Cardiac_ and_hypertensive_emergencies _quizes_for_practical.pptx

Be prepared for practical at med college.

1. Anesthesiology , Reanimatology & Intensive care Faculty with Ambulance/Paramed course. TSMU of RF Health ministry Cardiac and hypertensive emergencies

2. A Synchronized cardioversion B Valsalva maneuver C Discharge home and follow up within the next 48 hrs. D Obtain an ECG A 22-year-old baseball player comes into the ED complaining of 12 hours of intermittent chest pain and a pounding heartbeat. He denies a history of trauma. On examination, he is tachycardic. Which of the following is the best next step?

3. A Synchronized cardioversion B Valsalva maneuver C Discharge home and follow up within the next 48 hrs. D Obtain an ECG A 22-year-old baseball player comes into the ED complaining of 12 hours of intermittent chest pain and a pounding heartbeat. He denies a history of trauma. On examination, he is tachycardic. Which of the following is the best next step? One must characterize the rhythm before initiating treatment.

4. A Likely no further therapy is needed B Amiodarone C β -blocker D Obtain an ECG A 52-year-old healthy jogger is brought to the ED following a syncopal episode. A diagnosis of ventricular tachycardia is made, and the patient is cardioverted. She states that she has had prior episodes of VT lasting less than 30 seconds each. What is the most appropriate treatment?

5. A Likely no further therapy is needed B Amiodarone C β -blocker D Obtain an ECG A 52-year-old healthy jogger is brought to the ED following a syncopal episode. A diagnosis of ventricular tachycardia is made, and the patient is cardioverted. She states that she has had prior episodes of VT lasting less than 30 seconds each. What is the most appropriate treatment? Nonsustained VT is by definition a self-terminating event, and therefore usually no specific treatment is indicated. Rather, treatment is directed at any existing heart condition.

6. A Diving reflex B Carotid massage C Valsalva maneuver D Holding one’s breath at the end of expiration All of these are AV nodal blocking maneuvers except

7. A Diving reflex B Carotid massage C Valsalva maneuver D Holding one’s breath at the end of expiration All of these are AV nodal blocking maneuvers except AV nodal blocking maneuvers include Valsalva, diving reflex, and carotid massage. They act through the parasympathetic nervous system. If an SVT involves the AV node, slowing conduction through the node can terminate the arrhythmia.

8. A AVNRT B VT C Atrial flutter D Atrial fibrillation with rapid ventricular rate An 87-year-old woman presents with chest pain and shortness of breath. The 12-lead ECG shows a “sawtooth” pattern with a heart rate of 150 beats per minute. What is the most likely diagnosis?

9. A AVNRT B VT C Atrial flutter D Atrial fibrillation with rapid ventricular rate An 87-year-old woman presents with chest pain and shortness of breath. The 12-lead ECG shows a “sawtooth” pattern with a heart rate of 150 beats per minute. What is the most likely diagnosis? Classically atrial flutter presents with a saw tooth pattern on ECG. The rate of 150 bpm denotes that it’s likely a 2:1 conduction block.

10. A Ablation of atrial flutter is more difficult than that of atrial fibrillation. B Atrial flutter presents a risk of thromboembolism similar to that for atrial fibrillation. C Rate control in atrial flutter is easier than rate control in atrial fibrillation. D Atrial flutter is associated with fewer symptoms than atrial fibrillation. E Atrial flutter is caused by chaotic irregular atrial depolarizations. Which of the following statements regarding atrial flutter is true?

11. A Ablation of atrial flutter is more difficult than that of atrial fibrillation. B Atrial flutter presents a risk of thromboembolism similar to that for atrial fibrillation. C Rate control in atrial flutter is easier than rate control in atrial fibrillation. D Atrial flutter is associated with fewer symptoms than atrial fibrillation. E Atrial flutter is caused by chaotic irregular atrial depolarizations. Which of the following statements regarding atrial flutter is true? Atrial flutter is a fast, organized rhythm that follows a rather predictable circuit involving the right atrium and tricuspid valve isthmus in most cases. Atrial flutter is generally more difficult to rate-control and less responsive to antiarrhythmic therapy than atrial fibrillation, but its predictable pathway makes it quite amenable to successful ablation. The stroke risk related to atrial fibrillation and atrial flutter is considered to be similar.

12. A Metoprolol B Diltiazem C Digoxin D Cardioversion E Adenosine A 70-year-old woman with a history of Wolff-Parkinson-White (WPW) pattern noted on numerous prior ECGs, presents to the emergency department with palpitations and near-syncope. Her ECG on presentation reveals a wide complex irregular tachycardia with a rate of 200 bpm. What is the most appropriate therapy for this patient?

