EMT Final Exam|60 questions and answers.

When ventilating an unresponsive apneic adult with a bag-valve-mask device, you should ensure that: A) an airway adjunct has been inserted. B) you are positioned alongside the patient. C) ventilations occur at a rate of 20 breaths/min. D) the pop-off relief valve is manually occluded. A When ventilating an unresponsive apneic patient with a bag-mask device, you should ensure that an oral or nasal airway adjunct is inserted, which will keep the tongue off of the posterior pharynx and facilitate effective ventilation. When ventilating a patient with a bag-mask device, it is best for you to be positioned at the patient's head to allow for better control of the head. Ventilations in the apneic adult with a pulse (ie, not in cardiac arrest) should be provided at a rate of 10 to 12 breaths/min (one breath every 5 to 6 seconds). Generally, only pediatric-sized bag-mask devices have pop-off relief valves, which should NOT be occluded, because they help prevent overinflation of the patient's lungs. Which of the following would MOST likely cause a reduction in tidal volume? A) Flaring of the nostrils B) Accessory muscle use C) Unequal chest expansion D) Increased minute volume C Unequal (asymmetrical) or minimal expansion of the chest results in a decrease in the amount of air inhaled per breath (tidal volume). Accessory muscle use and nasal flaring are signs of increased work of breathing, which represents an attempt to maintain adequate tidal volume (and therefore, minute volume). An increase in tidal volume, respiratory rate, or both would result in an increase in minute volume. It should be noted, however, that a markedly fast respiratory rate would cause a natural decrease in tidal volume. For example, a patient breathing at a rate of 45 breaths/min would likely only inhale air into the anatomic dead space before promptly exhaling it. In which position would you expect a patient with severe dyspnea to be found? A) Prone B) Supine C) Fowler's D) Lateral recumbent C The preferred position of comfort for most patients with respiratory distress is Fowler's position (sitting up). A prone, supine, or lateral recumbent position would make it more difficult for the patient to breathe. If a patient with severe dyspnea is willing to lie flat, the EMT should take this as an ominous sign and should be prepared to assist the patient's ventilations. A 35-year-old male complains of shortness of breath. He is conscious and alert and is able to speak in complete sentences. Assessment reveals diffuse wheezing to auscultation, a respiratory rate of 22 breaths/min, a heart rate of 110 beats/min, and an oxygen saturation of 92%. Which of the following interventions would be of MOST benefit to this patient? A) A beta antagonist B) Assisted ventilation C) Supplemental oxygen D) Inhaled bronchodilator D The patient's clinical presentation is classic for bronchospasm, such as what occurs with asthma and other reactive diseases of the lower airway. Of the interventions listed, an inhaled bronchodilator (beta-2 agonist) would be of the most immediate benefit. Beta-2 agonists dilate the bronchioles, which improves airflow through them and makes it easier for the patient to breathe. The patient's oxygen saturation (92%) indicates mild hypoxemia; however, by dilating the bronchioles and increasing airflow, his oxygenation saturation will increase; if it does not, then administer a sufficient amount of oxygen to maintain his oxygen saturation at or above 94%. The patient does not require assisted ventilation at this time because he has no outward signs of inadequate breathing. A 60-year-old woman presents with acute respiratory distress. She is conscious and alert, but restless. Her respiratory rate is 26 breaths/min with adequate chest expansion, her breath sounds are clear to auscultation bilaterally, and her oxygen saturation is 84%. Which of the following is the MOST appropriate treatment for this patient? A) Supplemental oxygen with a nonrebreathing mask B) A nasopharyngeal airway and assisted ventilations C) A nasopharyngeal airway and supplemental oxygen D) A nasal cannula with the flowmeter set at 4 to 6 L/min A Although the patient is restless (a sign of hypoxemia), she is conscious and alert and able to maintain her own airway; therefore, an airway adjunct is not needed at this point. Furthermore, her respirations, although increased in rate, are producing adequate tidal volume as evidenced by adequate chest expansion. Therefore, she is not in need of assisted ventilation at this point. Considering