FP-C - Flight Paramedic-Certification Critical Care Cardiology Questions and Answers — Questions and Answers
Question 1: A 68-year-old male is being transported by air after a complicated PCI for a large anterior STEMI. He is now in cardiogenic shock, supported by an intra-aortic balloon pump (IABP). You notice the diastolic augmentation on the IABP waveform is suddenly significantly reduced. Which of the following is the LEAST likely cause for this change?
- The balloon has migrated distally and is now too low.
- There is a helium leak in the IABP catheter or console.
- The patient's cardiac output has significantly decreased.
- The patient has developed severe aortic regurgitation. (Correct answer)
Correct answer: The patient has developed severe aortic regurgitation.
Severe aortic regurgitation is an absolute contraindication for IABP placement because diastolic augmentation would worsen the regurgitation, increasing LV preload and afterload. It is not a cause of poor diastolic augmentation but rather a condition that precludes its use. A distally migrated balloon, a helium leak (causing incomplete inflation), or a severe drop in the patient's native cardiac output are all potential causes of decreased diastolic augmentation.
Question 2: You are transporting a patient with a left ventricular assist device (LVAD) who is now complaining of a severe headache and appears confused. The LVAD controller is alarming for high power consumption. What is the most likely cause of this presentation?
- Pump thrombosis (Correct answer)
- Gastrointestinal bleeding
- Driveline infection
- Controller malfunction
Correct answer: Pump thrombosis
Pump thrombosis can obstruct blood flow through the LVAD, causing the motor to work harder and leading to high power consumption alarms. The obstruction can lead to reduced systemic perfusion and an increased risk of thromboembolic events, such as a stroke, which would present with headache and confusion. While GI bleeding is a common complication in LVAD patients, it typically presents with signs of blood loss, not high power alarms. Driveline infections are also common but would present with localized or systemic signs of infection. A controller malfunction is possible, but the combination of neurological symptoms and a specific high-power alarm strongly points to a physiological problem like a thrombus.
Question 3: A flight paramedic is managing a 55-year-old female who is 12 hours post-ROSC from a V-Fib arrest. She remains comatose. According to current AHA/ERC guidelines for targeted temperature management (TTM), which of the following is the most appropriate intervention?
- Rapidly cool the patient to 30°C to maximize neuroprotection.
- Maintain a constant core temperature between 32°C and 36°C for at least 24 hours. (Correct answer)
- Allow passive rewarming as long as the patient's temperature remains below 38°C.
- Administer prophylactic antibiotics and begin cooling to 34°C for 48 hours.
Correct answer: Maintain a constant core temperature between 32°C and 36°C for at least 24 hours.
Current guidelines from major organizations like the American Heart Association (AHA) and European Resuscitation Council (ERC) recommend targeted temperature management (TTM) for comatose patients after cardiac arrest. The goal is to maintain a constant core body temperature between 32°C and 36°C for at least 24 hours to improve neurological outcomes. Cooling below 32°C (mild hypothermia) is not recommended as it can lead to cardiac instability. Simply preventing fever without active temperature control is insufficient, and a 48-hour duration is not the standard initial recommendation.
Question 4: You are treating a patient with an acute inferior wall STEMI who develops severe hypotension (BP 70/40 mmHg) and bradycardia after receiving a sublingual nitroglycerin tablet. A right-sided ECG reveals ST elevation in V4R. Which of the following is the most appropriate immediate intervention?
- Administer a 500 mL normal saline fluid bolus. (Correct answer)
- Initiate a dopamine infusion to support blood pressure.
- Administer a second dose of nitroglycerin.
- Immediately perform transcutaneous pacing.
Correct answer: Administer a 500 mL normal saline fluid bolus.
The clinical presentation of hypotension and bradycardia following nitroglycerin administration in a patient with an inferior STEMI, confirmed by ST elevation in V4R, is highly suggestive of a right ventricular myocardial infarction (RVMI). These patients are highly dependent on preload to maintain cardiac output. Nitrates and other preload-reducing agents are contraindicated. The first-line treatment is fluid resuscitation with an isotonic crystalloid, such as normal saline, to increase RV preload and improve cardiac output. Inotropes like dopamine may be needed if fluid therapy is insufficient, but volume expansion is the initial priority. Pacing would be indicated for symptomatic bradycardia unresponsive to other measures, but addressing the preload deficit is the primary concern.
Question 5: Which of the following conditions is an absolute contraindication to the placement and use of an intra-aortic balloon pump (IABP)?
- Cardiogenic shock
- Severe aortic insufficiency (Correct answer)
- Acute mitral regurgitation
- Left main coronary artery stenosis
Correct answer: Severe aortic insufficiency
Severe aortic insufficiency (or regurgitation) is an absolute contraindication for IABP therapy. The IABP inflates during diastole to increase coronary perfusion pressure. In a patient with aortic insufficiency, this diastolic augmentation would force more blood back into the left ventricle, worsening the regurgitation, increasing left ventricular end-diastolic pressure (LVEDP), and exacerbating heart failure. Cardiogenic shock, acute mitral regurgitation, and critical coronary artery stenosis are all potential indications for IABP use.
Question 6: A patient in cardiogenic shock is being managed with an IABP. The flight paramedic observes the arterial waveform and notes that balloon inflation occurs well after the dicrotic notch, and the peak of diastolic augmentation is lower than the patient's own systolic pressure. This timing error is best described as:
- Early inflation
- Late deflation
- Late inflation (Correct answer)
- Early deflation
Correct answer: Late inflation
Proper IABP timing involves inflating the balloon at the dicrotic notch, which signifies the closure of the aortic valve. When inflation occurs well after the dicrotic notch, it is termed 'late inflation'. This error results in suboptimal diastolic augmentation, leading to reduced coronary artery perfusion and a less effective increase in myocardial oxygen supply. Early inflation would occur before the dicrotic notch, and deflation errors (early or late) relate to the timing of balloon deflation relative to the start of the next systole.
FP-C - Flight Paramedic-Certification Critical Care Cardiology Questions and Answers
A 68-year-old male is being transported by air after a complicated PCI for a large anterior STEMI.
He is now in cardiogenic shock, supported by an intra-aortic balloon pump (IABP).
You notice the diastolic augmentation on the IABP waveform is suddenly significantly reduced.
Which of the following is the LEAST likely cause for this change?