13. A Metoprolol B Diltiazem C Digoxin D Cardioversion E Adenosine A 70-year-old woman with a history of Wolff-Parkinson-White (WPW) pattern noted on numerous prior ECGs, presents to the emergency department with palpitations and near-syncope. Her ECG on presentation reveals a wide complex irregular tachycardia with a rate of 200 bpm. What is the most appropriate therapy for this patient? This patient has atrial fibrillation in the setting of a known accessory pathway. The wide complex appearance is due to conduction down the accessory pathway into the ventricle, where it conducts cell to cell and produces a wide QRS. Cardioversion is required to abort conduction down the bypass tract, Sodium channel blockers can also do this. The remaining choices are all drugs that can block the AV node, which can be dangerous in atrial fibrillation with an accessory pathway because it can force all conduction down the accessory pathway and precipitate ventricular fibrillation.

14. An 83-year-old man with a history of hypertension and diabetes is referred to you for management after presenting to the emergency department last week with several hours of recent-onset palpitations. He was found to be in atrial fibrillation with a rapid ventricular rate and underwent successful electrical cardioversion. He was discharged to home from the ED with prescriptions for metoprolol and a limited supply of low-molecular-weight heparin to use while he began warfarin therapy. His point-of-care INR in the office today is 2.2 on warfarin 5 mg daily. The patient is questioning his need for anticoagulation, citing the fact that he is now back in normal rhythm after cardioversion and is not in atrial fibrillation permanently. He reports that his 50-year-old nephew has a diagnosis of atrial flutter and takes aspirin only for stroke prevention. He considers himself healthier than the average 83-year-old man and feels that his risk for stroke must be relatively low. He would like to know more about atrial fibrillation and his risk for stroke. You should tell him which of the following?

15. A His stroke risk is similar regardless of whether his atrial fibrillation is paroxysmal, persistent, or permanent. B His stroke risk would be considerably lower if he had atrial flutter like his nephew. C His stroke risk is similar to that of the age-matched general population. D His stroke risk 1 week after cardioversion is lower than it was prior to cardioversion E His stroke risk should be reduced to a similar extent by aspirin and warfarin.

16. A His stroke risk is similar regardless of whether his atrial fibrillation is paroxysmal, persistent, or permanent. B His stroke risk would be considerably lower if he had atrial flutter like his nephew. C His stroke risk is similar to that of the age-matched general population. D His stroke risk 1 week after cardioversion is lower than it was prior to cardioversion E His stroke risk should be reduced to a similar extent by aspirin and warfarin. A large percentage of patients with paroxysmal atrial fibrillation have clinically silent recurrences and some of these episodes can exceed 24 hours in length. Mechanical atrial contraction can remain impaired for days to weeks after cardioversion before normalizing, and for this reason patients are considered to be at increased risk for stroke in the weeks immediately after cardioversion. Atrial flutter is felt to confer approximately the same stroke risk as atrial fibrillation. Given this patient’s elevated CHA2DS2- VASc score, his stroke risk would be expected to exceed that of the general population and he would be expected to derive a greater benefit from warfarin than aspirin

17. Note: Each risk factor is given 1 point except stroke/TIA/ peripheral embolism, which is given 2 in both systems, and age >75 in the CHA2DS2-VASC score. A score of >2 is considered an indication for anticoagulation, whereas either aspirin or anticoagulation is recommended for a score of> 1, and aspirin fora score of 0.

18. Emergency medicine case file A 70-year-old man presents to the emergency department complaining of shortness of breath for the past 2 weeks. Previously, he could walk everywhere, but now he becomes fatigued after a short stroll through the grocery store. He also notes that he has felt his heart racing even when he is at rest. His past medical history is notable only for hypertension, for which he takes hydrochlorothiazide and amlodipine. On physical examination, he appears comfortable and speaks in full sentences without difficulty. His blood pressure is 130/90 mm Hg, heart rate is 144 beats per minute, respiratory rate is 18 breaths per minute, oxygen saturation is 98% on room air, and temperature is 37°C (98.6°F). His head and neck examination is unremarkable. His lungs are clear to auscultation. His heartbeat is irregular and rapid, without murmurs rubs or gallops. He has no extremity edema or jugular venous distension. His abdomen is soft and nontender, without masses. Labs show a normal CBC, normal electrolytes, BUN, creatinine, troponin, BNP, and thyroid stimulating hormone. A chest X-ray reveals a normal cardiac silhouette with no pulmonary edema. The ECG is shown below

19. What is the most likely diagnosis?

20. What is the most likely diagnosis? Atrial fibrillation with rapid ventricular response

21. What is the most likely diagnosis? Atrial fibrillation with rapid ventricular response What are some of the common contributing factors?

