Cardiac Catheterization Techniques and Considerations, Exams of Cardiology

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REGISTERED CARDIOVASCULAR INVASIVE

SPECIALIST EXAM RCIS EXAM | ALL

QUESTIONS AND CORRECT ANSWERS WITH

RATIONALES | GRADED A+ | VERIFIED

ANSWERS | LATEST VERSION

You are assisting a new cardiologist do a right heart cath on a cyanotic child. Before inflating the balloon he asks you "What should I use to inflate this balloon?" You should answer______. a. "Air" b. "CO2" c. "Sterile Saline" d. "50%-50%, contrast and saline" ---------CORRECT ANSWER----------------

• ANSWER b. CO2 is 20 times more soluble in blood than air. If the balloon breaks or leaks in the right heart it will be more quickly absorbed. Since cyanotic shunts move across the septum in a R-L direction, some of the gas may pass through the R-L shunt. If it does embolize into the left heart it might lead to a dangerous arterial embolism or stroke. Get the CO2 from a CO2 tank off the table. O2 gas is heavier than air, so let it bleed into a glass or basin through a sterile tube on the table. Then fill the balloon syringe by aspirating CO from the bottom of the glass. Use this to inflate the balloon. One problem with CO2 is that it diffuses rapidly through rubber. So you may have to replenish the CO2 frequently. Never inflate a Swan-Ganz balloon with any fluid, especially contrast! Its high viscosity may prevent you from removing it through the tiny catheter lumen. See: Baim and Grossman, chapter on "Balloon-tipped Flow-directed catheters" Keywords: Cyanotic kid When inserting a Swan-Ganz catheter the balloon should be inflated in the: a. Sheath b. Femoral vein c. IVC-RA

d. RV e. PA ---------CORRECT ANSWER-----------------ANSWER c. RA. The balloon should not be inflated until it reaches the large vena-cava or RA. If inflated in the sheath or small vein it may rupture the balloon or damage the vessel. In an average sized adult the RA is usually reached after inserting the catheter 15-20 cm from the Internal Jugular (I.J.) vein or 30 cm. from the femoral vein. The inflated balloon then floats downstream with the RA- RV-PA blood flow. See: Baim and Grossman, chapter on "Balloon-tipped Flow-directed catheters" Keywords: Inflate Swan balloon in RA The most stable place to leave a Rt. Ht. catheter positioned is with the tip in the: a. RA b. RV c. PA d. PAW ---------CORRECT ANSWER-----------------ANSWER c. PA. Most monitoring catheters are left in the PA position because it produces fewer arrhythmias than the RA (PACs) or RV (PVCs). After obtaining a PA wedge the balloon is deflated to prevent obstruction of blood flow, and the catheter is pulled back out of wedge so in cannot damage the lung. Monitoring Swan-Ganz catheters may be left in the PA position long term. See: Baim and Grossman, chapter on "Balloon-tipped Flow-directed catheters" Keywords: PA most stable position

305. On the second day of pulmonary artery catheter monitoring an RV waveform is observed from the distal catheter port. Which one of the following is the most appropriate action? a. Advance the catheter 10 cm with the balloon deflated b. Switch monitoring lines to the proximal port of the catheter c. Inflate the balloon with 1.5 ml air and withdraw the catheter d. Inflate the balloon with 1.5 ml air and advance the catheter e. Leave in RV, you can still get PA systolic pressure from RV --------- CORRECT ANSWER-----------------

All of the following statements regarding PA catheter insertion are true EXCEPT: a. Following vessel puncture, SaO2 analysis of a withdrawn blood sample should be <95%. b. Use a Paceport Swan in patients with LBBB. c. The major risk of internal jugular cannulation is carotid artery puncture. d. Air embolism is of concern at the time of guidewire and catheter insertion ---------CORRECT ANSWER-----------------ANSWER a. Following vessel puncture, SaO2 analysis of a withdrawn blood sample should be <95% is not true. The SvO2 (not SaO2) must be less than 85% to be sure you are in the vein. Patients may develop RBBB if the RBB is irritated during catheter passage through the RV. If the patient has pre-existing LBBB, complete heart block may ensue, requiring pacing via a paceport catheter, a pacing Swan or external transcutaneous pacing. The carotid artery is close to the internal jugular. Take precautions against air embolism by placing the patient in the Trandelenburg position. See: Darovic, chapter on "Pulmonary Artery Pressure Monitoring" and http://www.pacep.org/pages/start/ref.html?xin=asahq To help prevent pulmonary artery rupture when wedging a Swan-Ganz catheter: a. Check the pulmonary artery occlusion pressure frequently b. Withdraw PAC slightly if a PAOP waveform is obtained with inflation of <1.25 ml air c. Advance PAC slightly if a PAOP waveform is obtained with inflation of <1. ml air d. Always use 1.5 ml air to inflate the balloon for a PAOP ---------CORRECT ANSWER-----------------ANSWER b. Withdraw PAC slightly if a PAOP waveform is obtained with inflation of <1.25 ml air. You want the catheter to wedge with <1.5 ml of air. But, if the wedge air volume is <1.25 the hard catheter tip may be exposed. Darovic says: "The following guidelines should prevent damage or rupture of the pulmonary artery:

1. Do not advance the catheter with the balloon deflated
2. Slow balloon inflation while continuously observing the PA waveform. Inflation is stopped immediately when the PA trace changes to a wedged pressure trace.