her oxygen saturation of 84%, the most appropriate treatment would be to administer high-flow oxygen with a nonrebreathing mask and closely monitor her for signs of inadequate breathing (ie, shallow breaths [reduced tidal volume], decreased level of consciousness, cyanosis). An acutely hypoxemic patient often requires more oxygen than a nasal cannula can provide. Which of the following patients is the BEST candidate for an oropharyngeal airway? A) Any patient whom you suspect of being acutely hypoxemic B) A semiconscious patient who ingested a large quantity of aspirin C) An unresponsive patient with uncontrolled oropharyngeal bleeding D) An unresponsive trauma patient with blood draining from the nose D The oropharyngeal airway is used to keep the tongue off of the posterior pharynx and is indicated for unresponsive patients without a gag reflex. If an unresponsive patient has severe, uncontrolled oropharyngeal bleeding, your priority is to suction his or her airway to prevent aspiration and transport rapidly. Semiconscious patients typically have a gag reflex, although it may be somewhat depressed. Oxygen should be administered to any patient with suspected hypoxemia. In order to avoid forcing air into the stomach during bag-mask ventilation, you should: A) ventilate the patient at a rate of at least 10 to 12/breaths/min. B) squeeze the bag slowly and release when you observe chest rise. C) apply manual pressure to the abdomen during bag-mask ventilation. D) ensure that you are also delivering a high oxygen concentration. B The esophagus opens at approximately 20 cmH20. High airway pressures, such as what occurs when the bag-mask device is squeezed to quickly and/or forcefully, may generate greater than 20 cmH20 and force air into the stomach. This is why it is critical to squeeze the bag slowly, just until you observe chest rise, and then release. Faster ventilation rates can hyperinflate the lungs, squeeze the heart, and impair venous return; however, the pressure used to squeeze the bag is more influential in opening the esophagus. Obviously, applying manual pressure to the abdomen is inviting the patient to vomit and is clearly inappropriate. The amount of delivered oxygen has no influence on esophageal opening pressure. Which of the following assessment findings would indicate that a patient with a foreign body airway obstruction has poor air exchange? A) Stridor B) Anxiety C) Wheezing D) Tachycardia A If a patient thas ANY type of airway obstruction, you would expect him or her to be anxious and tachycardic, so these findings are not specific to a patient with poor air exchange. If the patient has adequate air exchange, he or she will be coughing forcefully, although you may hear wheezing (a whistling sound) in between coughs. The skin may be flushed and the patient's level of consciousness is not altered. Poor air exchange is characterized by a weak, ineffective cough; progressive respiratory distress; stridor (high-pitched sound heard during inhalation); cyanosis; and a decreasing level of consciousness. Signs of inadequate breathing in an unresponsive patient include: A) an irregular pulse. B) warm, moist skin. C) symmetrical chest rise. D) cyanotic oral mucosa. D Signs of inadequate breathing in both responsive and unresponsive patients include a respiratory rate that is too slow (less than 12 breaths/min) or too fast (greater than 20 breaths/min); shallow (reduced tidal volume), irregular, or gasping respirations; asymmetrical (unequal) chest rise; abnormal respiratory sounds, such as wheezing, stridor, or gurgling; and abnormal skin color and condition (ie, cool or cold skin, pallor, diaphoresis, cyanosis). An irregular pulse indicates a cardiac dysrhythmia. At the peak of the inspiratory phase, the alveoli in the lungs contain: A) large quantities of carbon dioxide. B) minimal levels of oxygen and carbon dioxide. C) equal levels of oxygen and carbon dioxide. D) more oxygen than carbon dioxide. D At the peak of the inspiratory (inhalation) phase, the alveoli are filled with fresh oxygen that the patient just breathed in. During the expiratory (exhalation) phase, the oxygen moves from the alveoli to the left side of the heart and the carbon dioxide is exhaled into the atmosphere. The process of oxygen and carbon dioxide exchange in the lungs is called pulmonary (external) respiration. Ventilation is defined as the: A) elimination of carbon dioxide from the body. B) movement of air into and out of the lungs. C) volume of air inhaled into the lungs in a single breath. D) exchange of oxygen