22. What is the most likely diagnosis? Atrial fibrillation with rapid ventricular response What are some of the common contributing factors? Increasing age, underlying cardiopulmonary disease (such as hypertension, heart failure, and COPD), hyperthyroidism, sepsis, pulmonary embolism, and electrolyte abnormalities

23. What is the most likely diagnosis? Atrial fibrillation with rapid ventricular response What are some of the common contributing factors? Increasing age, underlying cardiopulmonary disease (such as hypertension, heart failure, and COPD), hyperthyroidism, sepsis, pulmonary embolism, and electrolyte abnormalities ► What are some of the complications to this condition?

24. What is the most likely diagnosis? Atrial fibrillation with rapid ventricular response What are some of the common contributing factors? Increasing age, underlying cardiopulmonary disease (such as hypertension, heart failure, and COPD), hyperthyroidism, sepsis, pulmonary embolism, and electrolyte abnormalities ► What are some of the complications to this condition? Early — diminished cardiac output. Late — thromboembolism and cardiomyopathy

25. Case File A 54-year-old man presents to the emergency department complaining of tachypalpitations and lightheadedness. He denies syncope, chest pain, exertional dyspnea, orthopnea, lower extremity edema, nausea, vomiting, or diaphoresis. His symptoms have been intermittent for several weeks, usually lasting less than 1 minute. However, today his symptoms have persisted for several hours. His medical history includes coronary artery disease with a remote inferior myocardial infarction requiring stenting, hypertension, hyperlipidemia, diabetes mellitus, and a 40-pack/year history of smoking with moderate to severe chronic obstructive lung disease. His medications are aspirin, atorvastatin, metoprolol succinate, lisinopril, metformin, and an inhaled long-acting β -agonist and anti-cholinergic bronchodilator. On exam, he is mentating appropriately but appears anxious. His blood pressure is 105/68 mmHg. his pulse is 175 bpm. his oxygen saturation is 93%, and he is afebrile. There is no jugular venous distention. Pulmonary exam demonstrates a few scattered expiratory wheezes bilaterally but no rales. Cardiac exam is pertinent for tachycardia but no murmurs or rubs. The abdominal, musculoskeletal, neurologic, and skin exams are benign. Labs are normal, including potassium, magnesium, and a point- of-care troponin T ( TpT ). Baseline ECG (Figure 1) and ECG obtained on presentation (Figure 2) are shown.

26. Case File Figure 1. Baseline ECG for the main subject of this case. Figure 2 . P resenting ECG for the main subject of this case.

27. What is the most likely diagnosis?

28. What is the most likely diagnosis? Ventricular tachycardia .

29. What is the most likely diagnosis? Ventricular tachycardia . What is the best next diagnostic step?

30. What is the most likely diagnosis? Ventricular tachycardia . What is the best next diagnostic step? Review ECG for Brugada’s criteria.

31. What is the most likely diagnosis? Ventricular tachycardia . What is the best next diagnostic step? Review ECG for Brugada’s criteria. What is the best next step in therapy ?

32. What is the most likely diagnosis? Ventricular tachycardia . What is the best next diagnostic step? Review ECG for Brugada’s criteria. What is the best next step in therapy ? If the patient is unstable in any manner, perform emergent synchronized cardioversion. If the patient is stable, consider administration of an IV antiarrhythmic drug such as amiodarone and/or urgent cardioversion

33. Brugada`s algorithm for diagnosing ventricular tachycardia (VT)

34. Ischemia, Injury, and Infarction in Relation to the Heart Progression of an Acute Myocardial Infarction ■ Ischemia — Lack of oxygen to the cardiac tissue, represented by ST segment depression, T wave inversion, or both ■ Injury — Arterial occlusion with ischemia, represented by ST segment elevation ■ Infarction — Death of tissue, represented by a pathological Q wave

35. Ischemia, Injury, and Infarction in Relation to the Heart Location of MI by ECG Leads

36. ST Segment Elevation and Depression Primary Causes of ST Segment Elevation ■ ST segment elevation exceeding 1 mm in the limb leads and 2 mm in the chest leads indicates an evolving acute MI or an ST-elevation MI (STEMI) until there is proof to the contrary. In a STEMI there is usually complete occlusion of an epicardial coronary artery. Other causes of ST segment elevation are: ■ Pericarditis, ventricular aneurysm ■ Pulmonary embolism, intracranial hemorrhage

37. ST Segment Elevation and Depression Primary Causes of ST Segment Depression ■ Myocardial ischemia, or non–ST-elevation MI (NSTEMI) is caused by a partial obstruction of an epicardial coronary artery. ■ Intraventricular conduction defects, left ventricular hypertrophy ■ Medication (e.g., digitalis)

