Cardiovascular, ECG, ACS/STEMI, ACPE, Cardiac Arrest & ROSC. AEMCA prep

What is cardiac ischemia?

Inadequate blood flow and oxygen delivery to the myocardium.

What is ACS?

Acute coronary syndrome, a group of conditions caused by acute reduction of blood flow to the heart, including unstable angina and myocardial infarction.

What is a STEMI?

A myocardial infarction associated with ST-segment elevation on a 12-lead ECG.

What is the indication for the PCP Cardiac Ischemia Medical Directive?

Suspected cardiac ischemia.

What are the conditions for ASA under the PCP Cardiac Ischemia Medical Directive?

Age 18 years or older, unaltered level of awareness, and able to chew and swallow.

What is the PCP ASA dose for suspected cardiac ischemia?

160 to 162 mg PO.

How many doses of ASA are given under the PCP Cardiac Ischemia Medical Directive?

One dose.

What are the contraindications to ASA under the PCP Cardiac Ischemia Medical Directive?

Allergy or sensitivity to NSAIDs, an asthmatic patient with no prior ASA use, current active bleeding, or CVA or TBI within the previous 24 hours.

What are the conditions for nitroglycerin under the PCP Cardiac Ischemia Medical Directive?

Age 18 years or older, unaltered LOC, HR 60 to 159 bpm, normotension, and prior history of nitroglycerin use OR IV access obtained.

What are the contraindications to nitroglycerin under the PCP Cardiac Ischemia Medical Directive?

Allergy or sensitivity to nitrates, phosphodiesterase inhibitor use within the previous 48 hours, SBP drop of one-third or more after nitroglycerin, or a 12-lead compatible with right ventricular MI.

What is the nitroglycerin dose for cardiac ischemia?

0.3 mg or 0.4 mg SL.

What is the nitroglycerin dosing interval for cardiac ischemia?

Every 5 minutes.

What is the maximum number of nitroglycerin doses when there is NO STEMI?

6 doses.

What is the maximum number of nitroglycerin doses when a STEMI IS present?

3 doses.

What minimum SBP is required for nitroglycerin in the Cardiac Ischemia Medical Directive?

100 mmHg or greater.

What should be acquired before considering nitroglycerin for suspected cardiac ischemia?

A 12-lead ECG should be acquired and interpreted for STEMI.

What is the goal for obtaining a 12-lead ECG after first medical contact?

Less than 10 minutes where possible.

What should you suspect in every inferior STEMI?

A right ventricular myocardial infarction.

What lead should be obtained at minimum when assessing an inferior STEMI for right ventricular involvement?

V4R.

What ECG finding confirms right ventricular MI in V4R according to the ALS PCS?

ST elevation of 1 mm or greater in V4R.

Can nitroglycerin be administered in a right ventricular STEMI?

No.

Why is nitroglycerin dangerous in a right ventricular STEMI?

These patients may be preload dependent, and reducing preload can cause significant hypotension.

What should be applied when a STEMI is identified?

Defibrillation pads.

If a STEMI is identified, should serial 12-leads continue just to reconfirm it?

The Companion Document says there is no need to repeat the 12-lead once STEMI has been identified.

If no STEMI is identified but ischemia is still suspected, what ECG strategy is recommended?

Serial 12-lead ECGs are recommended.

What does a 3 or 4-lead ECG mainly assess?

Cardiac rhythm.

What does a 12-lead ECG provide that a rhythm strip does not?

A broader electrical view of the heart used to identify ischemia, injury, infarction, and other abnormalities.

Why is correct lead placement important?

Incorrect placement can alter the ECG tracing and lead to incorrect interpretation.

What are contiguous leads?

ECG leads that view neighboring areas of the myocardium.

What ECG features should an AEMCA candidate be able to identify?

P wave, Q wave, R wave, S wave, T wave, J-point, ST segment, TP segment, ST depression, ST elevation, T-wave inversion, and pathological Q waves.

What myocardial problems should you be able to recognize on a 12-lead ECG?

Myocardial ischemia, myocardial injury, and myocardial infarction including STEMI.