and carbon dioxide at the cellular level. B Ventilation is defined as the movement of air into and out of the lungs. During negative-pressure ventilation (normal breathing), the diaphragm and intercostal muscles contract, which increases the vertical and horizontal dimensions of the chest cavity. As a result, a vacuum is created in the chest and air is drawn into the lungs. Positive-pressure ventilation is the act of forcing air into the lungs (ie, bag-valve-mask ventilation). The volume of air inhaled or exhaled in a single breath is called tidal volume. The exchange of gases between the body and its environment is called respiration; therefore, the exchange of oxygen and carbon dioxide at the cell level is called cellular (internal) respiration. During pulmonary (external) respiration, oxygen and carbon dioxide are exchanged in the lungs; oxygenated blood returns to the left side of the heart and carbon dioxide is eliminated from the body during exhalation. You are administering oxygen at 15 L/min to a patient with respiratory distress. If you are using a D cylinder (cylinder constant, 0.16), which reads 1500 psi, how long will it take before you need to replace the oxygen cylinder? A) 9 minutes B) 11 minutes C) 14 minutes D) 18 minutes C The length of time you can use an oxygen cylinder depends on the type of cylinder you are using, the pressure in the cylinder, and the oxygen flow rate. A D cylinder is a small oxygen cylinder that is usually carried in the jump kit to the patient; it has a cylinder constant of 0.16. The following method can be used to calculate cylinder duration: gauge pressure (in psi) - the safe residual pressure (200 psi) × the cylinder constant / flow rate in L/min. Using this formula, your D cylinder will become depleted in about 14 minutes, as follows: 1500 (psi) - 200 (safe residual pressure) × 0.16 (cylinder constant) / 15 (flow rate in L/min) = 13.86 (14 minutes). A full oxygen cylinder should contain 2000 psi. The safe residual pressure is the lowest acceptable cylinder pressure before it should be replaced; it is usually 200 psi, although some EMS systems use 500 psi as a safe residual pressure. Although you will switch to your on-board oxygen (M cylinder) source when you load the patient into the ambulance, you should always have at least one backup portable cylinder (preferably two) when administering oxygen to a patient at the scene, especially if you are giving high-flow (12 to 15 L/min) oxygen and/or your on-scene time will be delayed (eg, lengthy extrication, moving a patient from the second floor). An unresponsive apneic patient's chest fails to rise after two ventilation attempts. You should: A) immediately proceed to chest compressions. B) suction the airway and reattempt ventilations. C) attempt to ventilate again using more volume. D) reposition the head and reattempt to ventilate. A If your initial attempt to ventilate an apneic patient is unsuccessful (ie, you meet resistance or the chest fails to visibly rise), reposition the patient's head and reattempt to ventilate. If the second ventilation is unsuccessful, you should proceed under the assumption that the patient has a severe (complete) airway obstruction. Perform 30 chest compressions, open the airway, and visualize the mouth (remove an object only if you can see it). If you are able to remove the foreign object, attempt to ventilate. If you cannot see a foreign object, continue chest compressions. Continue this sequence until the obstruction is relieved or an advanced life support (ALS) ambulance arrives. If ALS response will be delayed, transport the patient, continuing your attempts to relieve the obstruction en route, and coordinate a rendezvous with the ALS unit. All of the following would cause an increased level of carbon dioxide in the arterial blood, EXCEPT: A) reduced tidal volume. B) deep, rapid breathing. C) short exhalation phase. D) slow, shallow breathing. B Adequate oxygen intake and carbon dioxide elimination require a patent airway and adequate breathing. The level of carbon dioxide in arterial blood can rise for a number of reasons. Reduced tidal volume (shallow depth of breathing) results in insufficient oxygen intake and decreased carbon dioxide elimination. A patient who is breathing slowly (bradypnea) will also experience a decrease in oxygen intake and reduced carbon dioxide elimination. If exhalation is impaired, the body will not eliminate adequate carbon dioxide; therefore, it will accumulate in arterial blood. Deep, rapid breathing (hyperventilation), however, would likely increase