Acute Coronary Syndrome Flashcard 1
Rationale
B. Rationale: Atropine is the treatment of choice in symptomatic bradycardia, as it works at the nodal level to oppose vagal stimulation of the node. However, 2nd-degree (Mobitz II) AV block (as in this case) or 3rd-degree AV block are initiated below the node and thus are unlikely to respond to atropine. Instead, these patients should be managed with beta-adrenergic medications (e.g., epinephrine, dopamine) or transcutaneous pacing as a temporizing measure until transvenous pacing can be accomplished. Dobutamine is generally not recommended in bradycardia due to the high risk of hypotension. Defibrillation is not warranted in this alert patient with a pulse. Note that a new Mobitz type II AV block may be related to ACS with blockage of the left anterior descending artery. Evaluation for ACS with this patient’s classic symptoms is warranted.
Question
A 56-year-old man complains of persistent central chest pain and dyspnea. His BP is 94/63 mm Hg. His ECG is below:
Which one of the following is part of the management for this patient?
a. defibrillation
b. atropine 0.5 mg IV
c. 10 mcg/kg/min IV dobutamine infusion
d. 5 mcg/min IV epinephrine infusion
Answer
b. atropine 0.5 mg IV
Rationale
A. Rationale: While the MONA (morphine, nitroglycerin, oxygen, and aspirin) medications are typically given to all ACS patients, there is evidence that morphine is associated with worse outcomes in the non-STEMI group. Additionally, morphine should not be given to a patient who is hypotensive or hypovolemic as it causes vasodilation and can wosen hypotension. Morphine is typically given for chest pain that is refractory to nitroglycerin.
Question
A 57-year-old man presents with ST depression, T wave inversion, and chest pain. His oxygen saturation is 88% on room air, BP is 90/65 mm Hg, and respirations are 18/minute. Which of the following may be omitted in this patient?
a. Morphine
b. Nitroglycerin
c. Oxygen
d. Chewable aspirin (160–325 mg)
Answer
a. Morphine
Rationale
A. Rationale: This patient has central chest pain concerning for acute coronary syndrome (ACS). Only patients with ST segment elevation MI (STEMI) should undergo reperfusion therapy with fibrinolytics or percutaneous coronary intervention (PCI). For men 40 years or older, STEMI is defined as ST elevation of at least 0.2 mm in leads V1 and V2 and at least 0.1 mm in all other leads. Patients with non-STEMI or ST segment depression are not candidates for reperfusion and should be treated with antiplatelet and antithrombin therapy. Patients with angina and nonspecific ECG findings are likely to have chest pain from a non-ACS cause and should not receive fibrinolytics.
Question
A 73-year-old man presents with central chest pressure that began while sitting down. His pain has been ongoing for 20 minutes. He has had similar chest pain before, but it always occurred while climbing a flight of stairs or walking. What finding on ECG would indicate the need for reperfusion therapy?
a. ST segment elevation of 0.3 mm in V1 and V2
b. ST segment depression of 0.5 mm in V2 and V3
c. ST segment elevation of 0.05 mm in avL
d. Peaked T waves with wide QRS
Answer
a. ST segment elevation of 0.3 mm in V1 and V2
Rationale
C. Rationale: In acute coronary syndromes, fibrinolytic therapy must be given within 12 hours of the onset of chest discomfort.
Question
A patient is being treated for sudden crushing chest pain. EMS personnel always asks family members or the patient the time of symptom onset to gauge whether fibrinolytic therapy would be beneficial for the patient. In acute coronary syndromes, fibrinolytic therapy must be given within how many hours of the onset of chest discomfort?
a. 1 hour
b. 6 hours
c. 12 hours
d. 24 hours
Answer
c. 12 hours
Rationale
C. Rationale: When PCI is the treatment of choice, the door-to-balloon time should be within 90 minutes.
Question
After assessing a patient in the ED who was brought in for chest pain, the angiographer decides to perform percutaneous coronary intervention (PCI). When PCI is the treatment of choice, the door-to-balloon time should be within:
a. 30 minutes
b. 60 minutes
c. 90 minutes
d. it does not matter
Answer
c. 90 minutes
Rationale
C. Rationale: When PCI is the treatment of choice, the door-to-balloon time should be within 90 minutes.
Question
After assessing a patient with chest pain in the emergency department, the decision is made to proceed to percutaneous coronary intervention (PCI). When PCI is the treatment of choice, the door-to-balloon time should be within:
a. 30 minutes
b. 60 minutes
c. 90 minutes
d. does not matter
Answer
c. 90 minutes
Rationale
D. Rationale: When an acute coronary syndrome is highly suspected of causing cardiac arrest in a recently resuscitated patient, a 12-lead ECG must be obtained right after ROSC to determine if an ST elevation myocardial infarction is present.
Question
An acute coronary syndrome is suspected in a recently resuscitated patient. What diagnostic modality should be ordered for futher evaluation?
a. cardiac MRI
b. Doppler ultrasound
c. chest X-ray
d. 12-lead ECG
Answer
d. 12-lead ECG
Rationale
C. Rationale: Intracranial hemorrhage is the most significant adverse effect of fibrinolytic therapy.
Question
Fibrinolytic therapy for the treatment of stroke should be given only to select patients meeting specific criteria. Otherwise, it may cause more harm than good. What is the most significant adverse effect to avoid when administering fibrinolytic therapy to a patient with ischemic stroke?
a. upper GI bleed
b. intraocular hemorrhage
c. intracranial hemorrhage
d. anaphylaxis
Answer
c. intracranial hemorrhage
Rationale
D. Rationale: Intravenous nitroglycerin relieves chest discomfort, pulmonary edema, and hypertension in patients with ischemic syndromes.
Question
In the emergency department, the attending physician administers IV nitroglycerin to a patient with acute coronary syndrome. What is the purpose of intravenous nitroglycerin in patients with ischemic syndromes?
a. to relieve chest discomfort
b. to treat pulmonary edema
c. to treat hypertension
d. all of the above
Answer
d. all of the above
Rationale
A. Rationale: Intravenous nitroglycerin relieves chest discomfort, pulmonary edema, and hypertension in patients with ischemic syndromes.
Question
In the emergency department, the attending physician orders IV nitroglycerin to treat a patient with acute coronary syndrome. What is a key reason to use intravenous nitroglycerin in patients with ischemic syndromes?
a. to relieve chest discomfort
b. to improve oxygen saturation
c. to treat hypotension
d. to reduce the heart rate
Answer
a. to relieve chest discomfort