What areas of myocardial infarction should you be able to identify on ECG?

Anterior, septal, inferior, lateral, posterior, and right ventricular MI.

What is PEA?

Pulseless electrical activity, where organized electrical activity is present on ECG but there is no palpable pulse.

What two cardiac arrest rhythms are shockable?

Ventricular fibrillation and pulseless ventricular tachycardia.

Is asystole shockable?

No.

Is PEA shockable?

No.

What is ventricular fibrillation?

Chaotic ventricular electrical activity that produces no effective cardiac output.

What is pulseless ventricular tachycardia?

A rapid ventricular rhythm with no palpable pulse.

What is the indication for the PCP Medical Cardiac Arrest Medical Directive?

Non-traumatic cardiac arrest.

At what age can manual or AED/SAED defibrillation be used under the PCP Medical Cardiac Arrest Medical Directive?

Age 24 hours or older.

What rhythm allows manual defibrillation in the PCP Medical Cardiac Arrest Medical Directive?

VF or pulseless VT.

When is AED or SAED defibrillation used?

When the device indicates defibrillation.

What is refractory VF or pulseless VT under ALS PCS 5.4?

Persistent VF or pulseless VT after 3 consecutive shocks.

What advanced defibrillation strategies may be considered for refractory VF or pulseless VT?

Double Sequential External Defibrillation, DSED, if authorized, or Vector Change Defibrillation, VCD, if DSED is unavailable or not authorized.

After how many consecutive shocks is VF or pulseless VT considered refractory?

Three consecutive shocks.

What does DSED stand for?

Double Sequential External Defibrillation.

What does VCD stand for?

Vector Change Defibrillation.

What should happen after 3 doses of DSED or VCD according to the PCP Medical Cardiac Arrest Medical Directive?

Consider transport.

What special cardiac arrest patient should be considered for very early transport after at least one rhythm analysis and defibrillation if indicated?

A pregnant patient presumed to be 20 weeks gestation or greater, or a patient with a known reversible cause that cannot be corrected on scene.

How is pregnancy of 20 weeks or more estimated in cardiac arrest?

Fundus at or above the umbilicus.

What uterine maneuver should be performed in cardiac arrest when pregnancy is 20 weeks or greater?

Manual displacement of the uterus to the left.

When are pulse checks indicated after the initial pulse check in cardiac arrest?

When rhythm analysis shows a non-shockable rhythm such as PEA or asystole, or when signs of life are present.

How should an electrocution cardiac arrest without significant trauma generally be treated?

As a medical cardiac arrest.

How should an electrocution associated with significant trauma be treated?

As a trauma cardiac arrest.

How should commotio cordis generally be treated?

As a medical cardiac arrest unless life-threatening trauma is present.

How should hanging-associated cardiac arrest generally be treated?

As a medical cardiac arrest unless life-threatening trauma is present.

What is the purpose of defibrillation?

To terminate a shockable ventricular dysrhythmia and allow an organized rhythm with effective circulation to resume.

Why should the peri-shock pause be minimized?

To minimize interruptions in CPR and improve the chance of successful resuscitation.

Why is high-quality CPR critical in cardiac arrest?

It provides temporary blood flow to the heart and brain while definitive treatment such as defibrillation is performed.

What is compressor fatigue?

Declining compression quality as the rescuer becomes tired.

Why should rescuers rotate compressors?

To maintain effective compression depth, rate, and overall CPR quality.

What role can ETCO2 play during cardiac arrest?

It can help assess ventilation and the effectiveness of CPR and may provide information about changes in perfusion.

What does ROSC stand for?

Return of spontaneous circulation.

What is the indication for the PCP ROSC Medical Directive?

A patient who achieves return of spontaneous circulation after resuscitation has been initiated.

What is the oxygen saturation target after ROSC under ALS PCS 5.4?

94% to 98%.

What ETCO2 target should be used after ROSC when continuous waveform capnography is available?

30 to 40 mmHg.

What ventilation problem should be avoided after ROSC?

Hyperventilation.

What should be optimized immediately after ROSC?