carbon dioxide elimination from the body, thus lowering the carbon dioxide content of arterial blood. You are dispatched to a residence for an elderly female who has possibly suffered a stroke. You find her lying supine in her bed. She is semiconscious; has vomited; and has slow, irregular breathing. You should: A) perform the head tilt-chin lift maneuver and insert an oral airway. B) insert a nasal airway and begin assisting her breathing. C) manually open her airway and suction her oropharynx. D) administer high-flow oxygen and place her on her side. C This patient's airway is in immediate jeopardy! The first step in caring for any semiconscious or unconscious patient is to manually open the airway (eg, head tilt-chin lift, jaw-thrust) and ensure it is clear of obstructions or secretions. Because the patient has vomited, she likely has vomitus in her mouth, which must be removed with suction before she aspirates it into her lungs. Mortality increases significantly if aspiration occurs. After opening her airway and removing any vomitus or secretions from her oropharynx with suction, you should insert an airway adjunct (a nasal airway in this case; the patient is semiconscious and likely has an intact gag reflex) and begin assisting her breathing with a bag-valve-mask device. Her respiratory effort is inadequate and should be treated with some form of positive-pressure ventilation, not a nonrebreathing mask. Placing a semiconscious or unconscious patient on his or her side (recovery position) is appropriate if only he or she is breathing adequately; this patient is not. You receive a call for a 49-year-old woman who passed out. The patient's husband tells you that they were watching TV when the incident occurred. No trauma was involved. The patient is semiconscious and has cyanosis to her lips. After opening her airway with the head tilt-chin lift maneuver, you should: A) assess her respiratory effort. B) begin ventilation assistance. C) insert an oropharyngeal airway. D) insert a nasopharyngeal airway. D In the absence of trauma, open the patient's airway with the head tilt-chin lift maneuver. To help maintain airway patency, a nasopharyngeal airway should be inserted. Your patient is semiconscious, not unconscious, so she will likely gag if you attempt to insert an oropharyngeal airway; this may result in aspiration if she vomits. Remember, you must first open the patient's airway and, if needed, suction any secretions from the mouth. Next, insert an airway adjunct and assess respiratory effort. The method of oxygenation you provide depends on the adequacy of the patient's breathing. Which of the following patients would be the BEST candidate for treatment with continuous positive airway pressure (CPAP)? A) Conscious; respiratory distress; fever; and hypotension B) Unresponsive; labored breathing; cyanosis; and tachycardia C) Conscious; labored breathing; anxiety; and coarse crackles D) Semiconscious; shallow breathing; and audible wheezing C Continuous positive airway pressure (CPAP) therapy can effectively improve oxygenation and ventilation in patients with respiratory distress secondary to pulmonary edema (for example, CHF with coarse crackles heard during auscultation), or in patients with respiratory distress secondary to bronchospasm (as evidenced by wheezing). However, in order for the patient to benefit from CPAP therapy, he or she must be alert enough to follow verbal commands and should have relatively adequate tidal volume. If the patient is unable to follow verbal commands and/or his or her baseline breathing is so poor that respiratory arrest is imminent, you should assist his or her ventilations with a bag-mask device. CPAP is a form of non-invasive positive-pressure ventilation; as such, it can have a negative effect on cardiac output. If the patient is already hypotensive, CPAP could be more detrimental than beneficial. The MOST appropriate treatment for a semiconscious patient with slow, shallow respirations includes: A) a nasopharyngeal airway and assisted ventilation with a bag-valve-mask device. B) an oropharyngeal airway and high-flow oxygen via a nonrebreathing mask. C) a nasopharyngeal airway and high-flow oxygen via a nonrebreathing mask. D) an oropharyngeal airway and assisted ventilation with a bag-valve-mask device. A Semiconscious patients are not fully able to protect their own airway and require an airway adjunct. The nasopharyngeal airway is indicated for semiconscious patients because they often have an intact gag reflex; the oropharyngeal airway is contraindicated in any