3. Do not inflate the balloon with fluid...
4. Keep the wedging time and the number of balloon inflation/deflation cycles to a minimum. If a close pulmonary artery diastolic/wedge pressure relationship exists, pulmonary artery diastolic pressure may be used to assess left atrial pressure.
5. Position the catheter tip in a central pulmonary vessel so that the full or nearly full recommended inflation volume produces the wedge waveform.
6. Avoid excessive catheter manipulation
7. Avoid irrigating the pulmonary artery lumen under high pressure. ... The damped tracing may be due to spontaneous wedging, and forced irrigation may produce rupture of the pulmonary artery." See: Darovic, chapter on "Pulmonary Artery Pressure Monitoring" and http://www.pacep.org/pages/start/ref.html?xin=asahq Which statement regarding thrombus formation on Swan-Ganz catheters is most correct? a. All intravascular monitoring catheters are thrombogenic. b. Heparin should be added to the IV solutions of all patients with a PA catheter. c. Catheters occluded by thrombus should be flushed vigorously with saline to clear the catheter. d. Thrombus begins to form on catheters only after 3 to 5 days in the vessel ---------CORRECT ANSWER-----------------ANSWER a. All intravascular monitoring catheters are thrombogenic. Even heparin does not guarantee they will not clot. However, many physicians are not using heparin for right heart cath or PA monitoring. And, if a catheter does become clotted, do NOT flush the catheter into the circulation. That causes an embolus. Darovic says: "Any catheter in the vascular system can promote thrombus formation, particularly in patients who have prolonged circulatory failure.. .. Prevention of catheter thrombus formation requires consideration of anticoagulation I hypercoagulable patients if pulmonary artery pressure monitoring is prolonged or if catheter insertion is known to have been traumatic." See: Darovic, chapter on "Pulmonary Artery Pressure Monitoring" and http://www.pacep.org/pages/start/ref.html?xin=asahq

Prior to pulling back a Swan-Ganz catheter to record PA-RV pressures you should _________. a. Inflate the balloon b. Deflate the balloon c. Flush the distal lumen of the catheter d. Flush the proximal lumen of the catheter ---------CORRECT ANSWER---- -------------ANSWER b. Deflate the balloon. If you pull back an inflated balloon catheter across a valve, you may damage that valve. The balloon should be "up" when inserting and "down" when withdrawing the catheter. It won't hurt to flush the distal lumen through which your pressures are coming. It will reduce damping. But it is not necessary at this time. See: Baim and Grossman, chapter on "Balloon-tipped Flow-directed catheters" Keywords: deflate balloon when withdrawing Central venous pressure (CVP) can directly assess which 2 of the following?

1. RV function
2. LV function
3. Fluid volume status
4. Myocardial contractility a. 1&2 b. 2&3 c. 3&4 d. 1&3 e. 2&4 ---------CORRECT ANSWER--------------- --ANSWER d. 1 & 3: RV function and Fluid volume status. To measure CVP, a catheter may be placed in the SVC or a Swan-Ganz catheter may be monitored from the RA port. CVP or RA pressure directly measures right heart preload and RV function. The RV filling pressures will be elevated in right heart failure (assuming no tricuspid disease). Darovic say: "The central venous pressure measurement also can be used to assess and manage intravascular volume status because pressure in the great thoracic veins generally correlates with the volume of venous return. The amount of blood that returns to the heart is normally ejected by the heart. Therefore, in patients with hypovolemia, a decreased CVP measurement is associated with a decreased cardiac output, whereas patients with volume overload typically have increased CVP and cardiac output." CVP can indirectly monitor LV function, but only in normal young people. The frequent disparity between right and left heart function in critically ill patients requires a Swan-Ganz catheter so that each side of the heart can be evaluated independently.

See: Darovic, Chapter on "Monitoring Central Venous Pressure" Which of the following is most likely to be associated with hypovolemia? a. Increased central venous pressure b. Decreased RV end-diastolic pressure c. Increased PA occlusion pressure d. Decreased heart rate ---------CORRECT ANSWER----------------- ANSWER b. Decreased RV end-diastolic pressure. Darovic says: "Progressive intravascular volume losses produce greater decrements in right atrial pressure and CVP. Patients with acute, profound hemorrhage may have measurements as low as minus 8 to minus 10 mmHg." In acute decompensated hypovolemic shock vasoconstriction increases to maintain BP, skin is cool & pale, along with signs of tachycardia, lactic acidosis, and hypoxemia. See: Darovic, Chapter on "Monitoring the Patient in Shock" and http://www.pacep.org/pages/start/ref.html?xin=asahq Which one of the following statements about the pulmonary artery occlusion pressure (wedge) is most correct? a. The pulmonary artery occlusion pressure is measured through the most proximal catheter port b. Inflation of the balloon momentarily stops the flow of blood and creates a static column of blood between the tip of the catheter and the left atrium c. The PAOP waveform always contains 3 positive waves (a, c, v) d. During inflation of the balloon the pulmonary artery pressure changes to a right ventricular waveform ---------CORRECT ANSWER----------------- ANSWER b. Inflation of the balloon momentarily stops the flow of blood and creates a static column of blood between the tip of the catheter and the left atrium. This static column transmits the LA pressure back to the catheter tip. Since LA is the filling pressure of the LV, wedge tells us about the LV filling pressure and LV function. The PA occlusion pressure (wedge) is measured through the distal catheter port, as it is directed into the pulmonary capillary bed. The wedge waveform will show a and v waves, but commonly no c wave is visible, because it merges with the a wave. See: Darovic, chapter on "Pulmonary Artery Pressure Monitoring" and http://www.pacep.org/pages/start/ref.html?xin=asahq

