Cardiac Conditions (including CHF)

Question 1

CHF patients should be positioned ___________

Answer 1

upright with legs dependent

Question 2

The only indication for nitroglycerin administration for PCPs is:

Answer 2

Chest discomfort of suspected cardiac ischemic origin

Question 3

ACS patients who are SOB or in shock require __________(high-flow/low-flow) oxygen therapy

Answer 3

high-flow

Patients who are SOB or in shock require high flow O2. If there is difficulty with the probe acquisition due to patient condition, oxygen should be applied liberally

Question 4

It is important to have ACS patients chew ASA tablets because __________

Answer 4

it reduces the time of onset

reduces onset from 1 hour to 20 minutes

Question 5

Nausea is a common symptom of ACS and may be treated by PCPs with __________

Answer 5

Dimenhydrinate, 25-50mg IM or IV

Question 6

List all ways in which nitroglycerin administration is different for PCPs when the patient does not have a prescription vs. when they do have a prescription:

Answer 6

• Mandatory clinicall consult
• SBP must be maintained above 100mm Hg instead of 90
• HR must be maintained in a range of 50-150 BPM
• Dosing is identical

Question 7

Onset for Nitroglycerin when delivered as an SL spray is ___

Answer 7

1-3 minutes

Question 8

ACS patients may receive supplemental oxygen with caution to avoid __________.

Answer 8

hyperoxia

Question 9

If a PCP administers nitroglycerin without a prescription (following mandatory clinicall consult) it may be given as a 0.4 mg spray SL, q 3-5 minutes provided: Systolic blood pressure of >______ mmHg and a HR of >___ and <___

Answer 9

0.4 mg spray SL, q 3-5 minutes provided:

Systolic blood pressure of >100 mmHg
HR of >50 and <150

Question 10

If IV access is required in an ACS patient, the _____ (left/right) arm is preferred.

Answer 10

Left

Keep the middle and distal third of right forearm clear to facilitate potential radial artery access for percutaneous coronary artery intervention

Question 11

ASA exerts its therapeutic effect in ACS by _________

Answer 11

Inhibiting the formation of thromboxane A2 which is a potent platelet aggregate and vasoconstrictor

Question 12

PCPs _____ (may/may not) administer nitroglycerin to CHF patients without chest discomfort

Answer 12

may not

Question 13

Two populations who are more likely to present with atypical symptoms of ACS are __________.

Answer 13

Women and people with diabetes

Question 14

You respond to a 72YO CHF patient with acute pulmonary edema and significant dyspnea. They are alert, able to follow commands and maintain their own airway, tachypneic (RR=32) tachycardic (HR=124) with SBP=84mm Hg, and SpO₂=89% on high-flow oxygen. They have significantly increased work of breathing and accessory muscle use. CPAP is __________ (indicated/contraindicated)

Answer 14

contraindicated (SBP <90mm Hg)

This patient is hypotensive and is in cardiogenic shock. CPAP may potenitate further hypotension.

Question 15

ASA helps to prevent re-occlusion and _____ (will/will not) open the artery.

Answer 15

will not

It has been shown to reduce mortality and is one of the most important early treatments the patient can receive

Question 16

ACS patients without COPD who appear hemodynamically stable should have oxygen therapy titrated to target an Sp0₂ of _____

Answer 16

95%

Question 17

Contraindications to ASA administration are: (list 4)

Answer 17

• Allergy to aspirin or other non-steroidal anti-inflammatory (NSAIDS) agents. This includes many non-aspirin/non-Tylenol pain relievers such as Advil.
• Asthma (see special notes).
• Recent head injury, stroke or acute bleeding (significant) of any kind.
• Pediatric patients with viral symptoms.

• ASA has been linked to Reye’s syndrome in children with a viral history such as chicken pox, or influenza.*
• Asthma – contraindicated in patients who have experienced an exacerbation of their asthma after taking ASA.*

Question 18

CHF patients with failing respirations should be supported with __________

Answer 18

IPPPV with BVM +/- PEEP

Question 19

ASA should be given with caution in: (list 5)

Answer 19

• Recent internal bleeding (within last 3 months).
• Known bleeding diseases.
• Patients currently taking anticoagulant agent(s).
• Recent surgery.
• Possibility of pregnancy.