patient with an intact gag reflex. Slow, shallow respirations will not provide the minute volume needed to support adequate oxygenation and should be treated with positive-pressure ventilation with a bag-valve-mask device. A patient with a mild foreign body airway obstruction: A) is typically not cyanotic. B) presents with a weak cough. C) has a low oxygen saturation. D) has progressive difficulty breathing. A Patients with a mild (partial) airway obstruction are able to move adequate amounts of air, but will have varying degrees of respiratory distress. The patient can cough forcefully, although you may hear wheezing in between coughs. Because the patient is able to move air effectively, the level of oxygen in his or her blood remains adequate; therefore, cyanosis is typically absent. By contrast, the patient with a severe (complete) airway obstruction cannot move air effectively and cannot speak. If a cough is present, it is weak and ineffective. As the level of oxygen in the blood falls, cyanosis develops, oxygen saturation falls, and the patient's level of consciousness decreases. A foreign body airway obstruction, mild or severe, is an acute event that presents with an acute onset of difficulty breathing. Progressive (gradually worsening) difficulty breathing is more consistent with diseases such as congestive heart failure and pneumonia. The active, muscular part of breathing is called: A) expiration. B) inhalation. C) ventilation. D) respiration. B The active, muscular part of breathing is called inhalation (inspiration). During inhalation, the diaphragm and intercostal muscles contract. When the diaphragm contracts, it descends and enlarges the thoracic cage from top to bottom. When the intercostal muscles contract, they lift the ribs up and out. As the thoracic cage expands, the air pressure within the thorax decreases, creating a slight vacuum. This pulls air through the trachea, causing the lungs to fill. Exhalation (expiration) does not require muscular effort; it is a passive process. During exhalation, the diaphragm and intercostal muscles relax. In response, the thorax decreases in size, and the ribs and muscles assume a normal resting position. When the size of the thoracic cage decreases, air in the lungs is compressed into a smaller space. The air pressure within the thorax then becomes higher than the pressure outside and air is pushed out through the trachea. Respiration is defined as the exchange of gases between the body and its environment. Ventilation is defined as the movement of air into and out of the lungs. Patients with a hypoxic drive: A) may hypoventilate if given low concentrations of oxygen. B) are stimulated to breathe by low oxygen levels in the blood. C) rarely become cyanotic because of high blood oxygen levels. D) are accustomed to low levels of carbon dioxide in the blood. B Patients with chronic respiratory diseases (eg, emphysema) maintain decreased levels of oxygen and increased levels of carbon dioxide in the blood. The sensors in the brain become accustomed to this. Unlike in a healthy person, whose primary respiratory drive is influenced by increasing carbon dioxide levels in the blood, the primary respiratory drive of a patient with a chronic respiratory disease is influenced by low levels of oxygen in the blood (hypoxic drive). Cyanosis is common due to chronic hypoxemia. Some patients with a hypoxic drive may hypoventilate if given high concentrations of supplemental oxygen, although this is highly uncommon. High-flow supplemental oxygen may fool the brain into thinking the body has sufficient oxygen, causing it to send fewer signals to the diaphragm and intercostal muscles. The chest pain associated with an acute coronary syndrome is often described as: A) sharp. B) stabbing. C) pressure. D) cramping. C The pain associated with acute coronary syndrome (ie, unstable angina, acute myocardial infarction) is commonly described as a feeling of pressure or heaviness, discomfort, or a crushing pain. Stabbing or sharp (pleuritic) pain is often associated with conditions such as a spontaneous pneumothorax or pulmonary embolism. Do not rule out a cardiac problem just because the patient does not have the "classic" quality of pain, especially if the patient has a history of cardiac problems. A 65-year-old man has generalized weakness and chest pressure. He has a bottle of prescribed nitroglycerin, but states that he has not taken any of his medication. The EMT should: A) apply the AED and prepare the patient for immediate transport. B) administer up to 325 mg of aspirin