Which one of the following statements about abnormal central venous O saturation (SvO2) is most correct? a. SvO2 values <0.60 indicate threatened tissue oxygenation b. SvO2 values >0.80 indicate adequate or increased tissue oxygenation c. SvO2 values <0.60 indicate low oxygen consumption d. SvO2 values >0.80 indicate increased oxygen consumption --------- CORRECT ANSWER-----------------ANSWER a. SvO2 values <0.60 indicate threatened tissue oxygenation. This low venous saturation suggests low cardiac output (wide A-V difference) and poor tissue oxygenation. Darovic says: "SvO2 monitoring is a sensitive indicator of the oxygen supply/demand balance. When the SvO2 values fall to less than 50 percent, the patient should be rapidly assessed for conditions that increase oxygen demand.... Acute changes in the patient's oxygen supply/demand balance may be simply and safely assessed in the clinical setting by two technologies. First, continuous SvO2 monitoring [via Swan-Ganz fibreoptic catheters] ... Second, pulse oximetry can be used with cardiac index and hemoglobin values to estimate the amount of oxygen delivered to the body cells." See: Darovic chapter on "Continuous Monitoring of Mixed Venous Oxygen Saturation (SvO2)" and http://www.pacep.org/pages/start/ref.html?xin=asahq Which one of the following statements about hemodynamic waveforms is most correct? a. Hemodynamic pressures rise during inspiration in a patient breathing spontaneously b. Hemodynamic pressures fall during inspiration in a patient receiving positive-pressure mechanical ventilation c. Hemodynamic pressures should be read at end-expiration in a patient breathing spontaneously d. Hemodynamic pressures should be read at peak-inspiration in a patient receiving positive-pressure mechanical ventilation ---------CORRECT ANSWER-----------------ANSWER c. Hemodynamic pressures should be read at end-expiration in a patient breathing spontaneously and when the patient is receiving mechanical ventilation. So end- expiration is always

correct. The problem with mechanical ventilation is, end-expiration pressures tends to be at the bottom of the tracing, where it is normally at the top. Normal inspiration makes the pressures go down, while mechanical inspiration makes the pressures go up. See: Darovic, chapter on "Pulmonary Artery Pressure Monitoring" and http://www.pacep.org/pages/start/ref.html?xin=asahq

334. Indications for diagnostic myocardial biopsy include all the following EXCEPT: a. Cardiac transplant patient follow up b. LV hypertrophy associated with untreated chronic systemic hypertension c. Restrictive cardiomyopathy (Amyloidosis, hemochromatosis...) d. Viral myocarditis and/or Endocardial fibrosis ---------CORRECT ANSWER-----------------ANSWER b. LV hypertrophy associated with untreated chronic systemic hypertension. Hypertrophy due to pressure overload, and is a major cause of primary myocardial hypertrophy. Whereas, in the other myocardial conditions listed, distinct histologic changes occur in the muscle secondary to infection, tissue deposits, or rejection. Definitive diagnose of many of these conditions can only be made with microscopic tissue analysis. This tissue sample must be taken during an invasive biopsy procedure. Cardiac biopsies are small bites of tissue taken from the Ventricular myocardium with one of the bioptome catheters described below. See: Kern, Chapter "Special Techniques." Keywords: Indications for biopsy
335. From what part of the heart are intracardiac myocardial biopsy samples normally taken? a. RV septum b. RV outflow tract c. Inferior RV wall d. LV free wall ---------CORRECT ANSWER-----------------ANSWER a. The RV septum is the safest area from which to take a sample. Being part of the LV septum, it is the thickest part of the RV. Overzealous sampling may perforate the RV wall, leading to pericardial tamponade. 4-5 samples should be taken from the RV. It is not usually necessary to sample LV because most of the diseases diagnosed are diffuse and effect both

chambers. In addition, Kern states that sampling from the RV outflow tract (near the pulmonic valve) and inferior wall should be avoided. See: Baim and Grossman, Chapter on "Myocardial Biopsy." and Kern, Chapter "Special Techniques."

339. How much heparin should a patient receive for Right heart myocardial biopsy? How much for Left heart biopsy? RT. HEART BIOPSY LEFT HEART BIOPSY a. None, - - - None b. None, - - - 5000 u c. 5000u,---None d. 5000 u, - - - 5000 u ---------CORRECT ANSWER-----------------ANSWER b. None for RV, 5000 u for LV. Heparinization encourages the bleeding from biopsy sites and pericardial tamponade into perforations. Grossman states "We avoid right ventricular biopsy in any patient with a Prothrombin time greater than 17 sec, any patient who is heparinized or any patient with a clinical coagulopathy. On the other hand, left ventricular biopsies are generally performed with systemic anticoagulation (heparin 5000 u), which is not reversed with protamine at the end of the procedure to minimize the risk of thrombus formation at the biopsy site." RT. HEART BIOPSY LEFT HEART BIOPSY None, - - - 5000 u Bleeding from the right side is more serious than emboli (they will be filtered by the lung). Whereas, emboli from the left side are more serious (possibility of stroke). See: Baim and Grossman, Chapter on "Myocardial Biopsy." Keywords: No heparin for RV biopsy, 5000 u for LV biopsy The main hazard of myocardial biopsy is: a. Air embolism through the large sheath b. Bundle branch or complete heart block c. Coronary artery perforation and fistula d. Infection at the biopsy site e. Cardiac perforation ---------CORRECT ANSWER-----------------ANSWER e. RV perforation is the most dreaded complication since it can lead to fatal pericardial tamponade. The RV is only a few mm thick and with force any stiff catheter can perforate. That is why only septal wall samples are taken

