1. Cardiovascular Transport

2. While transporting a pt by RW, the pt”s ECG converts to VF
While transporting a pt by RW, the pt”s ECG converts to VF. Which of the following represents appropriate treatment?
Land aircraft, then defibrilate
Immediate defibrilation per transport protocol
100 mg lidocaine IV, followed by infusion
Initiate CPR until arriving at destination, the defibrillate once landed
The best answer is immediate defibrillation for VF if a defibrilator is immediately available, then start CPR. If a defibrilator is not available or not ready for use, perform CPR for 2 minutes uninterrupted then defibrilation one time and restart CPR.

3. Which of the following assessments would be of concern for a pt being transported with an IABP?
The lower extremity on the insertion side is cool to the touch and has no pulse
Urine output of greater than 35cc/hr
Diminishing chest pain
Heart rate less than 100 beats per minute
Limb ischemia is most common complication of IABP therapy. The other options are expected findings in IABP therapy.

4. While transporting a pt on a Biventricular Assist Device the transport nurse should be most concerned about which of the following?
The transport unit’s ability to provide sufficient AC power for the device
The weather at the receiving facility
The pt’s liver function
The pt’s heart rate
Many external ventricular assist devices draw more AC power than can be supplied by standard transport units, and often the battery life is insufficient to complete a transport. The weather may determine transport mode, and liver function may be altered later as evidence of end-organ failure. The pt’s heart rate will be determined by the device.

5. Classic diagnostic signs of cardiac tamponade are defined in Beck’s Triad. Beck’s Triad consists of:
Muffled heart tones, hypotension, and tachycardia
Distended neck veins, muffled heart tones, and hypertension
Hypotension, tachycardia, and distended neck veins
Distended neck veins, hypotension, and muffled heart tones
Although tachycardia is a common clinical sign, Beck’s Triad consists of distended neck veins, hypotension, and muffled heart tones. A, B, and C are incorrect because tachycardia and hypertension are not part of Beck’s Triad.

6. The purpose of IABP therapy is to:
Increase systolic BP
Decrease preload
Improve coronary artery perfusion
Augment mean arterial pressure
The goals of IABP therapy are to increase coronary artery perfusion pressure, decrease afterload, augment diastalic perfusion pressure, and decrease myocardial oxygen demands. Improved coronary blood flow improves perfusion to the heart providing improved cardiac output.

7. The IABP inflates after the closure of what valve?
Mitral
Tricuspid
Aortic
Pulmonic
The IABP balloon is inflated and deflated in synchrony with the cardiac cycle. The balloon is inflated during diastole. Diastole occurs when the aortic valve closes. Mitral valve closes on systole and is open on diastole. The tricuspid valve is between the right atrium and right ventricle and does not serve the coronary sinus. The pulmonic valve opens to allow blood for the RV to enter the pulmonary arteries.

8. Based on the theory of balloon pump counter pulsation, which pressure is responsible for increasing coronary artery flow?
Diastolic Augmentation
Diastolic Dip
Unassisted Systole
Assisted Systole
The period of time early in diastole in which diastolic pressure is enhanced is referred to as diastolic augmentation. Diastolic dip is when end diastolic pressure at balloon deflation is lower than the proceeding unassisted end diastolic pressure. Unassisted systole is not when coronary blood flow occurs or increases, it is lower than the preceding systole in 1:2 mode but is unassisted by balloon deflation.

9. During transport of a pt on an IABP your pt complains of left arm pain with parathesis. On further evaluation you note the extremity is pale and pulseless. The most likely cause of this condition would be?
Acute MI
Cerebrovascular accident
Balloon pump rupture
Migration of the IABP catheter to the Ascending Aorta
The balloon lies 2cm distal to the aortic arch and just distal to the left subclavian artery and above the renal artery. Pain in the arm(s) is common in some acute myocardial infarctions, but a decreased or absent pulse in on specific extremity is not likely to be related to a MI if an IABP is in place. Movement of the IABP increases the possibility of a migration of the IABP catheter. Any blood in the helium line is indicative of balloon rupture.