38. A 59-year-old man presents to the emergency department (ED) complaining of new-onset chest pain that radiates to his left arm. He has a history of hypertension, hypercholesterolemia, and a 20-pack-year smoking history. His electrocardiogram (ECG) is remarkable for T-wave inversions in the lateral leads. Which of the following is the most appropriate next step in management? A Give the patient two nitroglycerin tablets sublingually and observe if his chest pain resolves. B Place the patient on a cardiac monitor, administer oxygen, and give aspirin. C Call the cardiac catheterization laboratory for immediate percutaneous coronary intervention (PCI). D Order a chest x-ray; administer aspirin, clopidogrel, and heparin. E Start a β-blocker immediately

39. A 59-year-old man presents to the emergency department (ED) complaining of new-onset chest pain that radiates to his left arm. He has a history of hypertension, hypercholesterolemia, and a 20-pack-year smoking history. His electrocardiogram (ECG) is remarkable for T-wave inversions in the lateral leads. Which of the following is the most appropriate next step in management? A Give the patient two nitroglycerin tablets sublingually and observe if his chest pain resolves. B Place the patient on a cardiac monitor, administer oxygen, and give aspirin. C Call the cardiac catheterization laboratory for immediate percutaneous coronary intervention (PCI). D Order a chest x-ray; administer aspirin, clopidogrel, and heparin. E Start a β-blocker immediately

40. A 64-year-old female rushed to the emergency room, repeating over and over how "her head hurts". Her blood pressure was taken and was reported as 190/110. A fundoscopic exam revealed no damage to the retina. Her past medical history is significant for hypertension and depression. Her medications are lisinopril 10 mg QD and sertraline 50 mg QD. She is allergic to penicillins and develops hives. Her pertinent labs are: BUN 30 and SCr 3.1 mg/dL. How would you characterize her hypertension and what is the goal blood pressure? A Hypertensive urgency; < 160/100 mmHg over 4 hours B Hypertensive Emergency; mean arterial pressure of 105 mmHg in 2 hours C Hypertensive Emergency; diastolic blood pressure of 95 mmHg in 30 minutes D Hypertensive Emergency; < 120/80 mmHg in 4 hours Hypertensive urgencies and emergencies

41. A 64-year-old female rushed to the emergency room, repeating over and over how "her head hurts". Her blood pressure was taken and was reported as 190/110. A fundoscopic exam revealed no damage to the retina. Her past medical history is significant for hypertension and depression. Her medications are lisinopril 10 mg QD and sertraline 50 mg QD. She is allergic to penicillins and develops hives. Her pertinent labs are: BUN 30 and SCr 3.1 mg/dL. How would you characterize her hypertension and what is the goal blood pressure? A Hypertensive urgency; < 160/100 mmHg over 4 hours B Hypertensive Emergency; mean arterial pressure of 105 mmHg in 2 hours C Hypertensive Emergency; diastolic blood pressure of 95 mmHg in 30 minutes D Hypertensive Emergency; < 120/80 mmHg in 4 hours Hypertensive urgencies and emergencies

42. B Hypertensive Emergency; mean arterial pressure of 105 mmHg in 2 hours C Hypertensive Emergency; diastolic blood pressure of 95 mmHg in 30 minutes D Hypertensive Emergency; < 120/80 mmHg in 4 hours Hypertensive urgencies and emergencies In a hypertensive emergency, there are two goals to have in mind: lower mean arterial pressure by 20-25% in 1-2 hours OR lower diastolic blood pressure by 10-15% in 30-60 minutes. Mean arterial pressure = [(2 x diastolic) + systolic] / 3 = [(2 x 110) + 190] / 3 = 137. A reduction of 20-25% is about 105 mmHg in 1-2 hours. Therefore (B) is correct. Diastolic blood pressure reduction should occur in 30-60 minutes. 10-15% of 110 mmHg is approximately 95 mmHg. (C) is also correct because the percentage reduction and the time-frame are accurate. (D) is incorrect because we are not striving for "perfect" blood pressure. The patient's organs may have already acclimated to the higher blood pressure, so too much reduction too quickly will not allow adequate perfusion to the organs and they may fail that way.

43. A 58-year-old male reports to the emergency room after being seen at his primary care physician's clinic. His blood pressure upon entering the emergency room is 200/130 mm Hg and he has shortness of breath (SOB) with a headache. He has a past medical history of hypertension x 5 years. He denies smoking and illicit drug use. He rarely drinks alcohol. His medications are the following: Lisinopril 20 mg QD, HCTZ 25 mg QD. His labs are all within normal limits. How would you characterize her hypertension and what is the goal blood pressure? A Hypertensive Urgency; < 160/100 mmHg in 24-48 hours B Hypertensive Urgency; < 120/80 mmHg in 30-60 minutes C Hypertensive Emergency; Reduce mean arterial pressure to 120 mmHg in 2 hours D Hypertensive Emergency; < 160/100 mmHg over 2-6 hours Hypertensive urgencies and emergencies