and heparin is not given with RV biopsy. Simple pericardial centesis usually cures the tamponade problem. The other complications listed are also possible. This is a very safe procedure with approximately half the mortality of a left heart cath and coronaries (0.10% vs .05%). See: Baim and Grossman, Chapter on "Myocardial Biopsy." Keywords: Main complication biopsy = perforation A complication of myocardial biopsy is inadvertent puncture through the ventricular free wall. What lifesaving measure should be considered if hypotension develops following this procedure? a. Thoracentesis b. Pericardial centesis c. Coronary Artery Bypass surgery d. Aortic Valve Replacement surgery ---------CORRECT ANSWER------------ -----ANSWER b. Pericardial centesis. If blood build-up in the pericardial sack, causing restriction of ventricular filling, pericardial centesis may be lifesaving. See: Baim and Grossman chapter on "Percutaneou s Approach." Keywords: with biopsy wall puncture - treat pericardial tamponade with Pericardio-centesis Myocardial biopsy samples for light microscopic analysis are placed in a solution of: a. 10% formalin b. 56% formalin c. 5.0% Glutaraldehyde d. 50% Glutaraldehyde ---------CORRECT ANSWER-----------------ANSWER a. 10% formalin (formaldehyde) preserves the sample. 2.5% Glutaraldehyde solutions are used for electron microscopic analysis. See: Baim and Grossman chapter on "Myocardial Biopsy." Keywords: preserve biopsy samples in 10% formalin Histologic signs of cardiac transplant rejection found in myocardial biopsy samples include all the following EXCEPT:

a. Interstitial edema and inflammation b. Erythrocytehemolysis c. Lymphocyte infiltration d. Myocyte necrosis ---------CORRECT ANSWER-----------------ANSWER b. Erythrocyte hemolysis is rupture of red blood cells. It may occur in hypertonic solutions or mechanical valve turbulence (hemolytic anemia), but not with transplant rejection. Braunwald says, "The most important feature of post- transplant biopsies is the detection of lymphocyte infiltration and the presence of myocyte necrosis." That involves white blood cells (lymphocytes) rushing in to remove dying (necrotic) cardiac muscle cells (myocytes). The early stages of rejection also involve inflammation and edema of the transplanted myocardial cells. See: Baim and Grossman, Chapter on "Myocardial Biopsy." and Braunwald, Heart Disease..., Chapter on "Heart and Lung Transplantation." Keywords: histologic signs of rejection NOT Erythrocyte hemolysis

283. The first medication given to all ACLS patients should be: a. Nitroglycerine b. Morphine c. Aspirin d. Oxygen ---------CORRECT ANSWER-----------------ANSWER d. Oxygen. Note that the ABCD's should always be done first. The B includes providing ventilation and oxygen to all ACLS patients where it is available. Aspirin is important too, but it may be given at any time but only to suspected ischemic chest pain patients. The secondary ABCD's include IV and administration of medications. The ACLS 2000 Manual says: "Oxygen is always appropriate for patients with acute cardiac disease or pulmonary distress....During cardiopulmonary emergencies use supplemental oxygen as soon as it is available....In patients with acute MI, supplemental oxygen reduces both magnitude and extent of ST-segment changes on the ECG." See: AHA, ACLS Provider Manual, chapter on "VF/Pulseless VT" During ACLS certain drugs may be given down the ET tube. When most drugs are given by the endotracheal route you should __________ followed by several rapid bag inflations to aerosolize the medication.

a. Half the dose and flush in with 20 mL D5W b. Half the dose and dilute in 10 mL of normal saline c. Double the dose and flush in with 20 mL D5W d. Double the dose and dilute in 10 mL of normal saline ---------CORRECT ANSWER-----------------ANSWER d. Double the dose and dilute in 10 mL of normal saline or sterile saline. "If a tracheal tube has been placed before venous access is achieved, epinephrine, lidocaine, and atropine can be administered via the tracheal tube. Administer all tracheal medications at 2 to 2.5 times the recommended IV dose, diluted in 10 mL of normal saline or distilled water. Tracheal absorption is greater with distilled water as diluent than with normal saline, but distilled water has a greater adverse effect on PaO2. Pass a catheter beyond the tip of the tracheal tube, stop chest compressions, spray the drug solution quickly down the tracheal tube, follow immediately with several quick insufflations to create a rapidly absorbed aerosol, then resume chest compressions." D5W is not recommended during resuscitation unless the patient is hypoglycemic. This is the Vaughan Williams classification of antiarrhythmic drugs - Ia, Ib, Ic, II, III, and IV. Match the class with its action: I. Class I _______ II. Class II. _______ III. Class III. _______ IV. Class IV. _______ a. Calcium channel blockers b. Potassium channel blockers c. Beta-1 channel blockers d. Sodium channel blockers ---------CORRECT ANSWER-----------------I. Class I. = d. Block fast Sodium channel (slow Na from entering cell during phase 0) II. Class II. = c. Beta-1 channel blockers (block adrenergic sites) - most end in "-olol." III. Class III. = b. Potassium channel blockers ( prolong repolarization) IV. Class IV. = a. Block slow Calcium channel. Braunwald says: "the Vaughan Williams classification is widely known and provides a useful communication shorthand. It is listed here, but the reader is cautioned that the drug actions are more complex than those depicted by the classification." See: Braunwald, chapter on "Management of Patients with Cardiac Arrhythmias"

