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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