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SAEM CV
A 23-year-old male presents after a syncopal episode. EKG findings include normal sinus rhythm, a short PR interval (less than 0.12 seconds), QRS duration of 0.11seconds, and the presence of a "delta wave" (a slurred upstroke to the QRS complex). What condition most likely caused the syncopal episode? Answers: 1.Brugada syndrome 2.Dextrocardia 3.Vasovagal reaction 4.Wolff-Parkinson-White syndrome - correct answer 4.Wolff-Parkinson-White syndrome Of the options below, the therapy best for symptomatic 3rd degree heart block is: Answers: 1.lidocaine 2.transcutaneous pacer 3.atropine 4.oxygen 5.cardioversion - correct answer 2.transcutaneous pacer A 54 year old female presents with palpitations. She is otherwise asymptomatic. EKG shows atrial fibrillation. Vital signs are HR 130-150, BP 148/78, RR 16, T 36.7. What management intervention is most important to accomplish next?
Answers: 1.Anticoagulation 2.Cardioversion 3.Pharmacologic ventricular rate control 4.Radiofrequency ablation - correct answer 3.Pharmacologic ventricular rate control An 8 year old female presents with a regular, narrow-complex SVT. You diagnose AV nodal reentrant tachycardia. Which pharmacologic agent would be most appropriate for initial management? Answers: 1.Adenosine 2.Digoxin 3.Diltiazem 4.Lidocaine - correct answer 1.Adenosine A 65 year old male presents to the emergency department with chest pain. Cardiac monitoring shows a wide complex tachycardia. Past medical history is significant only for hypertension. His BP is 100/66, HR 144, RR 24, and T. 37.5. In addition to ongoing chest pain, he reports dyspnea. His level of consciousness is mildly decreased. Management should proceed on the assumption that he has what abnormal rhythm? Answers: 1.Sinus tachycardia with LVH 2.Supraventricular tachycardia with aberrancy
188/118. Which of the interventions below is the most appropriate step to take in response to the blood pressure assessment? Answers: 1.Administer a sublingual antihypertensive agent since the patient probably only has an ankle sprain and will not need an intravenous line 2.Establish intravenous access in order to optimize the onset of action of parenteral antihypertensive medications 3.Ignore the blood pressure since the patient is asymptomatic other than having ankle pain 4.Order an antihypertensive agent to be given in the emergency department because the patient will be discharged with a prescription for one 5.E. Take measures to relieve pain and recheck the blood pressure. - correct answer 5.E. Take measures to relieve pain and recheck the blood pressure. The blood pressure at which malignant hypertension is defined as present is: Answers: 1.an elevated arterial pressure associated with end organ damage 2.an elevated arterial pressure that exceeds the patient's baseline by 33% 3.diastolic blood pressure of 110 or greater 4.systolic blood pressure of 170 or greater 5.systolic blood pressure of 180 or greater - correct answer 1.an elevated arterial pressure associated with end organ damage Which of the ocular findings below is associated with hypertension?
Answers: 1.arterio-venous nicking 2.cherry red spot 3.increased cup-to-disk ratio 4.retinal nevus 5.Roth spots - correct answer 1.arterio-venous nicking With regard to targets for therapy of elevated blood pressure identified during an emergency department visit, which of the following is generally true? Answers: 1.Patients with hypertensive emergencies should have blood pressure normalized (for age) within an hour or less 2.Patients with hypertensive emergencies should have mean arterial blood pressure lowered by 50% within 50 minutes 3.Patients with hypertensive urgencies are preferably treated with sublingual nifedipine, as compared with intravenous agents 4.Patients with hypertensive urgencies should have blood pressure normalized (for age) within an hour 5.The target systolic pressure for patients with acute aortic dissection is an absolute number rather than a percent pressure reduction - correct answer 5.The target systolic pressure for patients with acute aortic dissection is an absolute number rather than a percent pressure reduction A 40 year old female presents to the emergency department complaining of a few days of headaches, excessive sweating, anorexia, heat intolerance and palpitations.
was negative. In the emergency department, assessment of tests sent from the clinic visit is noteworthy for a normal TSH, normal head CT scan, and markedly elevated urine metanephrine levels. If this woman were to require emergency department therapy for hypertension, which of the following agents should be AVOIDED: Answers: 1.alpha-adrenergic receptor blocker 2.beta-adrenergic receptor blocker 3.calcium channel blocker 4.ACE-inhibitor 5.nitroprusside - correct answer 2. beta-adrenergic receptor blocker In a patient with malignant hypertension, the patient's blood pressure should be reduced to what value in the initial 2 hours of treatment? Answers: 1.120/80 mm Hg 2.100/70 mm Hg 3.90/60 mm Hg 4.75% of the pretreatment mean arterial pressure (MAP) 5.50% of the pretreatment MAP - correct answer 4.75% of the pretreatment mean arterial pressure (MAP) You need to treat an adult with no past medical history, who presents with a hypertensive emergency. You have access to all of the following agents. Which of the following is the preferred agent and initial dose?