if the patient is not allergic to it. C) assist the patient with his nitroglycerin with medical control approval. D) perform a secondary assessment and obtain baseline vital signs. B Aspirin has clearly been shown to reduce mortality and morbitiy associated with acute coronary syndrome (ACS) and should be given as early as possible; the dose is 160 to 325 mg. Even though this patient has chest pain and prescribed nitroglycerin, you must first complete a secondary assessment and obtain baseline vital signs. Medical control will need this information--specifically, the patient's blood pressure--to determine whether you should assist the patient with his nitroglycerin. The AED is not indicated for this patient because he is not in cardiac arrest. The EMT is treating a man with chest pain and has assisted him with his nitroglycerin. Which of the following should the EMT anticipate during reassessment of this patient? A) Decreased blood pressure B) Increased level of anxiety C) Increased oxygen saturation D) Burning sensation in the chest A Because nitroglycerin is a vasodilator, you should expect that the patient's blood pressure will be lower when you reassess it. Some patients experience only a minor decrease in blood pressure; other patients may experience a more significant decrease (one of the many reasons to reassess your patient). Nitroglycerin typically does not increase anxiety; the fact that it relieves their chest pain, however, may actually decrease their anxiety. Nitroglycerin has no effect on oxygen saturation. Some patients may experience a burning sensation under their tongue; a burning sensation in the chest is not typical following nitroglycerin administration. While assessing a patient with chest pain, you note that his pulse is irregular. This indicates: A) acute myocardial infarction or angina pectoris. B) a dysfunction in the left side of the patient's heart C) high blood pressure that is increasing cardiac workload. D) abnormalities in the heart's electrical conduction system. D An irregular pulse indicates abnormalities in the electrical conduction system of the heart. The electrical conduction system, beginning with the sinoatrial node as the primary pacemaker, is responsible for initiating the electrical impulses that stimulate the myocardium to contract. An irregular pulse could indicate a potentially lethal dysrhythmia that could result in cardiac arrest. You should document an irregular pulse and report this important finding to the emergency department. Which of the following assessment findings is LEAST suggestive of a cardiac problem? A) Rapid, irregular heart rate B) Anxiety and pale, cool skin C) Palpable pain to the chest D) Nausea and epigastric pain C Signs and symptoms of cardiac compromise include nonreproducible pain, pressure, or discomfort in the chest or epigastric region; nausea; pale, cool, clammy (diaphoretic) skin; and an irregular pulse that is either fast or slow. Pain of cardiac origin typically is not reproducible by palpation. Palpable pain to the chest suggests a musculoskeletal problem, not a cardiac problem. However, because some patients with a cardiac problem present atypically, you should transport any patient with chest pain, pressure, or discomfort to the hospital. A 58-year-old man is found unresponsive by his wife. According to his wife, he was complaining of a "dull ache" in his chest the day before, but refused to allow her to call 911. His blood pressure is 70/50 mm Hg, his pulse is 120 beats/min and weak, and his respirations are 28 breaths/min and labored. Further assessment reveals that his skin is cool, pale, and clammy. You should suspect: A) cardiogenic shock. B) hypovolemic shock. C) acute septic shock. D) pulmonary embolism. A The patient in this scenario likely experienced an acute myocardial infarction the day before. However, because he refused medical care, the infarction has likely damaged a significant portion of his heart, resulting in cardiogenic shock. Cardiogenic shock occurs when the heart fails as a pump and can no longer meet the metabolic needs of the body; it has a very high mortality rate. The patient's labored breathing is likely caused by pulmonary edema, which occurs when blood backs up into the lungs because the heart cannot effectively pump it forward. There is no evidence of hypovolemia (ie, poor skin turgor) or sepsis (ie, fever). A pulmonary embolism typically presents with an acute onset of pleuritic (sharp) chest pain and difficulty breathing, and is also commonly associated with cyanosis. Chest compression