10. During FW transport of the pt on the 5000t BiVAD, it is important to recognize that placing the pt in the aircraft with their head toward the tail will:
Decreased preload
Increase in preload
Have no effect on the pt
Require more fluid resuscitation
When the pt is positioned with their head toward the tail, an increase in preload on take off will result. A decrease in preload occurs if the pt’s head is toward the front of the aircraft. Aircraft acceleration exposes pts to G forces and the position of the pt does effect their hemodynamics.

11. What type of problem produces a Delta wave on the EKG?
Hypothermia
Acute coronary syndrome
Wolf-Parkinson-White (WPW)
Pericarditis
WPW which is characterized by a short PR-interval, a broadened QRS, and Delta waves. The slurred upstroke of the QRS, called a delta wave, is best seen in leads V1-V2. In hypothermia you see an Osborne or “J” wave which is an extra deflection at the junction of the QRS and ST segment. Diffuse ST elevation can be seen in pericarditis. In acute coronary syndrome 12 lead EKG shows development of ST depression and T wave inversion.

12. The partial pressure of O2 decreases as altitude increases
The partial pressure of O2 decreases as altitude increases. Pts with cardiac conditions require supplemental O2 during air transport to compensate for this decrease in the partial pressure of O2. You would also expect these pts to utilize which of the following compensatory mechanisms to maintain an adequate supply of O2 to the tissues?
Increase resp rate, increase heart rate, increase stroke volume, and decreased cardiac output
Increase resp rate, increase heart rate, increase stroke volume, and increased cardiac output
Increase resp rate, decrease heart rate, decrease stroke volume, and decreased cardiac output
Decrease resp rate, decrease heart rate, decrease stroke volume, and decreased cardiac output
Increased respiratory rate augments the amount of O2 delivered to the lungs. Heart rate and stroke volume both increase resulting in an increased cardiac output to provide adequate delivery of the O2 to the tissues. (Cardiac Output = Heart Rate x Stroke Volume). Answer A would be incorrect as cardiac output would be increased if there is an increase in heart rate and stoke volume. Answer C is incorrect as there would be no compensatory mechanism to circulate the increased O2 resulting from increased respiratory rate. Answer D would be incorrect as a decreased in all four parameters would not provide any compensation for the decreased partial pressure of O2.

13. Which of the following coronary artery blockages would cause the most extensive damage to the myocardium?
Proximal Left Main coronary artery occlusion
Distal Right Coronary Artery (RCA) occlusion
Proximal Left Circumflex (LCX) coronary artery occlusion
Proximal Left Anterior Descending (LAD) coronary artery occlusion
The left main coronary artery branches in to the LAD artery and the LCX artery thus a blockage prior to that bifurcation would occlude blood flow to the vast area of myocardium receiving oxygenated blood from both the LAD artery and LCX artery. A distal occlusion is always better than a proximal infusion because less myocardium is deprived of oxygenated blood. Answers C and D are incorrect as occlusions to either the LAD or LCX arteries would be more distal than a left main artery occlusion thus deprives less of the myocardium of blood flow.

14. Which of the following signs and symptoms would you most likely see with a pt diagnosed with an acute inferior myocardial infarction?
Flash pulmonary edema
Tachycardia
Bundle brand block
Bradycardia and hypotension
85% of the population are right dominant meaning the right coronary artery (RCA) and it’s branches deliver blood flow to the inferior portion of the left ventricle, poster third of the septum and the right ventricles. The RCA also supplies blood to the sinoatrial (SA) and atrioventricular (AV) nodes. Decreased blood flow to the SA node causes bradycardia, and decreased right ventricular function can lead to hypotension. Flash pulmonary edema is usually caused by severe mitral valve regurgitation associated with lateral wall MI sue to an occlusion of the LCX. Tachycardia is usually not present as the SA node is also being deprived of oxygenated blood in an inferior myocardial infarction. Bundle branch blocks are complications commonly seen with anteroseptal myocardial infarctions due to an occlusion of the left anterior descending artery (LAD).