Answers: 1.clonidine PO 0.1 mg 2.esmolol IV 100-500 mic/kg load 3.hydralazine IM 0.1-0.2 mg/kg 4.labetolol IV 0.2-1.0 mg/kg bolus 5.metoprolol PO 10 mg - correct answer 2.esmolol IV 100-500 mic/kg load A 51-year-old male with long-standing hypertension presents with abrupt onset of severe chest pain radiating to the back. He describes a tearing sensation. Vital signs are HR 110, BP 175/105, RR 20, T 37.4. EKG shows LVH. CBC, electrolytes, BUN/Creatinine are all normal. CXR is as shown below. What diagnostic test would be most appropriate for making a definitive diagnosis at this time? [PICTURE DEMONSTRATES WIDENDED MEDIASTINAUM] Answers: 1.Aortogram 2.CT of the chest with IV contrast 3.Esophagram using Gastrografin 4.MRI of the thoracic spine - correct answer 2.CT of the chest with IV contrast A 63-year-old female presents to a rural ED at 1am after three hours of substernal chest pain and pressure, with radiation to both arms. Paramedics gave oxygen, aspirin, and sublingual nitroglycerin without change in her symptoms. EKG shows 3- 5 mm of ST-segment elevation in leads V2-V6. CXR is unremarkable. Past medical history is significant for hypertension, and subarachnoid hemorrhage three years ago. Your hospital does not have cardiac catheterization capability at this time of day, but a nearby tertiary care center does. Transport time would be 90 minutes.
1.CXR
2.D-dimer 3.Echocardiogram 4.EKG with right-sided leads - correct answer 4.EKG with right-sided leads A 71-year-old male presents after a syncopal episode. He reports 12 hours of recurrent substernal chest pressure. A report from the patient's primary care physician's office states that an EKG performed four days ago was completely normal. Repeat EKG in the ED reveals no ST-segment elevation, but you do note a right bundle-branch block, and a left anterior fascicle block. Troponin I is elevated above normal at 1.6. What intervention would be indicated to provide definitive management for the findings seen on EKG in this patient? Answers: 1.Continuous cardiac monitoring for 24-48 hours 2.Emergent revascularization with thrombolytics or percutaneous coronary intervention (PCI) 3.Radiofrequency ablation 4.Urgent placement of a cardiac pacemaker - correct answer 4.Urgent placement of a cardiac pacemaker A 23-year-old male presents after a syncopal episode. EKG findings include normal sinus rhythm, a short PR interval (less than 0.12 seconds), QRS duration of 0. seconds, and the presence of a "delta wave" (a slurred upstroke to the QRS complex). What condition most likely caused the syncopal episode? Answers: 1.Brugada syndrome 2.Dextrocardia
3.Vasovagal reaction 4.Wolff-Parkinson-White syndrome - correct answer 4.Wolff-Parkinson-White syndrome A 60-year-old male is brought in by paramedics after a witnessed cardiac arrest. He remains pulseless and apneic. Rhythm strip is shown below. In addition to providing effective cardiopulmonary resuscitation, what management step is most likely to result in survival? [EKG DEMONSTRATES SECOND DEGREE HEART BLOCK] Answers: 1.Atropine 2.Identification and treatment of a reversible underlying etiology 3.Transcutaneous pacing 4.Vasopressin - correct answer 2.Identification and treatment of a reversible underlying etiology A 54-year-old female presents with palpitations. She is otherwise asymptomatic. EKG shows atrial fibrillation. Vital signs are HR 130-150, BP 148/78, RR 16, T 36.7. What management intervention is most important to accomplish next? Answers: 1.Anticoagulation 2.Cardioversion 3.Pharmacologic ventricular rate control 4.Radiofrequency ablation - correct answer 3.Pharmacologic ventricular rate control
2.One-half to one-third the standard dose should be used 3.Two to three times the standard dose should be used 4.Ten times the standard dose should be used - correct answer 3.Two to three times the standard dose should be used A 65-year-old female presents with a chief complaint of palpitations and dyspnea on exertion. Vital signs are BP 130/84, HR 160 (and irregularly irregular), RR 14, T 37.8. EKG shows a narrow complex, irregularly irregular rhythm with absence of p-waves and an undulating baseline. What endocrine abnormality is most likely to be a direct cause of this abnormal rhythm? Answers: 1.Addison's disease 2.Cushing's syndrome 3.Hyperparathryoidism 4.Hyperthyroidism - correct answer 4.Hyperthyroidism The standard initial ACLS dose of IV epinephrine is: Answers: 1.0.1 mg 1:10, 2.1mg of 1:10, 3.10mg of 1:10, 4.1mg of 1:1,000 - correct answer 2.1mg of 1:10,
The next step in treatment for a patient with ventricular fibrilation, which is refractory to multiple countershocks and epinephrine, is: Answers: 1.lidocaine 2.bicarbonate 3.calcium 4.trancutaneous pacing 5.adenosine - correct answer 1.lidocaine Which of the following is the treatment of choice for torsades de pointes? Answers: 1.external pacing 2.lidocaine 3.magnesium sulfate 4.defibrillation 5.sodium bicarbonate - correct answer 3.magnesium sulfate A 45 year old male preents to the emergency department with CP. While you are talking to him he becomes unresponsive. The monitor shows ventricular tachycardia. The correct seequence of treatment is: Answers: 1.immediate defibrillation up to three times
