10 free Paramedic practice questions: Cardiogenic Shock and Decompensated Heart Failure

Pink frothy sputum: a sign of advanced pulmonary edema, the condition CPAP treats. A sicker pulmonary edema patient is still a CPAP patient as long as they can protect the airway and follow instructions.

Very fast, labored breathing: Fast, labored breathing is the work of breathing CPAP reduces. The breathing problems that rule CPAP out are apnea, agonal breathing, and arrest, where the patient has no effective breathing of their own for the device to support.

Severe hypertension: CPAP raises intrathoracic pressure and reduces preload, so the pressure that makes it unsafe is a low one: hypotension with a systolic pressure commonly below 90 mmHg. Severe hypertension is not on the contraindication list.

An allergic reaction to the CPAP mask material: An allergic reaction to the mask would give you hives, new wheezing, or swelling of the face or airway. This question gives you none of those.

Resolution of the underlying pulmonary edema: The easier breathing and the SpO₂ of 96% can look like the pulmonary edema has resolved. Pulmonary edema does not resolve within minutes. The timing of the blood pressure drop lines up with a known effect of CPAP instead.

Peak effect of a home antihypertensive medication taken earlier: A home blood pressure medication can lower the pressure. The question never says the patient took one. The drop started on CPAP, and CPAP explains the drop much better.

Increased venous return that restores adequate cardiac preload: CPAP does change blood flow, but in the opposite direction from this option. Raising the pressure in the chest decreases venous return and lowers preload. Lower preload actually helps a fluid-overloaded left ventricle. The question asks about oxygenation, and the better oxygenation comes from the reopened alveoli.

Relaxation of coronary artery smooth muscle that increases myocardial blood flow: Relaxing coronary artery smooth muscle describes nitroglycerin. Nitroglycerin dilates the veins and coronary arteries and lowers preload and afterload. CPAP has no direct effect on the coronary arteries.

Increased systemic vascular resistance that raises alveolar perfusion pressure: CPAP does not raise systemic vascular resistance. Raising systemic vascular resistance would increase the afterload on a failing ventricle. Higher afterload makes pulmonary edema worse, not better.

The sudden onset of difficulty breathing at rest: Acute pulmonary edema can come on over minutes too, so sudden onset does not tell an embolism from a failing heart. How fast the breathing trouble started narrows your thinking, but it does not decide the shock type.

The oxygen saturation of 86% on room air: An SpO₂ of 86% can come from a massive embolism or from pulmonary edema, so it cannot separate the two. The saturation tells you this patient needs oxygen now. It does not tell you whether the problem is before the lungs, like an embolism, or after them, like a failing left ventricle.

The heart rate above 130 with a systolic in the 70s: Every kind of shock on the list can give you a heart rate above 130 and a systolic in the 70s. Those numbers tell you this patient is in shock, not which kind.

An early pneumonia settling into both bases: Pneumonia can settle into the lung bases. Pneumonia gives you a fever, a productive cough, and abnormal sounds over the affected part of the lung. This patient has clear lungs and nothing that points to infection.

Volume depletion from two weeks of poor intake: Two weeks of eating and drinking less can leave an older patient dry. A dry patient has flat neck veins because there is not enough volume to fill them. This patient's neck veins are distended and the ankles pit. The fluid is there, and it is backed up into the body.

Left-sided failure backing fluid into the lungs: Left-sided failure is the right organ but the wrong side. When the left ventricle fails, fluid backs up into the lungs and you hear crackles. This patient's lungs are clear in every field.

A single large bolus of isotonic fluid run wide open: This patient does need volume, so fluid is the right direction. Running one large bolus wide open takes away the chance to recheck after each amount. The left ventricle can still flood the lungs if you give too much.

Sublingual nitroglycerin to open the vessels: Nitroglycerin opens the vessels and is a normal part of treating chest pain. Nitroglycerin drops preload, and preload is the one thing this right ventricle cannot afford to lose. Giving nitroglycerin here can turn a soft pressure into a crash.

Supine positioning with the legs raised and nothing else: Raising the legs does move a little blood toward the core, and raising the legs does no harm. Positioning alone is not enough for a pressure of 82/58, and positioning is not the treatment this pattern calls for.

Assist breathing with a BVM at 20 breaths per minute: A BVM is for a patient who can no longer breathe well enough without help. This patient is alert, following commands, and pulling breaths on their own. The ability to do the work of breathing has not been lost. Ventilating with a BVM is where you go if that changes.

Lay the patient supine and run a 500 mL fluid bolus: Laying the patient flat and running fluid is the reflex for most other kinds of shock. A systolic of 98 is low, but this patient's lungs are already flooded. A 500 mL bolus adds more fluid to them. Sitting upright lets gravity keep some of the fluid out of the upper lungs, and laying the patient flat takes that away.

Place an NRB at 15 liters per minute and transport: An NRB at 15 liters per minute is a reasonable first move while you set up CPAP. An NRB only gives a richer oxygen mix. The alveoli are still full of fluid, so the oxygen still cannot get across. Pressure is what moves the fluid out, and an NRB gives no pressure.

Tighten the mask straps and coach the patient through it: Coaching is what gets most patients through the first minutes on CPAP. Coaching and tightening straps are the right move when the problem is the mask. This seal is already intact, and the device is delivering the set pressure. Tighter straps fix a mechanical problem this patient does not have.

Increase the CPAP pressure by one step per protocol: Stepping the pressure up inside the protocol range helps a patient who is holding on. More pressure only helps a patient who can still pull breaths through it. This patient is breathing 8 times a minute with shallow chest rise. Turning the pressure up gives a stiffer mask and no more air.

Remove the CPAP and place an NRB at 15 liters: Removing CPAP from a patient who can no longer use it sounds reasonable, since CPAP asks for work this patient has stopped doing. An NRB at 15 liters gives less support, and this patient needs more support. The patient would still be breathing 8 times a minute without help. Those breaths have to be replaced with ventilations.

The rising pulse is anxiety from the mask: A CPAP mask can make a patient anxious, and anxiety raises the pulse. Anxiety does not cool the fingertips or slow the capillary refill. Those two findings make this a perfusion problem.

The patient is responding well to the treatment: The saturation did improve, but the pulse and the skin both got worse. A faster pulse with cooler skin means the patient is working harder to hold the same pressure, and that is not a good response.

The CPAP is no longer reaching the alveoli: CPAP that stops reaching the alveoli would drop the saturation. This saturation went up from 88% to 91%. The lungs are the part of this patient that improved.

Administer a large-volume normal saline bolus: A large fluid bolus is the standard fix for hypovolemic shock, where the hypotension and tachycardia come from too little volume. This patient has bilateral crackles and JVD, and the patient is not low on fluid. The ventricle is failing, not empty. A large bolus floods lungs that are already backing up.

Withhold treatment until a 12-lead ECG is obtained: A 12-lead ECG helps find an infarct or a dysrhythmia behind the pump failure. This patient already has hypotension and cool, mottled skin from poor perfusion. Holding treatment for a test delays the vasoactive support that needs to start now.

Administer a high-dose diuretic to reduce total body fluid: A diuretic pulls fluid off a patient with pulmonary congestion. This patient is already hypotensive. Lowering the blood volume further drops the perfusion pressure and makes the shock worse. The diuretic does nothing for the failing pump that is causing the shock.