15. You are requested for an interfacility transport of a 76 year old female who was admitted to the referring facility several hours earlier with SOB and hypotension. The pt now responds only to painful stimuli. The pt is in the ICU, intubated and has a pulmonary artery catheter with the following readings and vitals: PAS/PAD – 48/42, CVP – 17, CO – 3.2, SVR – 1400, PCWP – 21, HR – 122, BP – 76/54, RR – 24. Based on these findings, what condition do you suspect the pt experiencing?
Septic shock
Hypovolemic shock
Spinal shock
Cardiogenic shock
Cardiogenic shock is evident by the low cardiac output. The elevated heart rate and systemic vascular resistance (SVR) are compensatory mechanisms for the failing pump. Pts with septic shock will have normal to low cardiac output, tachycardia, a low SVR, a low CVP and a low pulmonary capillary wedge pressure (PCWP). Pts with hypovolemic shock will have decreased intravascular volume leading to decreased preload represented by a low CVP and PCWP. Pts with spinal shock will not be able to constrict vessels in the periphery to compensate thus they will exhibit a low SVR and CVP.

16. Hypertrophic Cardiomyopathy is a diastolic dysfunction disease state
Hypertrophic Cardiomyopathy is a diastolic dysfunction disease state. Medical management of this disease process should include which of the following?
Digoxin (Lanoxin)
Captopril (Capoten)
Metoprool (Lopressor) and Verapamil (Calan)
Furosemide (Lasix)
Beta-blocker are appropriate for treating Hypertrophic Cardiomyopathy (HCM) as they decrease the myocardial oxygen demand, decrease prevalence of angina and decrease the outflow obstruction during physical activity. Calcium Channel Blockers are used to decrease the myocardial contractility and help the myocardium relax to increase ventricular filling. Digoxin would intensify this condition due to its inotropic properties. Captopril and Furosemide would decrease preload via vasodilation and diuresis.

17. You are transporting a 56 year old C/O chest pain 10/10
You are transporting a 56 year old C/O chest pain 10/10. You place him on the monitor and see the following rhythm. You recognize this as:
First degree block
Second degree type I
Second degree type II
Third degree heart block
Second degree type II (Wenkebach) has a progressive lengthening of the P-R interval until a P wave is NOT followed by a QRS complex. The atrial rhythm is regular. Progressive prolongation of the P-R interval indicates increasing conduction delay in AV node before the non-conducted beat.

18. Which of the following represents the 4 “P’s” of vascular insult?
Pallor – parathesia – pain – polar
Pallor – pain – polar – pulseless
Pallor – parathesia – polar – pulseless
Parathsia – pain – polar - pulseless
A. The four “P’s” of vascular insult are pallor, parathesia, pain, and polar.

19. In transporting a patient with an IABP if the IABP deflates before the ventricles are ready systole it indicates:
Late inflation
Early inflation
Late deflation
Early deflation
In early deflation the balloon deflates before the ventricles are ready for systole. Late inflation occurs after ventricular diastole has started. Early inflation occurs without completion of ventricular systole. In late deflation the balloon is still inflated during ventricular systole.

20. The BVS 5000t system is designed specifically for the transport environment. It has a fixed beat rate of ____ bpm. 65 70 75 80
The BVS 5000t operation is asynchronous with the normal cardiac cycle with a beat rate fixed at 75 bpm.

21. Pts with ventricular assist devices should have anticoagulation therapy initiated within 24 hours and the activated clotting times maintained between ____ - ____ sec.
Heparin for anticoagulation is used in nearly 100% of ventricular assist device pts and the activated clotting times should be maintained between sec.

