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You are functioning as a prehospital ACLS provider today in a community more than 2 hours away from the closest cardiac catheterization facility. Acute STEMIs are therefore treated in your local hospital with thrombolytics. You are dispatched to a local accounting firm to help a 39-year-old black male with a chief complaint of retrosternal chest discomfort with minimal radiation to the left shoulder. The pain came on while he was sitting at his desk, is described as a pressure, and has been present for a little over 3 hours. He admits to mild nausea, but denies vomiting, diaphoresis, or shortness of breath. He has not tried antacids or nitroglycerin for relief. He awoke with a similar discomfort about three nights ago, went into the bathroom and got a drink, and then lay down and fell asleep again. He has had no exertional chest discomfort with exercise such as mowing the lawn with a push lawnmower.

He has been told in the past that his blood pressure was "a little high," but no medications were prescribed. He smokes one pack of cigarettes daily. His father died quite suddenly in his early 50s.

Physical examination reveals a mildly obese black male who appears anxious. Pulse, 80. Respirations, 20. BP, 184/112. His skin is warm and dry. He has no jugular venous distention. The lungs are clear. Hearth rhythm is regular, and the heart tones are not muffled. You can hear no gallop, murmurs, or friction rubs. He has no peripheral edema.

1. With regard to the pain, you conclude that:

a) the history is sufficient to be compatible with ACS.

b) the history is not compatible with ACS.

2. With regard to the physical examination, you conclude that:

a) the physical examination lends support to the diagnosis of ACS.

b) the physical examination neither confirms nor denies the possibility of ACS.

3. Your first procedural step should be to:

a) give 0.4 mg sublingual nitroglycerin.

b) start a medical IV, attach the patient to a cardiac monitor, and start O2.

c) perform a 12-lead electrocardiogram.

d) question the patient regarding contraindications to thrombolytic therapy.

4. Your second procedural step should be to:

a) give 0.4 mg sublingual nitroglycerin.

b) start a medical IV, attach the patient to a cardiac monitor, and start O2.

c) perform a 12-lead electrocardiogram.

d) question the patient regarding contraindications to thrombolytic therapy.

5. Your third procedural step should be to:

a) give 0.4 mg sublingual nitroglycerin.

b) start a medical IV, attach the patient to a cardiac monitor, start O2.

c) perform a 12-lead electrocardiogram.

d) question the patient regarding contraindications to thrombolytic therapy.

You have performed a 12-lead ECG (Figure 14.1). Questioning conducted during performance of the ECG revealed that the patient had a hernia repair 2 years ago. He admits to an allergy to aspirin and states that he breaks out in hives when he takes the drug.

6. Upon completion of the ECG, you quickly note that the patient's electrocardiogram shows:

a) a normal axis.

I II III aVR aVL aVF V1 V2 V3 V4V5V6

I II III aVR aVL aVF V1 V2 V3 V4V5V6

Figure 14.1.

d) an indeterminate axis.

7. With regard to contraindications to aspirin, you conclude that:

a) contraindications exist.

b) no contraindications exist.

8. With regard to contraindications to thrombolytic agents, on the basis of currently available information you conclude that:

a) absolute contraindications exist.

b) relative contraindications exist.

c) no contraindications exist.

9. Upon contacting medical command by radio, you report that the ECG shows:

a) an acute inferior STEMI.

b) an acute anterior STEMI.

c) an inferior myocardial infarction that may be old.

d) an anterior myocardial infarction that may be old.

e) benign early repolarization changes.

f) a LBBB simulating anterior STEMI.

g) acute pericarditis.

i) nonspecific ST changes.

10. Your field assessment, as reported to medical command, is that:

a) sufficient evidence of STEMI exists to recommend thrombolytic therapy and to institute the prehospital thrombolytic protocol.

b) sufficient evidence of STEMI exists to recommend thrombolytic therapy with the exception of aspirin, if relative contraindications can be removed.

c) evidence of STEMI exists, but absolute contraindications prohibit thrombolytic therapy.

d) evidence of STEMI exists, but relative contraindications rule out thrombolytic therapy.

e) Insufficient evidence of STEMI exists to recommend either throm-bolytic therapy or implementation of the prehospital thrombolytic protocol.

f) Insufficient evidence of STEMI exists to recommend thrombolytic therapy at present, but the index of suspicion is still high enough to warrant implementation of the prehospital thrombolytic protocol, with the exception of aspirin.

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