Many drugs have antagonists that can counteract their action. Match the drug to its antagonist. I. Heparin antagonist_____________ a. Narcan II. Demerol/morphineantagonist_____________ b. III. Midazolam (Versed) antagonist_____________ c. IV. tPA antagonist_____________ d. V. Warfarin (Coumadin) antagonist_____________ e. Protamine Romazicon Amicar Vitamin K ---------CORRECT ANSWER-------- ---------ANSWER I. Heparin antagonist = II. Demerol/morphine antagonist = III. Midazolam (Versed)antagonist = IV. Thrombolytic (tPA) antagonist = V. Warfarin (Coumadin) antagonist = e. Flumazenil (Romazicon) rapidly reverses the effects of Versed. It binds to benzodiazepine receptors in the CNS and block them. It may cause rapid withdrawal, which is shorter acting than the Versed itself - leading to delayed re-sedation. Side effects are panic attacks, seizures, cardiac ischemia and pulmonary edema. Narcan (naloxone) is an antagonist to opiate medications such as demerol, fentanyl, and morphine. However, it is shorter acting than the drug itself and may need to be redosed. The thrombolytic (tPA) can be reversed with aminocaproic Acid (Amicar). Warfarin can be reversed with vitamin K or infusion of fresh frozen plasma. However, these two drugs do not completely reverse the primary drug effect. Loebl, The Nurses Drug Handbook, Chapter on "Thrombolytic drugs" b. Protamine a. Naloxone (Narcan) c. Romazicon (Mazicon, flumazenil) d. Aminocaproic Acid (Amicar) Vitamin Stimulation of different autonomic receptor sites causes specific hemodynamic effects. Match each receptor site to the hemodynamic effect it causes. I. Alpha 1 _____ II. Beta 1 _____ III. Beta 2 _____ IV. Parasympathetic _____

a. Dilate lung bronchioles b. Stimulate heart muscle & AV node c. Vasoconstrict vascular smooth muscle (peripheral arteriolar arterioles...) d. Slow heart rate and AV node conduction ---------CORRECT ANSWER---- -------------ANSWER I. Alpha 1 = c Vasoconstrict vascular smooth muscle (peripheral arteriolar vasoconstriction...) II. Beta 1 = b. Stimulate heart muscle & AV node (catecholamine effect)) III. Beta 2 = a. Dilate lung bronchioles (reverse broncho- constriction in asthma) IV. Parasympathetic = d. Slow heart rate and AV node conduction Remember alpha (α) adrenergic as follows: the Greek letter (α) alpha looks like a knot in a suture tied around a vessel - constricting it. Adrenergic receptors To remember the 2 types of Beta receptors say the acronym "We have one heart, two lungs". To remind us that Beta 1 (one heart) causes cardiac stimulation, and beta 2 (2 lungs) causes bronchial dilation and some vascular dilation of skeletal muscle. Stimulation of these receptors can come either from a sympathetic neural discharge or from circulating norepinephrine stimulating the heart. Thus, a total sympathetic discharge would prepare you for "fight or flight" by stimulating these receptors. These are important because the actions of many of the cardiac drugs effect these receptor site. Over a wide range of arterial blood pressure (70 - 160 mmHg) the sympathetic and parasympathetic systems have opposite effects; sympathetic - speeds, parasympathetic - slows. Like your cars gas pedal (speeds) and brake (slows). When your reflexes tell you to stop, you remove your foot from the gas and hit the brake. In the same way, the sympathetic and parasympathetic systems provide a push/pull control. See: Todd, CV Review Book Vol. I, Chapter on "Autonomic CNS" Vasopressin has several advantages over Epinephrine in VF/pulseless VT. Circle the 3 advantages of vasopressin. a. Increased alpha and beta stimulation b. Reduced cardiac ischemia and irritability c. More effective in Asystole and PEA d. One-time dose simplifies administration

e. Reduced propensity for VF f. Shorter half-life ---------CORRECT ANSWER-----------------ANSWER b, d, & e. b. Reduced cardiac ischemia and irritability (Epi. should be given cautiously in MI because its beta effects makes the heart beat faster and harder, whipping the heart, which may lead to ischemia and irritability) d. One-time dose simplifies administration (Yes, You can only give it once, whereas epi. must be given every 3-5 minutes) e. Reduced propensity for VF (High catecholamine state may make the heart return to VF) The 2000 ACLS manual says: "Vasopressin produces the same positive effects as epinephrine in terms of vasoconstriction and increasing the blood flow to the brain and heart during CPR. Moreover, vasopressin does not have the negative, adverse effects of epinephrine on the heart, such as increased ischemia and irritability and paradoxically, the propensity for VF.... Vasopressin is not recommended for asystole and PEA at this time simply because its value in the treatment of these cardiac arrest rhythms has not yet been documented in human trials. Give vasopressin as a single, 1-time dose (40 u IV) a regimen based on the much longer half-life of vasopressin (10 to 20 minutes) compared with epinephrine (3 to 5 minutes)....higher epinephrine doses may contribute to return of spontaneous circulation, but they have also been associated with greater postresuscitation myocardial dysfunction, and they may create a "toxic hyperadrenergic state." Many hospitals give the vasopressin 1st and then start epi. and antiarrhythmics after 10 minutes when the vasopressin wears off. See: AHA, ACLS Provider Manual, chapter on "VF/Pulseless VT" Match the maximum dose of these antiarrhythmic medications. I. Amiodarone ______________ II. Lidocaine ______________ III. Procainamide ______________ IV. Atropine ______________ a. 17 mg/Kg b. 3 mg/Kg c. 2.2 g/24 hrs d. 0.03 mg/Kg (~2 mg) ---------CORRECT ANSWER-----------------ANSWER I. Amiodarone II. Lidocaine III. Procainamide IV. Atropine = c. 2.2 g/24 hrs