22. Maintain O2 at 4 liters/minute
You are preparing to transport a 48 year old male from a small community hospital ER to a Tertiary Care Center via RW for emergent cardiac catherization. The referring physician has made the diagnosis of Acute MI based on hyper-acute T waves on the 12 lead EKG and a 3mm elevation in leads II, III, and aVF. Vital signs are as follows: BP 105/62, HR 96, SpO2 94% on 4 liters via nasal canula. Which interventions need to be implemented in order to transport this pt at an altitude of 4,000 feet above sea level?
Maintain O2 at 4 liters/minute
Place pt on NRB mask at 12 liters/minute and give Lopressor 5mg IV x 3
Place pt on simple face mask at 4 liters/minute and give Lopressor 5mg IV x 3
Place pt on simple face mask at 15 liters/minute
An increase in the supplemental O2 is required to transport this pt at altitude due to the decrease in partial pressure, so the non-rebreather mask is the best O2 delivery given as a choice. A beta blocker (Lopressor) would also be indicated to decrease the O2 demand of the heart. Maintaining the same O2 delivery of 4 liters/min would cause less available O2 at altitude and is not coupled with giving a beta blocker. A face mask at 4 liters/min is too low of an O2 choice and 15 liters/min is too high for a simple face mask.

23. You are preparing to transport a 38 year old female pt who presented to the ER with N/V, diaphoresis, and SOB. She is being transferred with a diagnosis of acute MI. The 12 lead EKG shows ST elevation in leads I. aVL, and V3-6. The transport team recognizes that the pt is having a:
Posterior MI
Anteroseptal MI
Inferior MI
Anterolateral MI
Anterolateral shows ST elevation in leads I, aVL, and V3-6. Posterior would show elevation in leads V6 only. Anterolateral elevates in leads V1-4. An inferior MI’s show elevation in leads II, III, and aVF.

24. Which statement by the referring nurse would show correct placement of the IABP balloon?
IABP balloon tip is in the thoracic aorta, 2cm distal to the aortic arch, above the renal artery.
IABP balloon tip is in the thoracic aorta, 2cm anterior to the aortic arch, above the renal artery.
IABP balloon tip is in the abdominal aorta, 2cm distal to the aortic arch, above the renal artery
IABP balloon tip is in the abdominal aorta, 2cm anterior to the aortic arch, above the renal artery
The correct placement is in the thoracic aorta with the tip 2cm distal to the aortic arch to allow filling of the coronary arteries during diastole. Placement above the arch would not allow the optimal filling and could cause rupture of the aorta. Placement in the abdominal aorta would cause limb ischemia.

25. Which of the following statements is true regarding transport of a pt with aortic dissection?
The pt should have a maintenance IV with IV fluids running wide open
Blood should be available during the transport
You should delay the transport to obtain all x-rays and CT scan films
The pt must be intubated prior to transport
If the pt becomes suddenly hypotensive, it may mean rupture or further progression of the dissection. Blood would be needed to help optimize cardiac output. Restrict fluids initially unless severe hypotension or rupture occurs, and then run fluids until blood is available. Do not delay transport of an aortic dissection for copies of x-rays. Provide the highest concentration of O2 the pt can tolerate to optimize tissue perfusion. Intubation prior to departure is not required unless the pt’s condition warrants it. However, the transport team should be prepared to intubate the pt in-flight if the pt decompensates.

26. You are transporting a pt via FW with a diagnosis of cardiogenic shock
You are transporting a pt via FW with a diagnosis of cardiogenic shock. The pt is receiving Nitroprusside. You suspect the pt has developed Histotoxic Hypoxia. Your next action is:
Increase the O2 concentration to the pt
Stop the Nitroprusside infusion
Give the pt 1 mg Atropine IV
Intubate the pt
Cyanide toxicity can cause Histotoxic Hypoxia. You must stop the infusion to prevent the hypoxia from progressing. Increasing the O2 concentration to the pt will not stop the hypoxia. Giving Atropine is not indicated for this diagnosis. It is not necessary to intubate the pt.

27. You are transporting a pt with ST elevation in EKG leads II, III, aVF and reciprocal changes in leads I, aVL, and V1-4. Which intervention is indicated based on your findings?
Large volumes of Crystalloid fluids
Restricting IV fluids
IV infusions of Dobutamine
Cardiac Transcutaneous Pacing
An inferior MI often extends to the right ventricle causing the pt to need fluids to supplement the preload and optimize hemodynamics. Restricting fluids will compromise preload and decrease the pt’s hemodynamic status. Dobutamine may help, but is not a required intervention. Pacing is not indicated based solely on the diagnosis of an inferior MI.