Final exam question on heart monitor

[paramedicmike]

Finding the irregular pulse on your primary assessment IS a reason to include the monitor sooner than later.

Just to see how you're thinking, why?

You know he has a history of A-fib. What's big about a-fib?

You know he's on meds to treat the a-fib. What will this particular med do to the patient?

Knowing the answers to these questions, why would an irregular heartbeat be a reason to put him on the monitor (which is what the question is asking)?

Just as a side, what other piece of information is available that might lead you to figure out what happened? Mobey touched on it but then let it drop focusing instead on the irregular heart rate.

[EMS49393]

](*,)

Is this a true/false type of test? I misunderstood it to be in essay type format. If it is a true/false test, it's a poorly written question. At any rate, you had a 50% chance of getting it correct.

If you were given the scenario, and asked the question "How do Karl's pre-existing medical problems effect you assessment?" the answer would be easy in essay format.

Tachycardia is one of the first signs of compensated shock. The patient may not become tachycardic secondary to the medication he is taking (Lanoxin). Also, it's safe to consider this patient is a diabetic since he is taking Micronase. A BGL should be checked early secondary to the altered LOC. Lastly, your patient is taking Lasix, and currently has fluid in the bases of his lungs per the primary assessment. A provider might then begin to worry about heart failure on top of his other problems.

The monitor is not indicated simply because you find an irregular heart rate. I wouldn't even worry about the irregular heart rate, given the history and medications. I'd worry about cardiac contusion and heart failure after I made sure his BGL was normal. If he were a real patient, he would be on high flow Os, get immobilized, and I'd begin transporting before I monkeyed around with any other assessment or treatment. Everything else can be done en route.

[Dustdevil]

I'd sure like to see what B, C, D, and E were, because I would not choose A. As has already been stated, the PMH does not cause me to run an EKG, because I would have already done that regardless of his PMH. Unless it is just a piss-poorly worded question, I don't think A would be true.

[becksdad]

I agree its poorly worded. But I also think several people have mentioned points to be taken together, and there's more that I think would affect your assessments/interpretation. Sure, the A-fib renders the irregular pulse a somewhat moot point, and yes, hypoglycemia can contribute to altered LOC. But The steering wheel was bent - that takes a ggod amount of force. The patients sternum is bruised, and there is pain on palp to left chest. Note that drivers door was struck as well as frontal impact. MOI and S/S lead me to be looking at the chest VERY closely and frequently. Cardiac contusion? hemo/pnuemothorax? cardiac tamponade? internal bleeding? Meds might keep HR down, so it won't be a reliable indicator of shock. I'd be keeping a very close eye on BP, resps (rate and sounds), changing LOC, skin color. I don't think, as mentioned previously, that only LOC is the reason for rapid transport - I think its everything together. The monitor would go on - but NOT because of PMH. It would be because of MOI and S/S. Seems like the way assessments would be affected the most, would be to keep looking very closely at signs of shock, and not be lulled into a false sense of security based on a HR that stays under 100. But thats just an EMT's view. I'm sure I'm missing probabilities.

[medic001918]

I agree its poorly worded. But I also think several people have mentioned points to be taken together, and there's more that I think would affect your assessments/interpretation. Sure, the A-fib renders the irregular pulse a somewhat moot point, and yes, hypoglycemia can contribute to altered LOC. But The steering wheel was bent - that takes a ggod amount of force. The patients sternum is bruised, and there is pain on palp to left chest. Note that drivers door was struck as well as frontal impact. MOI and S/S lead me to be looking at the chest VERY closely and frequently. Cardiac contusion? hemo/pnuemothorax? cardiac tamponade? internal bleeding? Meds might keep HR down, so it won't be a reliable indicator of shock. I'd be keeping a very close eye on BP, resps (rate and sounds), changing LOC, skin color. I don't think, as mentioned previously, that only LOC is the reason for rapid transport - I think its everything together. The monitor would go on - but NOT because of PMH. It would be because of MOI and S/S. Seems like the way assessments would be affected the most, would be to keep looking very closely at signs of shock, and not be lulled into a false sense of security based on a HR that stays under 100. But thats just an EMT's view. I'm sure I'm missing probabilities.

+1. This patients previous history of a-fib would have nothing to do with my decision to apply the cardiac monitor to this patient. This patient is getting worked based on presentation and mechanism of injury. There is a high potential for internal injury in this patient that needs to be addressed.

An irregular pulse alone is not often times a reason to apply the monitor. You have to look at the complete picture and see what's going on to make informed decisions.

Shane

NREMT-P

[Lithium]

I'm on the same side as Dust, as purely because of his PmHx of 'heart' problems, that is not my rational for applying a monitor. The way the question is worded however, it is TRUE.

A monitor is just that ... a machine that lets you monitor the electrical activity of this dudes cardium. What it doesn't do is interpret the rhythm for you and put it into context of your patient. This you have to do on your own. I'll admit, EVERY patient I encounter (except those who are obviously dead ... ) will have the cardiac monitor applied to them during my initial assessment. Whether it stays on or not, will be based on their event and medical history. It's another piece of information that helps me come to a clinical decision, and, has saved my butt on a few occasions.

If anything, this patient is at high-rish for a cardiac tamponade, which, with a monitor in place, you can start to see signs of. Remeber, early alert of your receiving facility with your suspicions will provide better care for him when he arrives.

peace

[Dustdevil]

Now the real question is whether your instructor worded this question this way because he is an idiot, or because he wanted to prepare you for the sort of confusing, nonsensical questions you will see on the NR exam.

This indeed is the sort of crap that is on NR. :roll:

[tniuqs]

Now the real question is whether your instructor worded this question this way because he is an idiot, or because he wanted to prepare you for the sort of confusing, nonsensical questions you will see on the NR exam.

This indeed is the sort of crap that is on NR. :roll:

For the statement above...ANSWER:

TRUE

[mobey]

I think ur contradicting yourself lithium. The question implies you woulden't put on the monitor if not for the irregular pulse. you and me say that's FALSE. MOI is enough for me to put a monitor on. Heck just the age of the pt. is enough for me.

Sighns of a Tamponade on the monitor? you have peaked my interest.

What is a NR exam?

[chbare]

Mobey, there are in fact non specific findings associated with cardiac tamponade.

Electrical Altrans related to the heart moving within the pericardial sack.

Low voltage QRS complexes.

The National Registry of EMT's is a standardized testing organization for EMT's in the USA. They test a written exam and a psychomotor exam based on the US Department of Transportation National Standard Curriculum Many states will accept NREMT credentials and allow reciprocity. This is what we talk about when we say NR test or NREMT. Check out the website for more information. www.nremt.org .

Take care,

chbare.