3.Call cardiology to request a stat echocardiogram to check for wall motion abnormalities and aortic dissection. 4.Call her primary care physician. 5.Call cardiology for a decision between thrombolytic and percutaneous coronary intervention. - correct answer 5.Call cardiology for a decision between thrombolytic and percutaneous coronary intervention. A patient with nontraumatic chest pain is administered nitroglycerin in the field and has subsequent drop in blood pressure. An EKG reveals ST-segment elevation in lead V4R. What is the diagnosis? Answers: 1.anteroseptal MI 2.pericarditis 3.pulmonary embolism 4.unstable angina 5.right-ventricular MI - correct answer 5.right-ventricular MI Which coronary vessel is usually the cause of the myocardial infarction in a patient with ST elevation in V1, V2, and V3? Answers: 1.left anterior descending (LAD) 2.left circumflex artery 3.posterior descending branch of the right coronary artery
4.right coronary artery (RCA) 5.right ventricular branch of the right coronary artery - correct answer 1.left anterior descending (LAD) Once aortic dissection is suspected the physician should plan for early cardiothoracic surgery consultation; additionally, which of the following is the best next step? Answers: 1.Start IV beta blocker to decrease shearing forces on the aorta and IV sodium nitroprusside to lower blood pressure. 2.Order an MRI to characterize the dissection's anatomy. 3.Start IV nitroglycerin to lower blood pressure and give aspirin to inhibit platelets. 4.Start IV nitroglycerin to lower blood pressure and IV beta blocker to decrease shearing forces on the aorta. 5.Start IV sodium nitroprusside to decrease shearing forces on the aorta. - correct answer 1.Start IV beta blocker to decrease shearing forces on the aorta and IV sodium nitroprusside to lower blood pressure. A 60 year old male with known coronary artery disease presents complaining of recentchest pain. The chest pain typically occurs after exertion and lasts about 15 minutes. He takes a sublingual nitroglycerin or rests and the pain subsides. He is currently pain free. He has had similar episodes for the last 6 months with no change in frequency or intensity of the chest pain. He most likely has: Answers: 1.acute coronary syndrome 2.acute myocardial infarction 3.stable angina
5.pregnancy induced hypertension - furosemide - correct answer 2.aortic dissection
- nitroprusside/propranolol A 64 year old female presents to the emergency department with chief complaints of occipital headache and chest pain. Physical examination reveals a blood pressure of 200/118 as well as edema of the optic disk. Of the diagnoses below, the most likely is: Answers: 1.acute hypertensive (non-emergency/non-urgency) episode 2.hypertensive crisis 3.hypertensive urgency 4.moderate hypertension 5.white-coat hypertension - correct answer 2.hypertensive crisis A 29-year-old male presents to the emergency department complaining of substernal chest pressure. The patient used cocaine and alcohol 3 hours prior to admission. On exam, the patient has a blood pressure of 160/100 mm Hg and heart rate of 150 beats per minute with ST-segment changes in the inferior leads on EKG. Which of the following is the best medication to treat the patient's cardiovascular status? Answers: 1.Lidocaine 2.Lorazepam 3.Metoprolol 4.Phenoxybenzamine - correct answer 2.Lorazepam
A 56 year old female presents to the emergency department complaining that she can't catch her breath. She has associated intermittent sharp chest pain on the right side of her chest that began 3 days ago after she returned from a trip to Europe. She has a history of hypertension (HTN) and is on a beta blocker and hormone replacement therapy. Her physical exam is unremarkable except for a heart rate of 110 and respiratory rate of 28. Her EKG shows sinus tachycardia. Her SpO2 is 90% on 4L nasal cannula and her chest X-ray is normal. The next test should be: Answers: 1.Bedside echocardiogram 2.Chest CT scan 3.Exercise treadmill 4.Lower extremity doppler - correct answer 2.Chest CT scan A 32 year old G1P0 at 33 weeks EGA comes into the emergency department complaining of a severe headache. She has contractions every 3 minutes. She is experiencing flashes of light in front of her eyes. Her pregnancy has been uncomplicated until this time, and her only medical problem is mild asthma. Her vital signs are: T 36.5 C (97.7 F), BP 172/114, P 78, R 14, and a room air SpO2 99%. Her lungs have bilateral crackles at the bases, and her cervix is dilated at 3 cm and effaced at 50%. Her urinalysis has 2+ protein, and her complete blood count shows: WBC 8,000/mm3, hematocrit 38%, platelets 215,000/mm3. Her BUN and creatinine are normal, her AST is 250 U/L, and her ALT is 316 U/L. The electronic fetal monitor shows a reactive and variable heart tracing at a rate in the 150s. What is the appropriate next step in management for her? Answers: 1.A. Administer magnesium sulfate. 2.B. Discharge the patient and tell her to return for a cervical check the next day. 3.C. Give furosemide. 4.D. Start PGE2 gel.