effectiveness is MOST effectively assessed by: A) listening for a heartbeat with each compression. B) carefully measuring the depth of each compression. C) palpating for a carotid pulse with each compression. D) measuring the systolic blood pressure during compressions. C When chest compressions are in progress, the most reliable method of determining their effectiveness is to palpate for a carotid or femoral pulse. If compressions are of adequate depth for the patient's age, you should be able to feel a pulsation during each compression. It should be noted that you may not be able to feel a pulse in severely hypovolemic patients, despite adequately performed chest compressions. A 72-year-old female complains of dyspnea that woke her from her sleep. Her feet and ankles are swollen, and auscultation of her lungs reveals crackles to both lung bases. She has a history of hypertension, type II diabetes, and a heart attack 2 years ago. Her BP is 170/94 mm Hg, her pulse is 110 beats/min and irregular, her respirations are 24 breaths/min and labored, and her oxygen saturation is 85% on room air. What should you suspect? A) Acute asthma attack B) Congestive heart failure C) Acute hypertensive crisis D) Emphysema exacerbation B The patient's clinical presentation is consistent with congestive heart failure (CHF) with acute pulmonary edema. Dyspnea that awakens a person from sleep is called paroxysmal nocturnal dyspnea (PND), and is classic for CHF. Crackles auscultated over her lungs further support the diagnosis of pulmonary edema, and her low oxygen saturation indicates hypoxemia. Swelling to the feet and ankles suggest an element of right heart failure as well. Emphysema is unlikely because there is no mention of it in her medical history. Furthermore, patients with emphysema typically have dyspnea all the time, not just when they lie down to sleep. Acute asthma is also unlikely; one would expect wheezing (not crackles) in the lungs. While the patient's BP is elevated, she has no other signs of acute hypertensive crisis, such as a headache, nausea and vomiting, and ringing in the ears. Ischemic heart disease is a condition in which: A) a portion of the heart muscle dies because of a prolonged lack of oxygen. B) there is a decrease in blood flow to one or more portions of the heart muscle. C) the coronary arteries dilate, thus preventing effective blood flow to the heart. D) an acute event leads to a significant decrease in the pumping force of the heart. B Chest pain or discomfort that is related to the heart usually stems from a condition called ischemia (insufficient oxygen). Because of a partial or complete blockage of blood flow through one or more coronary arteries, the tissue of the heart muscle (myocardium) fails to get enough oxygen and nutrients relative to its needs. Therefore, ischemic heart disease is a condition involving a decrease in blood flow, and therefore oxygen, to one or more portions of the myocardium. If blood flow to the ischemic portion of the myocardium is not restored, it eventually dies (myocardial infarction). Dilation of the coronary arteries increases, not decreases, blood flow to the heart. If an event such as a myocardial infarction damages the heart and significantly decreases its ability to contract forcefully, heart failure may occur. Your assessment of a middle-aged female with chest pressure reveals that she is confused, is diaphoretic, and has a blood pressure of 70/50 mm Hg. In caring for this patient, it is MOST important for you to: A) request an ALS unit to respond to the scene. B) assist her with her nitroglycerin if she has any. C) reassess her vital signs at least every 5 minutes. D) prepare for immediate transport to the hospital. D Your patient is in shock, which is most likely the result of heart failure (cardiogenic shock). Immediate transport to the closest appropriate hospital is critical. Assess for and manage problems with airway, breathing, and circulation, and then get on the road! She needs definitive care that can be provided only at the hospital. Reassess her vital signs at least every 5 minutes, but do it en route! If you can rendezvous with an ALS unit en route, do so. However, you should not remain at the scene to wait for them. Nitroglycerin is clearly contraindicated for this patient; her BP is dangerously low. Following administration of nitroglycerin to a man with crushing chest pressure, he experiences a significant increase in his heart rate. This is MOST likely the result of: A) a cardiac dysrhythmia. B) preexisting hypertension. C) a drop in blood