=b.3mg/Kg = a. 17 mg/Kg = d. 0.03 mg/Kg (~2 mg) Note: the International consensus recommends a higher max. dose of 0.04 mg/k (~3 mg) See: AHA, ACLS Provider Manual, chapter on "VF/Pulseless VT" You have just completed an echocardiogram. Your patient asks you to interpret the results of his diagnostic examination. Your response as a healthcare professional should be to: a. Say you don't know how to interpret results b. Explain that the physician will interpret it and report the results c. Explain that the final results are inconclusive d. Honestly interpret it to the best of your ability ---------CORRECT ANSWER-----------------ANSWER b. Explain that the physician will interpret it and report the results. One of the 10 principles of professional conduct adopted by the ARRT is "Radiologic Technologists shall not diagnose, but in recognition of their responsibility to the patient, they shall provide the physician with all information they have relative to radiologic diagnosis for patient management." We do not possess all the information or training necessary to diagnose the patient. Diagnosis, pathology and treatment are the physician's final responsibility. We can often reinforce his comments, clarify things and respond to our patient's questions, but always with the qualification that the physician has the final say. See: Torres, chapter on "The Radiologic Technologist and professionalism" Prior to any cardiac invasive procedure the ultimate responsibility for obtaining informed consent lies with the: a. Patient's primary care physician (GP) b. The operating physician (Cardiologist) c Circulating nurse assigned to the case d. Patient and his/her family ---------CORRECT ANSWER----------------- ANSWER b. The operating physician (Cardiologist). The ultimate responsibility for obtaining permission is the operating physician's, usually the operating cardiologist. The cath lab staff are responsible for checking that the consent is on the chart, properly signed, and that the information

on the form is correct. See: Allmers, Review for Surgical Tech. Exam, chapter on "Fundamentals" A recommended position for a patient in acute pulmonary edema is: a. Prone position, to encourage maximum rest, thus decreasing respiratory and cardiac rates b. Sitting up position to facilitate breathing and decrease venous return c. Trendelenburg position, to drain blood from leg veins into the heart. d. Recovery position, lateral with upper leg flexed and forward, and upper hand across the chest with back of hand held supporting his cheek. --------- CORRECT ANSWER-----------------ANSWER b. Sitting up position to facilitate breathing and decrease venous return. A patient with dyspnea is usually uncomfortable in a lying supine position (orthopnea). This is because gravity increases fluid in the lungs which increases edema in CHF patients. They often have less difficulty breathing when placed in either a semi- sitting (mid- Fowler's) position 30o, sitting (high- Fowler's) position 45o, or reverse Trendelenburg position (body tilted head up). See: Medical Dictionary When charting in the medical record you should: a. Avoid generalizations like "appears, inadvertently, seems to..." b. Avoid writing with fountain pens with liquid ink c. Avoid documenting routine safety measures d. Chart care as you are planning it, not after it is given ---------CORRECT ANSWER-----------------ANSWER a. Avoid generalizations like "appears, inadvertently, seems to..." Kern says: "Information in the medical record should reflect only accurate facts regarding the particular patient. Avoid generalizations and speculating by charting only what you see, hear, feel, and smell. Do not use words such as inadvertently, unfortunately, appears, resembles, and the like.... Chart after the delivery of care, not before. Never make an entry in anticipation of something to be done...The chart note should identify precautionary or protective measures that have been taken for the safety of the patient, including the use of side rails and restraints." Charting should always be done with a permanent ink pen, although especially runny ink may smear. See: Kern, chapter on "Documentation in the Cardiac Catheterization Laboratory"

To be legally valid, what is the LATEST that the patient should sign the informed consent form? a. Before administration of preoperative medications (such as demerol) b. Before administration of conscious sedation (such as Versed) c Before any invasive incisions or percutaneous punctures are made d. Before any interventions are made (PTCA, Stent...) ---------CORRECT ANSWER-----------------ANSWER a. Before administration of preoperative medications. Consent forms must be signed before the administration of preoperative medications. This is to ensure that the patient fully understands and is informed about the procedure and the risks involved. If his mind is clouded by preoperative medications such as demerol the consent is not legally valid. See: Allmers, Review for Surgical Tech. Exam, chapter on "Fundamentals" A patient's informed consent: a. Authorizes all routine hospital procedures b. Protects patient from high risk procedures .c Protects the operating physician and the hospital from claims of an unauthorized operation d. Authorizes the physician to withhold lifesaving measures as he deems appropriate ---------CORRECT ANSWER-----------------ANSWER c. Protects the operating physician and the hospital from claims of an unauthorized operation. An informed consent (operative permit) protects the operating physician and the hospital from claims of an unauthorized operation. A general consent authorizes the physician and staff to render treatment and perform procedures which are routine duties normally carried out at the hospital. It also protects the patient from procedures they have not been informed about. The physician cannot perform different procedures or withhold lifesaving measures unless it has been approved by the patient. See: Allmers, Review for Surgical Tech. Exam, chapter on "Fundamentals" Your patient with hypertension has been noncompliant in taking his antihypertensive medications. He should be taught that one relatively common complication of uncontrolled hypertension is:

