Download Chapter 12 Emergency Medications Case PowerPoint Answers

Nancy Caroline’s Emergency Care in the Streets, Seventh Edition
Chapter 12: Emergency Medications
Chapter 12
Emergency Medications
Case PowerPoint Answers
1. What are your initial care priorities for Fred?
Answer: The initial care priorities for Fred include supportive measures for ABCs,
supplemental oxygen, and administration of 324 mg baby Aspirin po or an adult Aspirin
(325 mg) po within 5 minutes. Since Fred is having active chest pain suggestive of
ischemia, obtaining a 12- or 15-lead ECG within the first few minutes is very important.
2. What diagnostic test should be performed quickly upon arrival?
Answer: Since Fred is having active chest pain suggestive of ischemia, obtaining a 12- or
15-lead ECG within the first few minutes is very important. If ECG changes are present
with his active symptoms you will be able to diagnose his myocardial infarction.
However, only about 60% of ECGs are diagnostic. He could possibly have an
undiagnostic ECG. Obtaining the ECG quickly will allow you to contact the receiving
facility early and arrange transport to a cardiac catheterization center for reperfusion
treatment.
3. What is your differential diagnosis?
Answer: Your differential diagnosis would most likely include acute coronary syndrome
(ACS), acute myocardial infarction (AMI), pulmonary embolism, or gastric esophageal
reflux disease (GERD) to name a few.
4. What type of facility would provide Fred with the best care?
Answer: Since Fred is having active chest pain we must assume that his chest pain is
ischemic in nature and due to coronary artery occlusion (blockage). Therefore, the best
transport decision would include transport to a facility with cardiac catheterization
capabilities. These facilities offer the best chance of restoring perfusion to oxygen
deprived areas of the heart.
5. What additional questions must be answered as part of your patient interview?
Answer: There are some other important details we would like to know. What was the
onset of the chest pain? Since treatment is time sensitive, knowing when it started can
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Nancy Caroline’s Emergency Care in the Streets, Seventh Edition
Chapter 12: Emergency Medications
affect his treatment. Furthermore, we should have Fred tell us how he knows what time it
started. For example, maybe the pain started when the baseball game came on TV, etc.
6. What additional medications should be administered? Explain why.
Answer: Medications such as sublingual NTG must be administered to try to resolve his
chest pain. Unfortunately, NTG sublingual did not ease his pain. We can now consider
narcotic analgesics such as Sublimaze, Dilaudid, or morphine sulfate. Since his pain is a
direct measure of the ischemia his heart is experiencing, we want to completely resolve
his pain to a “0”. We should also administer an antiemetic such as Phenergan or Zofran
for his nausea. Phenergan has a fast onset of action so we might consider it first.
7. Fred wanted to be transported to a local hospital that was closer. How would you explain
your transport rationale to Fred?
Answer: Fred is the patient and has the right to make decisions regarding his health care
(autonomy). However, we would be neglect in our duty if we did not effectively explain
how he will benefit from being evaluated and treated at a facility with cardiac
catheterization capabilities. Scientific evidence has demonstrated that chest pain patients
have an improved outcome when they are treated at accredited chest pain centers that
have a cardiac catheterization lab. This is an important part of the 2010 American Heart
Association (AHA) Guidelines.
8. What monitoring devices would you use during transport?
Answer: Monitoring devices include midstream waveform capnography, automatic blood
pressure and vital sign monitoring, continuous pulse oximetry, and frequent repeat 12- or
15-lead ECG monitoring to name a few.
9. Considering that Fred’s pain and nausea have not resolved, what additional medications
should be administered?
Answer: We know Fred has an inferior wall MI. Since sublingual NTG and IV
Sublimaze have not relieved his pain, we must begin a NTG IV (Tridil) infusion. Tridil is
titrated to effect as we continually reassess his pain, vital signs, and ECG. Again, our
goal is to make Fred pain free. We should also administer another antiemetic such as
Zofran to relieve his nausea and vomiting.
10. Describe your frequent reassessment of Fred. How would you know if the treatment is
effective?
Answer: Fred’s reassessment would include continuous pulse oximetry, mainstream
waveform capnography, pain assessment, vital signs, and repeat 12- or 15-lead ECG
monitoring. We will know that our treatment is effective when we see a decrease in his
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Nancy Caroline’s Emergency Care in the Streets, Seventh Edition
Chapter 12: Emergency Medications
ST elevation or when the ST segment returns to normal. In addition, Fred’s chest pain
and dyspnea will resolve and his vital signs will stabilize.
11. Why did medical control order Lopressor for Fred?
Answer: Lopressor is indicated for patients experiencing an acute MI who have rapid
heart rates. In Fred’s case he remains in sinus tachycardia even after his pain decreases to
a “3”. Since tachycardia can contribute to increased cardiac oxygen demand, we want to
slow the heart rate down to reduce the oxygen demand on the heart. In some studies
Lopressor has shown to reduce myocardial ischemia and damage in some patients with
selected AMIs.
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