1. Which is not true of cardiopulmonary resuscitation (CPR)?
A. Closed chest massage is as effective as open chest massage.
B. The success rate for out-of-hospital resuscitation may be as high as 30% to 60%.
C. The most common cause of sudden death is ischemic heart disease.
D. Standard chest massage generally provides less than 15% of normal coronary and cerebral blood flow.
DISCUSSION: Closed chest massage is not as effective as open-chest massage in normalizing blood pressure or perfusion of
vital organs, and closed chest massage does generally deliver 5% to 15% of normal coronary and cerebral blood flow. The
success rate for out-of-hospital resuscitation has been as high as 30% to 60% when communities are prepared to institute CPR
early after a cardiac arrest. Ischemic heart disease is the most common cause of sudden death.
DISCUSSION: Basic life support does involve calling for help, obtaining an airway, and beginning ventilation before starting
chest compression. Electrical cardioversion requires special equipment and trained personnel and thus is part of advanced
cardiac life support.
B. Intravenous epinephrine, 10 ml. of 1:10,000.
C. Intravenous calcium gluconate, 10 ml. of 10% solution.
D. Intravenous atropine, 0.5 mg.
DISCUSSION: Recommended treatment for asystole is administration of atropine. If atropine is unsuccessful epinephrine is given. Ultimately cardiac pacing is necessary if atropine and epinephrine do not establish an adequate heart rate. Calcium has no clear role in treating asystole.
DISCUSSION: Multiple studies in the literature confirm that injuries to the coronary arteries are the most important factor in determining outcome after a penetrating cardiac injury. Tangential injuries are the least serious. Injury to a single chamber\u2014 even if comminuted\u2014or to multiple chambers is less likely to be fatal than are injuries that involve a major coronary artery.
5. The most useful incision in the operating room for patients with penetrating cardiac injury is:
A. Left anterior thoracotomy.
B. Right anterior thoracotomy.
C. Bilateral anterior thoracotomy.
DISCUSSION: The subxyphoid incision is useful for determining if there is blood in the pericardium and if there is an
intracardiac injury; however, exposure is extremely limited, and definitive repair can rarely be performed through the incision.
Left (or right) anterior thoracotomy is easily performed, especially in the emergency room, and gives adequate exposure to
certain areas of the heart. However, each has significant limitations in exposure. Either may be extended across the
thoracotomy into the other side of the chest, thus producing a bilateral anterior thoracotomy. Exposure is excellent through this
incision, and most injuries can be satisfactorily repaired through this approach. Most cardiac operations today are performed
through median sternotomy incisions. If the patient is in the operating room, this incision is easily performed and always
provides excellent exposure for all areas of the heart.
B. Distended neck veins.
C. Decreased heart sound.
D. All of the above.
DISCUSSION: Hypotension, increased venous pressure (distended neck veins), and decreased heart sounds make up the
classic Beck's triad associated with cardiac tamponade. If these three findings are present in a person who has a penetrating
chest wound, intracardiac injury is almost certain and operative intervention is mandatory.
7. Which of the following would be an acceptable method of repair for a neonate with symptomatic isolated coarctation of
A. Resection with end-to-end anastomosis.
B. Prosthetic patch aortoplasty.
C. Subclavian flap aortoplasty.
D. Prosthetic tube graft repair.
DISCUSSION: The most commonly used methods for coarctation repair are resection with anastomosis and subclavian flap aortoplasty. Both have been shown to provide adequate relief of the obstruction with acceptable rates of restenosis. The choice of repair depends on the patient's anatomy and the surgeon's experience. Patch aortoplasty was used frequently in the past; however, because of concern over restenosis and aneurysm formation it is no longer commonly performed. Prosthetic tube graft repair is avoided except in some complex cases and some cases of recoarctation.
8. Which of the following constitutes a true vascular ring?
A. Pulmonary artery sling.
B. Double aortic arch.
C. Anomalous origin of right subclavian artery from the descending aorta.
D. Cervical aortic arch.
DISCUSSION: Only the double aortic arch secondary to persistence of the right and left fourth aortic arches forms a true
vascular ring. Pulmonary artery sling may cause symptoms that are due to compression of the trachea, and an anomalous right
subclavian may cause dysphagia, but these anomalies do not constitute complete rings. Cervical aortic arch, which is thought
to be secondary to persistence of the third aortic arch, is not a complete ring and usually is asymptomatic.
9. Which of the following may be physical examination findings in a young adult with coarctation of the aorta?
A. Posterior systolic murmur between the scapulas.
B. Diminished femoral pulses.
C. Elevated blood pressure in left arm as compared with right arm.
DISCUSSION: A systolic murmur that radiates posteriorly is characteristic of coarctation of the aorta. Coarctation produces
obstruction to aortic flow, and thus the femoral pulse has a diminished volume with delayed upstroke. Hypertension in
coarctation is multifactorial, but the most important factors are diminished renal flow (single clip, single kidney-Goldblatt
model) and mechanical factors. If the right subclavian artery is anomalous and arises distal to the coarctation, blood pressure
may be greater in the left arm than in the right. Isolated coarctation does not produce cyanosis.
DISCUSSION: PDA causes a left-to-right shunt that produces left ventricular volume overload. Physical findings include
evidence of hyperdynamic circulation with a prominent apical impulse and bounding peripheral pulses. The classic murmur of
PDA is a continuous or mechanical murmur heard over the precordium and radiating to the medial third of the clavicle.
Diminished femoral pulses are not seen with isolated PDA and would suggest other anomalies. PDA may result in
hepatomegaly but does not cause jaundice.
C. Retrograde aortography via an umbilical artery catheter.
D. Two-dimensional echocardiography with continuous-wave and color-flow Doppler echocardiography.
DISCUSSION: Echocardiography is the best method for confirming the diagnosis of a PDA. Two-dimensional
echocardiography can demonstrate PDA and exclude associated anomalies. Doppler echocardiography can demonstrate the
shunt, determine direction of shunting, and provide an estimate of shunt magnitude. The chest film is not particularly helpful
and may be normal or show cardiomegaly with pulmonary congestion. In general, cardiac catheterization should be reserved
for older patients and those with suspected associated anomalies or pulmonary hypertension.
DISCUSSION: Coarctation of the aorta produces an obstruction to blood flow and hypertension, turbulent flow, and increased
left ventricular afterload. There is an increased incidence of coronary artery disease. Prior to the introduction of effective
techniques for relief of coarctation, the most common causes of death were endocarditis, aortic rupture, congestive heart
failure, and cerebrovascular accident. Pulmonary vascular disease does not occur with isolated coarctation.
B. Sinus venosus defect.
C. Ostium primum defect.
D. Complete atrioventricular (AV) canal defect.
E. Coronary sinus defect.
DISCUSSION: Although partial anomalous return of the pulmonary veins can occur with any of the ASDs listed, it is particularly common with sinus venosus defects and is considered by many to be part of this lesion. The most common anomaly is drainage of the right superior pulmonary vein to the lateral aspect of the superior vena cava.
14. The direction of an intracardiac shunt at the atrial level is controlled by:
A. The size of the defect
B. The compliance of the right and left ventricles.
C. The systemic oxygen saturation.
D. Right atrial pressure.
E. The presence or absence of an associated ventricular septal defect (VSD).
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