a. Thrombophlebitis b. Herniation of the aorta c. Destruction of valves in the venous system d. Hemorrhaging of blood vessels in the brain - --------CORRECT ANSWER- ----------------ANSWER d. Hemorrhaging of blood vessels in the brain. "Hemorrhaging and occlusion of blood vessels in the body are relatively common complications of uncontrolled hypertension and occur in various places in the body, but most often in the brain (stroke), the eyes, the heart (myocardial infarction) and the kidneys." Just as in coronary disease we should encourage patients to beware of the symptoms of MI, we should alert hypertensive patients about the risk of stroke of failing to take their medication. See: Lippincott's State Board Review for NCLEX-PN. Your patient is told that he has a poor prognosis, but says he believes there is some mistake. According to Dr. Elisabeth Kubler- Ross, this patient is most probably in what grief stage? a. Anger b. Denial c. Bargaining d. Depression ---------CORRECT ANSWER-----------------ANSWER b. Denial. "When a terminally ill person states that there must be a mistake or that he is being confused with someone else, he is most probably denying his impending death. These 5 stages of grief are described by Dr. Elisabeth Kubler- Ross: 1. Denial & disbelief "What! There must be some mistake" 2. Anger "Why me?" 3. Bargaining "If I'm healed, I promise to..." 4. Depression "Oh God! Wherefore art thou?" 5. Acceptance "OK. Thy will be done." See: Lippincott's State Board Review for NCLEX-PN. Your patient is to receive vein stripping surgery for varicose veins. She asks you how her circulation will be provided in her leg after surgery with the veins gone? You should base your response on knowledge that: a. Such information should only be provided by the physician b. New veins develop to replace the removed veins c. Veins deep in the leg take over the work of the removed veins d. The end of ligated veins are anastomosed for continuity of veins --------- CORRECT ANSWER-----------------ANSWER c. Veins deep in the leg take

over the work of the removed veins. When veins are ligated and stripped, the affected veins are severed and removed. The blood then returns through veins deeper in the leg so that return circulation continues. New veins do not replace those removed, nor do arteries take over the functions of veins. Entire veins often are removed and their ends are ligated, such as the saphenous vein for CABG surgery, without compromise to the patients venous circulation. See: Lippincott's State Board Review for NCLEX-PN Which of the following is NOT a predisposing factor for acute MI? a. Diabetes b. Hypertension c. Hyperlipidemia d. High estrogen levels ---------CORRECT ANSWER-----------------ANSWER d. High estrogen levels is incorrect. Estrogen, the female hormone, appears to protect women from heart disease. After menopause, when estrogen levels fall in women, they begin to develop coronary disease akin to men. Diabetes, hypertension, and hyperlipidemia (high cholesterol) are all risk factors for atherosclerosis. See: Braunwald, chapter on "Coronary Risk Factors" If you suspect that your patient has an organic heart murmur, the cause of such a murmur would probably be a defect in the: a. Conduction system b. Coronary arteries c. Mixing of blood d. Action of the heart valves ---------CORRECT ANSWER----------------- ANSWER d. Action of the heart valves. An organic heart murmur is caused by a defect in the action of heart valves such as stenosis or leakage (regurgitation or shunt). A functional heart disorder, in contrast to an organic heart disease, is a disturbance in function only with no organic cause. A functional heart murmur is often caused by anxiety or exercise. Heart murmurs are unrelated to oxygenation of blood, the heart's ability to pump, or the capacity of coronary arteries. See: Lippincott's State Board Review for NCLEX-PN.

Your patient reports having had an illnesses which predisposed her to having a heart murmur. What childhood disease was this: a. Measles b. Mononucleosis c. Rheumatic fever d. Infectious hepatitis ---------CORRECT ANSWER-----------------ANSWER c. Rheumatic fever. Patients who have had rheumatic fever often have heart valve problems, such as mitral stenosis, later in life. Although mostly eliminated in the USA due to the advent of antibiotics, it is common in tropical countries. See: Lippincott's State Board Review for NCLEX-PN. Retrosternal chest pain that is associated with sweating, nausea or vomiting, and not relieved by rest and nitroglycerine is most likely due to: a. Pericarditis b. Variant angina c. Aortic dissection d. Myocardial infarction ---------CORRECT ANSWER-----------------ANSWER d. Myocardial infarction. Braunwald says about MI: "The pain of AMI is variable in intensity; in most patients it is severe...prolonged. described as constricting, crushing, oppressing,... The pain is usually retrosternal in location, spreading frequently to both sides of the anterior chest, with predilection for the left side. Often the pain radiates....Nausea and vomiting occur in more than 50 percent of patients with transmural MI and severe chest pain,.... See: Braunwald, chapter on ""Acute Myocardial Infarction" One indicator of cardiogenic shock is: a. Decreased heart rate b. Increased blood pressure c. Increased body temperature d. Decreased urine output ---------CORRECT ANSWER----------------- ANSWER d. Urine output decrease, low BP, weak rapid heart rate, cold clammy skin, cyanosis - are all indicators of shock (cardiogenic or hypovolemic). Braunwald states that "Shock encompasses the syndromes associated with an acute reduction in effective blood flow with failure to maintain the transfer and delivery of essential substrates to sustain the

function of vital organ systems." In shock, blood is shunted to vital organs (such as the brain), and away from less essential tissues (like skin). See: Braunwald, chapter on "Acute Circulatory Failure (Shock)." Amaurosis Fugax is a symptom that involves the patient's: a. Sight b. Hearing c. Equilibrium d. Sensation of pain ---------CORRECT ANSWER-----------------ANSWER a. Sight. Amaurosis Fugax is a temporary episode of blindness in one eye, or partial blindness. It is often a sign of TIA or cerebral ischemia suggesting carotid stenosis. See: Medical dictionary A patient's blood pressure is 80/45 and heart rate of 56. This pressure and HR is: a. Hypertensive, tachycardia b. Hypertensive, bradycardia c. Hypotensive, tachycardia d. Hypotensive, bradycardia ---------CORRECT ANSWER----------------- ANSWER d. Hypotensive, bradycardia. Normal blood pressure is 120/80. Below 100 is hypotensive. Normal HR is 60-100. Below 60 is bradycardia. However, in resting athletic young people the rate may normally go as low as 50 bpm. See: Lippincott's State Board Review for NCLEX-PN. Which body fluid is LEAST likely to transmit HIV to a health care worker?: a. Semen b. Blood c. Pericardial fluid d. Saliva - --------CORRECT ANSWER-----------------ANSWER d. Saliva. The CDC says: "HIV has been isolated from blood, semen, saliva, tears, urine, vaginal secretions, cerebro-spinal fluid, breast milk, and amniotic fluid, but only blood and blood products, semen, vaginal secretions, and possibly breast milk (this needs to be confirmed) have been directly linked to transmission of HIV. Contact with fluids such as saliva and tears has not