44. A 58-year-old male reports to the emergency room after being seen at his primary care physician's clinic. His blood pressure upon entering the emergency room is 200/130 mm Hg and he has shortness of breath (SOB) with a headache. He has a past medical history of hypertension x 5 years. He denies smoking and illicit drug use. He rarely drinks alcohol. His medications are the following: Lisinopril 20 mg QD, HCTZ 25 mg QD. His labs are all within normal limits. How would you characterize her hypertension and what is the goal blood pressure? A Hypertensive Urgency; < 160/100 mmHg in 24-48 hours B Hypertensive Urgency; < 120/80 mmHg in 30-60 minutes C Hypertensive Emergency; Reduce mean arterial pressure to 120 mmHg in 2 hours D Hypertensive Emergency; < 160/100 mmHg over 2-6 hours Hypertensive urgencies and emergencies

45. A Hypertensive Urgency; < 160/100 mmHg in 24-48 hours Hypertensive urgencies and emergencies Our patient is a 58-year-old male. He has a blood pressure of 200/130. To even be considered as a hypertensive crisis, one have to have a systolic blood pressure of at least 180 OR a diastolic blood pressure of at least 110. The key part here is distinguishing between "urgency" and "emergency". The difference is that hypertensive urgency is WITHOUT end organ damage. If organ damage had been present, you would have seen statements such as "retinal damage" and "serum creatinine". These indicate dysfunction with an organ, which is NOT the case here, so this is a hypertensive urgency. In a hypertensive urgency, you still want to act fast, but you have a little leeway in time. Emergencies would obviously require swift action since organs are failing, but an urgency buys you some time. This is why you "only" need to lower the blood pressure to the safe level and do it gradually.

46. A 58-year-old male reports to the emergency room after being seen at his primary care physician's clinic. His blood pressure upon entering the emergency room is 200/130 mm Hg and he has shortness of breath (SOB) with a headache. He has a past medical history of hypertension x 5 years. He denies smoking and illicit drug use. He rarely drinks alcohol. His medications are the following: Lisinopril 20 mg QD, HCTZ 25 mg QD. His labs are all within normal limits. Which of the following is an appropriate treatment option? A Sodium nitroprusside 0.75 mcg/kg/min IV B Metoprolol tartrate 25 mg PO C Hydralazine 15 mg IV bolus D Labetalol 20 mg IV push then 15 mg every 10 minutes Hypertensive urgencies and emergencies

47. A 58-year-old male reports to the emergency room after being seen at his primary care physician's clinic. His blood pressure upon entering the emergency room is 200/130 mm Hg and he has shortness of breath (SOB) with a headache. He has a past medical history of hypertension x 5 years. He denies smoking and illicit drug use. He rarely drinks alcohol. His medications are the following: Lisinopril 20 mg QD, HCTZ 25 mg QD. His labs are all within normal limits. Which of the following is an appropriate treatment option? A Sodium nitroprusside 0.75 mcg/kg/min IV B Metoprolol tartrate 25 mg PO C Hydralazine 15 mg IV bolus D Labetalol 20 mg IV push then 15 mg every 10 minutes Hypertensive urgencies and emergencies

48. B Metoprolol tartrate 25 mg PO Hypertensive urgencies and emergencies As stated before, this is going to be a hypertensive urgency. Action is needed but it does NOT need to be as extreme as an emergency. That is, the therapy required for a hypertensive urgency revolves around ORAL medications. During an emergency, blood pressure must be dropped down to prevent more organ damage and thus IV would be appropriate. Since this is an urgency, oral medications will suffice. (A), (C), and (D) are viable IV options for emergencies. They each have their benefits and risks that must be weighed carefully before use. It must be noted that one of the goals is NOT to reduce blood pressure rapidly. Although that might intuitively seem like a good idea, it is very risky. Organs acclimate to the higher blood pressure and immediately dropping the pressure to a "goal" will lead to HYPO- perfusion of the organ and may lead to organ failure that way. Organs need blood flow no matter what, even if it means artificially raising the blood pressure to do so.

