplasmadigoxin(Lanoxin)levelof5.2ng/mL(nml-2.6)?* A-SyrupofIpecac* B-Digoxinimmunefab(Digibind)* C-Hemodialysis* D-Atropine
Review
* A-SyrupofIpecac* B-Digoxinimmunefab(Digibind)* C-Hemodialysis* D-AtropineRationale:Digibindremovesdigoxinmolecuelsfromtissue-bindingsitesandiseffectiveinloweringtheactiveserumdiglevel
Review
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