been shown to result in infection. Although other fluids have not been shown to transmit infection, all body fluids and tissues should be regarded as potentially contaminated by HBV or HIV, and treated as though they were infectious...." HIV may also be transmitted by sexual contact, including semen. See: Dept Labor/Dept Health & Humans Services, Joint advisory Notice, "Protection against occupational exposure to HBV and HIV" Which body fluid is MOST likely to transmit Hepatitis B virus to a health care worker? a. Urine b. Blood c. Pericardial fluid d. Vomitus ---------CORRECT ANSWER-----------------ANSWER b. Blood. The CDC says: "Blood contains the highest HBV titers of all body fluids and is the most important vehicle of transmission in the health- care setting. HBsAg is also found in several other body fluids, including breast milk, bile, cerebrospinal fluid, feces, nasopharyngeal washings, saliva, semen, sweat, and synovial fluid. However, the concentration of HBsAg in body fluids can be 100- 1000 - fold higher than the concentration of infectious HBV particles. Therefore, most body fluids are not efficient vehicles of transmission because they contain low quantities of infectious HBV....Feces, nasal secretions, saliva, sputum, sweat, tears, urine and vomitus are not considered potentially infectious unless they contain blood. The risk for transmission of HBV, HCV, or HIV infection from these fluids and materials is extremely low." See: Dept Labor/Dept Health & Humans Services, Joint advisory Notice, "Protection against occupational exposure to HBV and HIV" Which virus is commonly transmitted by food workers who fail to wash their hands? a. Hepatitis A b. Hepatitis B c. AIDS d. HIV ---------CORRECT ANSWER-----------------ANSWER a. Hepatitis A is a food borne virus. HAV is found in the feces of HAV-infected persons. It is

commonly spread by food workers who don't wash their hands after using the toilet. HIV, Hepatitis B and Hepatitis C viruses are found in the body fluids of infected individuals; and can be transmitted to health workers during invasive procedures via needle sticks, skin lesions, or splashing body fluids onto mucous membranes. HIV virus leads to the AIDS syndrome, which occurs in the final stages of the HIV infection. See: www.immunize.org Which of the following exposures pose the greatest risk for bloodborne pathogen infection? a. A nurse sustains a needle-stick while drawing up insulin to administer to a patient with diabetes b. A lab worker is splashed in the eye with urine from a patient with HIV c. A scrub tech who gets blood on his chapped hands while assisting in a surgery on a patient with hepatitis B infection d. While cleaning the bathroom, a housekeeper's intact skin has contact with feces ---------CORRECT ANSWER-----------------ANSWER c. A scrub tech who gets blood on his chapped hands while assisting in a surgery on a patient with hepatitis B infection. Blood is the most infectious body fluid, especially when it gets into an open wound as may be found on chapped hands. The nurse's needle-stick appears to be from a clean needle. CDC says: "Feces, nasal secretions, saliva, sputum, sweat, tears, urine and vomitus are not considered potentially infectious unless they contain blood." See: Dept Labor/Dept Health & Humans Services, Joint advisory Notice, "Protection against occupational exposure to HBV and HIV" Many health care workers who develop hepatitis B viral infections have not been exposed to HBV infected patients. How were these workers probably infected? a. Private sexual encounters b. Tattooing or ear piercing c. Inhalation of aerosolized nasal secretions d. Direct contact with dried blood on environmental surfaces e. Ingestion of contaminated food or drinking water ---------CORRECT ANSWER------------- ----ANSWER d. Contact with Dried blood on environmental surfaces. Such secondary infection is the main reason all blood spills and spatters must be

cleaned up and disinfected and why it is so important to wash your hands frequently. The CDC says: "Although percutaneous injuries are among the most efficient modes of HBV trans mission, these exposures probably account for only a minority of HBV infections among health care professionals (HCP). In several investigations of nosocomial hepatitis B outbreaks, most infected health care professionals could not recall an overt percutaneous injury, although in some studies, up to one third of infected HCP recalled caring for a patient who was HBsAg- positive. In addition, HBV has been demonstrated to survive in dried blood at room temperature on environmental surfaces for at least 1 week. Thus, HBV infections that occur in health care professionals with no history of nonoccupational exposure or occupational percutaneous injury might have resulted from direct or indirect blood or body fluid exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces..., There is no evidence that HBV or HIV can be transmitted via food, drinking water, or airborne aerosols." See: Dept Labor/Dept Health & Humans Services, Joint advisory Notice, "Protection against occupational exposure to HBV and HIV" For which viruses currently are there NO immunizing vaccines? a. HIV and HBV b. HIV and HCV c. HAV and HBV d. HAV and HCV ---------CORRECT ANSWER-----------------ANSWER b. HIV and HCV have NO immunizing vaccines as of year 2002. These are the Human Immunodeficiency Virus and the Hepatitis C Virus. Unfortunately both of these virus can be spread by blood or body fluids from infected individuals. See: www.immunize.org After an accidental needle-stick from the needle used on an infected patient, which bloodborne pathogen poses the greatest risk of infection to health care workers? a. Hepatitis A b. Hepatitis B c. Hepatitis C