Ventilation and oxygenation.

Should transport be delayed while completing all ROSC treatments?

No. Transport should be considered in parallel with treatment.

When may a 0.9% NaCl bolus be considered after ROSC?

For a hypotensive patient age 2 years or older with clear chest auscultation, if available and authorized.

What is a contraindication to a 0.9% NaCl bolus after ROSC?

Fluid overload.

What is the ROSC fluid bolus dose?

10 mL/kg IV.

What is the maximum total fluid volume under the PCP ROSC Medical Directive?

1,000 mL.

How often should fluid response be reassessed in a ROSC patient age 2 to under 12 years?

Every 100 mL.

How often should fluid response be reassessed in a ROSC patient age 12 years or older?

Every 250 mL.

What cardiac test should be considered after ROSC?

A 12-lead ECG.

What is acute cardiogenic pulmonary edema?

Fluid accumulation within the lungs caused by cardiac dysfunction that interferes with oxygen exchange.

What is the most common prehospital cause of cardiogenic pulmonary edema described in the Companion Document?

Congestive heart failure with impaired ventricular function.

What are common findings in acute cardiogenic pulmonary edema?

Dyspnea, bilateral crackles, hypertension, signs of fluid overload, and often a history of CHF, ACS, or dysrhythmia.

What are the indications for the PCP Acute Cardiogenic Pulmonary Edema Medical Directive?

Moderate to severe respiratory distress AND suspected acute cardiogenic pulmonary edema.

What are the age and heart rate conditions for nitroglycerin in ACPE?

Age 18 years or older and HR 60 to 159 bpm.

What blood pressure condition is required for nitroglycerin in ACPE?

Normotension.

What are the contraindications to nitroglycerin in the ACPE directive?

Allergy or sensitivity to nitrates, phosphodiesterase inhibitor use within the previous 48 hours, or an SBP drop by one-third or more after nitroglycerin.

What are major treatment priorities in acute cardiogenic pulmonary edema?

Effective oxygenation and ventilation, supportive ventilation including CPAP when appropriate, nitroglycerin when indicated, and rapid transport.

Why is nitroglycerin used in ACPE?

Primarily to cause peripheral vasodilation and reduce preload and afterload.

Is a 12 or 15-lead ECG required before the FIRST nitroglycerin dose under the ACPE directive?

No, but it should be acquired and interpreted as soon as possible.

What should happen if a STEMI is identified in an ACPE patient?

Follow the Cardiac Ischemia Medical Directive for nitroglycerin administration and dose scheduling.

Can nitroglycerin be given under BOTH the ACPE and Cardiac Ischemia directives to the same patient?

No.

Can a patient with ACPE and suspected cardiac ischemia receive both nitroglycerin and ASA?

Yes. Nitroglycerin may be given under the ACPE directive and ASA under the Cardiac Ischemia Medical Directive if indicated.

Is nitroglycerin indicated for non-cardiogenic pulmonary edema?

No.

What are examples of non-cardiogenic pulmonary edema causes listed in the Companion Document?

Pneumonia, sepsis, ARDS, drug ingestion, toxic inhalation, and near-drowning.

Can CPAP still be appropriate in non-cardiogenic pulmonary edema?

Yes, when clinically appropriate.

Why can wheezing occur in pulmonary edema?

Increased pulmonary capillary pressure can cause airway edema, producing wheezing even without true bronchospasm.

What is cardiogenic shock?

A state where the damaged heart cannot pump enough blood to adequately perfuse organs, tissues, and cells, commonly causing hypotension.

What is the main AEMCA approach to a cardiac patient?

Assess ABCs and life threats, obtain history and vital signs, perform cardiac monitoring and 12-lead ECG when indicated, identify the likely cardiac condition, apply the appropriate BLS and ALS treatment, determine destination, and continuously reassess.

What cardiovascular skills does the AEMCA syllabus expect?

ECG interpretation, recognition of dysrhythmias and myocardial infarction patterns, assessment of cardiac patients, CPR and defibrillation, ACS management, CPAP concepts, ROSC management, and application of BLS and ALS standards.