pressure. D) coronary vasoconstriction. C Nitroglycerin (NTG) is a vasodilator drug. It dilates not only the coronary arteries, but also other arteries in the body. In some patients, NTG may cause a drop in blood pressure, especially if they are taking other medications that cause vasodilation (eg, erectile dysfunction drugs [Viagra, Levitra, Cialis]). In response to a drop in blood pressure, the nervous system attempts to compensate by increasing the heart rate (tachycardia). Common side effects of NTG include a headache, a burning sensation under the tongue, and a bitter taste in the mouth. Always assess the patient's vital signs both before and after administering nitroglycerin. A 44-year-old male complains of dizziness and lightheadedness. His BP is 88/62 mm Hg; his heart rate is 190 beats/min and weak; and his skin is cool, clammy, and pale. Which of the following would BEST explain why his BP is low? A) Widespread systemic vasoconstriction B) Decreased ventricular filling time C) Increased ventricular stroke volume D) Decreased myocardial oxygen demand B When the heart is beating exceedingly fast, there is less time in between contractions for the ventricles to fill. As a result, stroke volume decreases and the blood pressure falls; this is the most likely cause of this patient's hypotension. Widespread vasoconstriction would increase the blood pressure, not decrease it. Decreased myocardial oxygen demand simply means that the heart is not working too hard; this does not affect blood pressure. The MOST important initial treatment for a patient whose cardiac arrest was witnessed is: A) defibrillation. B) cardiac drug therapy. C) rapid transport. D) high-quality CPR. D Regardless of whether a patient's cardiac arrest is witnessed or unwitnessed, the single most important initial treatment is high-quality CPR. Delays in performing CPR have been clearly linked to poor patient outcomes. After CPR has been initiated, apply the AED as soon as it is available. Cardiac drug therapy and rapid transport enhance the patient's chance of survival, but are useless without minimally interrupted, high-quality CPR. While transporting an elderly woman who was complaining of nausea, vomiting, and weakness, she suddenly becomes unresponsive. You should: A) analyze her cardiac rhythm with the AED. B) open her airway and ensure that it is clear. C) assess for signs of breathing and a pulse. D) place her on her side in case she vomits. C If a patient is found unresponsive or becomes unresponsive in your presence, your first action should be to assess for breathing and a pulse; this assessment can occur simultaneously and should take no more than 10 seconds. If the patient is breathing adequately and has a pulse, position her on her side and administer oxygen if needed. If the patient has a pulse but is not breathing, open the airway and provide rescue breathing. If the patient is not breathing (or has agonal gasps) and does not have a pulse, begin CPR (starting with chest compressions) and apply the AED as soon as possible. If you are transporting a patient who becomes unresponsive, pulseless, and apneic, you should begin CPR and instruct your partner to stop the ambulance and prepare the AED. Which of the following patients is the BEST candidate for fibrinolytic therapy? A) 50-year-old man who has slurred speech and left arm weakness that started 45 minutes ago; history of a heart attack 8 months ago B) 53-year-old woman who experienced a sudden, severe headache and is now unresponsive; history of a hemorrhagic stroke 3 years ago C) 59-year-old man whose mental status has declined over the past 12 hours; history of renal failure, hypertension, and type 2 diabetes D) 63-year-old woman had a syncopal episode and is now confused; she takes blood thinners and has a history of deep vein thrombosis A To be the most effective, fibrinolytic medications for stroke should be administered within the first 3 hours following the onset of signs and symptoms. In some patients, this time frame may be extended to 4.5 hours. Any history of intracranial hemorrhage, regardless of how long ago it was, is a contraindication for fibrinolytic therapy. Other contraindications include bleeding disorders (ie, hemophilia), use of blood thinning medications (ie, Coumadin, Eliquis, Pradaxa), and any active hemorrhage. The ultimate decision to initiate fibrinolytic therapy is the physicians at the emergency department, in consultation with the neurologist. However, EMS can, through a targeted assessment, identify those who would most likely benefit from it.