49. A 60-year-old female reports to the emergency room and said she hadn't urinated in a few days while battling a headache. She took her blood pressure at home and became worried so she traveled to the emergency department. Her blood pressure was taken again and it was 200/130. Her past medical history is significant for hypertension and osteoporosis. She takes HCTZ 25 mg QD and alendronate 70 mg weekly. Her pertinent labs are as follows: BUN 36 mg/dL; Sr.Cr 2.2 mg/dL. How would you characterize her hypertension and what is her goal pressure? How would you characterize her hypertension and what is the goal blood pressure? A Hypertensive urgency; < 180/100 mmHg in 1 hour B Hypertensive urgency; < 160/100 mmHg in 36 hours C Hypertensive emergency; reduce mean arterial pressure to 120 mmHg in 2 hours D Hypertensive emergency; < 120/80 mmHg in 30 minutes Hypertensive urgencies and emergencies

50. A 60-year-old female reports to the emergency room and said she hadn't urinated in a few days while battling a headache. She took her blood pressure at home and became worried so she traveled to the emergency department. Her blood pressure was taken again and it was 200/130. Her past medical history is significant for hypertension and osteoporosis. She takes HCTZ 25 mg QD and alendronate 70 mg weekly. Her pertinent labs are as follows: BUN 36 mg/dL; Sr.Cr 2.2 mg/dL. How would you characterize her hypertension and what is her goal pressure? How would you characterize her hypertension and what is the goal blood pressure? A Hypertensive urgency; < 180/100 mmHg in 1 hour B Hypertensive urgency; < 160/100 mmHg in 36 hours C Hypertensive emergency; reduce mean arterial pressure to 120 mmHg in 2 hours D Hypertensive emergency; < 120/80 mmHg in 30 minutes Hypertensive urgencies and emergencies

51. C Hypertensive emergency; reduce mean arterial pressure to 120 mmHg in 2 hours Hypertensive urgencies and emergencies The symptoms in this 60-year-old woman that are conducive to an emergent situation. Classic symptoms are that she has decreased urine output and her headache. The real difference here between an urgency and an emergency is that she has lab values that are indicative of organ damage. BUN and SCr are those two values. BUN is normally around 18 and SCr should be less than 1. High values of both indicate some sort of dysfunction with the kidneys. Because of this, her situation is classified as hypertensive emergency and must be treated as such.

52. Hypertensive urgencies and emergencies In a hypertensive emergency, it is important to reduce the blood pressure to prevent further damage to organs and this needs to happen relatively quickly. (A) and (B) are eliminated for the reason that it is not an urgency. Actually, (B) would be correct if the situation was a hypertensive urgency. (D) is not a correct goal because that may or may not be feasible since organs in her body may have acclimated to a higher blood pressure while she was taking her HCTZ. Therefore, a "good" blood pressure of 120/80 may be too low for some organs and they be HYPO- perfused. (C) is correct. A Hypertensive urgency; < 180/100 mmHg in 1 hour B Hypertensive urgency; < 160/100 mmHg in 36 hours C Hypertensive emergency; reduce mean arterial pressure to 120 mmHg in 2 hours D Hypertensive emergency; < 120/80 mmHg in 30 minutes

53. C Hypertensive emergency; reduce mean arterial pressure to 120 mmHg in 2 hours Hypertensive urgencies and emergencies Mean arterial blood pressure can be determined by the following [(2 x diastolic) + systolic] / 3. In this case, it would be [(2 x 130) + 200] / 3 = 153. The goal in an emergency is to lower this value by 20-25% in the next 1-2 hours. So a 20% reduction will drop the blood pressure to around 120, and that needs to be achieved at the latest of 2 hours. Alternatively, the diastolic blood pressure could be reduced by 10-15% (or to around 115 mmHg) in 30-60 minutes. This will really relieve some of the stress on the heart. Once the patient is stable, the goal would then be to reduce the blood pressure to the safe limits.

54. A 60-year-old female reports to the emergency room and said she hadn't urinated in a few days while battling a headache. She took her blood pressure at home and became worried so she traveled to the emergency department. Her blood pressure was taken again and it was 200/130. Her past medical history is significant for hypertension and osteoporosis. She takes HCTZ 25 mg QD and alendronate 70 mg weekly. Her pertinent labs are as follows: BUN 36 mg/dL; Sr.Cr 2.2 mg/dL. How would you characterize her hypertension and what is her goal pressure? Which of the following is an appropriate treatment option for her? A Metoprolol 25 mg PO B Lisinopril 20 mg PO C Furosemide 80 mg PO D Labetalol 20 mg IV then 15 mg IV every 10 minutes thereafter Hypertensive urgencies and emergencies

55. Which of the following is an appropriate treatment option for her? A Metoprolol 25 mg PO B Lisinopril 20 mg PO C Furosemide 80 mg PO D Labetalol 20 mg IV then 15 mg IV every 10 minutes thereafter Hypertensive urgencies and emergencies In a hypertensive emergency, IV drugs must be used. This is a serious problem that requires immediate action, which makes it significantly different from hypertensive urgency. This is because organ damage is present (kidneys in this case). (A), (B), and (C) are all oral medications, which won't act fast enough to lower the blood pressure and relieve stress on the heart.