Question 20

The classic presentation of chest heaviness with radiation to arms or jaw is present in _____% of ACS patients.

Answer 20

30%

Question 21

CHF patients in respiratory distress may be treated with __________ following a mandatory clinicall consult

Answer 21

CPAP

Question 22

Adult dosage of ASA is _____

Answer 22

160mg PO

Have the patient chew ASA before swallowing​

Question 23

ACS patients with COPD, especially if on home oxygen, should have their saturation titrated to around_____ (range)

Answer 23

92-95%

Question 24

Two benefits of CPAP for CHF patients with acute pulmonary edema are:

Answer 24

Improved gas exchange and reduced preload

CPAP acts to prevent alveolar collapse by holding fluid filled alveoli open resulting in improved gas exchange. Increased functioning alveoli allow for improved oxygenation and ultimately decrease the patient’s work of breathing. A secondary benefit of CPAP with CHF patients is the increased pressure in the airways results in an increased intra-thoracic pressure which may help to decrease the volume of blood returning to the congested heart (preload)

Question 25

ASA _____ (does/does not) typically reduce chest pain in ACS patients

Answer 25

does not

Question 26

Adult dosage of nitroglycerin for ACS is ____ mg SL, q _____ minutes, provided SBP remains above _____ mm Hg so long as the patient already has a prescription for nitroglycerin.

Answer 26

0. 4 mg spray SL, q 3-5 minutes provided systolic blood pressure remains above 90 mmHg
   * Consider CliniCall consultation if needing to go beyond 3 doses, for extended transport times, or if patient condition changes/deteriorates markedly*

Question 27

Entonox _____ (is/is not) an appropriate pain management strategy for patients with chest discomfort and suspected ACS

Answer 27

is

Entonox should not be given within 5 minutes of last NTG administration

Question 28

Indications for ASA administration in ACS are:

Answer 28

Chest pain or atypical symptoms consistent with cardiac ischemia/AMI

Question 29

Patients with signs of both CHF (acute pulmonary edema) and hypotension/hypoperfusion are in __________ shock

Answer 29

cardiogenic

These patients are acutely unwell and must be transported to hospital without delay for mechanical support and intervention

Question 30

Adverse efffects of nitroglycerin administration are: (list 3)

Answer 30

• Hypotension - Do not administer if blood pressure is < 90 systolic or patient exhibits signs of significant hypoperfusion
• Nausea
• Headache

Question 31

Nitroglycerin __________ (has/has not) demonstrated an improvement in outcomes for ACS patients.

Answer 31

has not!

Nitroglycerin may relieve the pain of angina but will not relieve the pain of M.I. and may well worsen outcomes if it causes hypotension. It is absolutely contraindicated in hypo-perfusing patients with right sided infarcts on ECG as it can cause significant hypotension.

Question 32

Nitroglycerin should be used with caution in patients with: (list 4)

Answer 32

• Open or closed angle glaucoma
• Hepatic or renal insufficiency.
• Concurrent anti-hypertensive therapy.
• Inferior Myocardial Infarction on 12 lead ECG

Question 33

PCPs _____ (may/may not) administer nitroglycerin to patients without a presciption.

Answer 33

May

This may only be done following a mandatory consult with CliniCall

Question 34

Contraindications for nitroglycerin administration are: (list 7)

Answer 34

• Allergy or known hypersensitivity to nitroglycerin or other nitrates
• Viagra or Levitra use in the past 24 hours
• Cialis use in the past 48 hours
• Hypotension or uncorrected hypovolemia
• Severe anaemia
• Constrictive pericarditis and pericardial tamponade
• Right Sided Myocardial Infarction on 12 lead ECG

Question 35

The primary goal of care in ACS patients is __________

Answer 35

Transport to hospital where the artery can be opened or kept open