56. 45-year-old male presents to the emergency room with chest pain and SOB. His blood pressure is immediately taken and it is recorded as 190/120. His past medical history is relevant for hypertension, GERD, and back pain. His medications are lisinopril 10 mg QD, omeprazole DR 20 mg QD, and hydrocodone-acetaminophen 5-325 mg q6h PRN pain. He has no drug allergies. Pertinent lab values are BUN 30 and SrCr 2.7 mg/dL. Which of the following is the most appropriate treatment for this Pt. A Esmolol 1 mg/kg IV loading dose over 1 minute then appropriate titration B Losartan 50 mg PO C Hydralazine 25 mg PO D Hydralazine 15 mg IV bolus with possible re-bolus q20 minutes Hypertensive urgencies and emergencies

57. 45-year-old male presents to the emergency room with chest pain and SOB. His blood pressure is immediately taken and it is recorded as 190/120. His past medical history is relevant for hypertension, GERD, and back pain. His medications are lisinopril 10 mg QD, omeprazole DR 20 mg QD, and hydrocodone-acetaminophen 5-325 mg q6h PRN pain. He has no drug allergies. Pertinent lab values are BUN 30 and SrCr 2.7 mg/dL. Which of the following is the most appropriate treatment for this Pt. A Esmolol 1 mg/kg IV loading dose over 1 minute then appropriate titration B Losartan 50 mg PO C Hydralazine 25 mg PO D Hydralazine 15 mg IV bolus with possible re-bolus q20 minutes Hypertensive urgencies and emergencies

58. A Esmolol 1 mg/kg IV loading dose over 1 minute then appropriate titration B Losartan 50 mg PO C Hydralazine 25 mg PO D Hydralazine 15 mg IV bolus with possible re-bolus q20 minutes Hypertensive urgencies and emergencies Once again, this is a hypertensive emergency for all the same reasons as before. The treatment requires IV medications, thus eliminating (B) and (C)

59. A Esmolol 1 mg/kg IV loading dose over 1 minute then appropriate titration D Hydralazine 15 mg IV bolus with possible re-bolus q20 minutes Hypertensive urgencies and emergencies Esmolol is cardioselective beta-blocker that will decrease the rate and contractility of the heart. The other positive about this drug is that it is NOT affected by renal or hepatic function, which is ideal in this situation. The patient has renal failure and we want to try our best to avoid damaging the body more. Esmolol is ideal when the cardiac output, heart rate, and/or blood pressure are increased because of its cardioselectivity. It works quickly and has minimal side effects, thus making it the best option in this patient. Hydralazine is a vasodilator that is useful in pregnancy, but does have the unfortunate qualities of reflex tachycardia and aggravation of angina. The patient already complains of chest pain so aggravating that will not be suitable. Therefore, (C) may not be the best for this patient.

60. A 64-year-old female rushed to the emergency room, repeating over and over how "her head hurts". Her blood pressure was taken and was reported as 190/110. A fundoscopic exam revealed no damage to the retina. Her past medical history is significant for hypertension and depression. Her medications are lisinopril 10 mg QD and sertraline 50 mg QD. She is allergic to penicillins and develops hives. Her pertinent labs are: BUN 30 and SCr 3.1 mg/dL. Which of the following is an appropriate treatment option for PL? A Sodium nitroprusside 5 mcg/kg/min IV followed by appropriate titration B Diltiazem 120 mg PO C Hydralazine 10 mg PO D Labetalol 20 mg IV push then 15 mg every 10 minutes thereafter Hypertensive urgencies and emergencies

61. A 64-year-old female rushed to the emergency room, repeating over and over how "her head hurts". Her blood pressure was taken and was reported as 190/110. A fundoscopic exam revealed no damage to the retina. Her past medical history is significant for hypertension and depression. Her medications are lisinopril 10 mg QD and sertraline 50 mg QD. She is allergic to penicillins and develops hives. Her pertinent labs are: BUN 30 and SCr 3.1 mg/dL. Which of the following is an appropriate treatment option for PL? A Sodium nitroprusside 5 mcg/kg/min IV followed by appropriate titration B Diltiazem 120 mg PO C Hydralazine 10 mg PO D Labetalol 20 mg IV push then 15 mg every 10 minutes thereafter Hypertensive urgencies and emergencies

62. A Sodium nitroprusside 5 mcg/kg/min IV followed by appropriate titration D Labetalol 20 mg IV push then 15 mg every 10 minutes thereafter Hypertensive urgencies and emergencies Sodium nitroprusside is toxic. It contains 44% cyanide by weight, which can lead to cyanide toxicity. The liver will metabolize cyanide into thiocyanate, which isn't nearly as toxic as cyanide. It is then cleared by the kidneys. The problems arise when either the liver can't metabolize the cyanide OR the kidney can't eliminate the thiocyanate. In this patient cyanide will just accumulate in the body and cause poisoning. Because of this, you shouldn't use this drug for long periods of time, so it should be limited to 24-48 hours. PL has poor kidney function. This can be seen with the BUN and SCr values, which are elevated. This indicates some sort of acute kidney damage. Thiocyanate will not be cleared and cyanide will accumulate. Therefore, sodium nitroprusside should not be used in this patient. If you ever want to use this medicine, the patient MUST have good liver AND kidney functions.

63. 31-year-old pregnant female is admitted to the emergency room for complaints of chest pain and nausea. Her blood pressure reading is 200/110. Her past medical history is significant for hypertension. Her current medications are HCTZ 50 mg PO QD and folic acid 1 mg PO QD. A fundoscopic exam shows slight tears in the retina. She has no medication allergies. All lab values are within normal. Which of the following is the most appropriate treatment for this Pt. A Carvedilol 6.25 mg PO B Lisinopril 10 mg PO C Labetalol 20 mg IV then 15 mg q10 minutes thereafter D Enalaprilat 5 mg IV bolus Hypertensive urgencies and emergencies

64. 31-year-old pregnant female is admitted to the emergency room for complaints of chest pain and nausea. Her blood pressure reading is 200/110. Her past medical history is significant for hypertension. Her current medications are HCTZ 50 mg PO QD and folic acid 1 mg PO QD. A fundoscopic exam shows slight tears in the retina. She has no medication allergies. All lab values are within normal. Which of the following is the most appropriate treatment for this Pt. A Carvedilol 6.25 mg PO B Lisinopril 10 mg PO C Labetalol 20 mg IV then 15 mg q10 minutes thereafter D Enalaprilat 5 mg IV bolus Hypertensive urgencies and emergencies

65. C Labetalol 20 mg IV then 15 mg q10 minutes thereafter D Enalaprilat 5 mg IV bolus Hypertensive urgencies and emergencies Enaliprilat is an IV ACE inhibitor, which is good if there is left ventricular failure Unfortunately, its use is contraindicated in pregnancy and should thus be avoided. In fact, answer choice (B), which is lisinopril, should also be avoided in pregnancy (Pregnancy Category D). As a result, labetalol would be the safest and most correct option. Enalaprilat was purposefully placed as an answer choice to stress that pregnancy must also be taken into consideration for these cases. Hypertensive urgencies and emergencies are not limited to the elderly or those non-adherent to their hypertensive medications. It may be tempting to assume labetalol is a safe choice almost every time. Indeed, it is safe to use in those with coronary artery disease and pregnancy. However, because it is a non-selective beta-blocker, it does have the ability to block beta-2 receptors in the bronchial smooth muscle. Because of this, it should be avoided in those with asthma and COPD.

66. Ventricular dysrhythmia Ventricular fibrillation Bradycardia Tachycardia Which of the following cardiac dysrhythmias cannot produce a pulse?

67. PRI measurement of 0.11 seconds Regularly irregular appearance No visible P wave Presence of wide QRS complex 2. What characterizes atrial fibrillation (AF) on an ECG strip?

68. Irregular rhythm with variable conduction Sawtooth shape resembling picket fence Presence of multiple P waves before each QRS complex QRS complex measuring 0.11 seconds (110 ms ) or less 3. Which characteristic distinguishes atrial complexes in atrial flutter from those in normal sinus rhythm?

69. Thrombolytic therapy Antiarrhythmic medication Intravenous fluid bolus Beta-blocker or calcium channel blocker 4. What may be administered to a stable but symptomatic patient with atrial flutter?

70. Blood clot formation in the fibrillating atria Improved atrial contraction Decreased heart rate Reduced blood viscosity 5. Why does atrial fibrillation (AF) increase the risk of stroke?

71. Normal p waves with constant PR intervals Missing QRS complexes Progressively prolonged PR intervals Regular atrial rhythm 6. Which of the following is NOT a finding in a Second-Degree Type II heart block (Mobitz II) ECG reading?

72. a gradually lengthening PR interval with a random dropped QRS complex a PR interval >0.20 seconds a constant PR interval with random dropped QRS complexes independent p waves and QRS complexes 7. A hallmark finding in a First-Degree Heart Block is?

73. Coughing Lowering the head between the knees Stretching the arms and body Valsalva's maneuver 8. Which mechanical measure stimulates the vagus , delays AV conduction, and blocks reentry mechanisms, terminating arrhythmia?

74. 6 mg 10 mg 4 mg 8 mg 9. What is the initial bolus dose of i.v. adenosine used to terminate episodes of paroxysmal supraventricular tachycardia?

75. Procainamide Synchronized DC cardioversion Lidocaine Amiodarone 10. What is the treatment indicated for Acute Ventricular Tachycardia if hypotension, heart failure, or angina is present?

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