Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
CARDIOVASCULAR EMERGENCIES
Objectives:
At the completion of this section, the learner will be able to:
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Define preload, afterload, cardiac output and stroke volume
Recognize problems with implanted pacemakers that present to the emergency department
List drugs that are used to control tachycardic rhythms
State nursing interventions for a patient experiencing an acute aortic dissection
Differentiate between the symptoms of a right-sided myocardial infarction and a left-sided myocardial infarction
Differentiate treatments implemented for arterial versus venous peripheral vascular occlusions
The CEN exam contains twenty questions on cardiovascular emergencies which involve the following topics:
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Acute coronary syndromes
Aneurysm/Dissection
Cardiopulmonary arrest
Dysrhythmias
Endocarditis
Heart Failure
Hypertension
Pericardial tamponade
Pericarditis
Peripheral vascular disease (e.g. arterial, venous)
Thromboembolic disease (DVT)
Normal cardiac output: 4 – 8 L/minute
Normal heart rates;
 Neonate: 140 BPM
 Toddlers: 120 BPM
 School age: 100 BPM
 Adult: 60 – 100 BPM
Cardiac
Output
Stroke
Volume
Heart Rate
Normal respiratory rates:
 Neonate = 40 BPM
 Toddlers = 30 BPM
 School age = 20 BPM
 Adults = 12 – 16 BPM
Normal stroke volume: 60 – 130
mL/contraction
Preload
 Trauma
Definition: Mean Arterial
Pressure – average pressure over
the entire cardiac cycle
[(2 x diastolic + systolic)/3]
Definition: Chronotropes affect heart rate
Afterload
Contractility
Normal central venous pressure (CVP): 2 -6
mm Hg
Definition: Dromotropes – affect
automaticity (rate at which
electricity moves through the
heart.)
Definition: Inotropes – affect
contractility
Memory Tip – To determine the
normal systolic blood pressure for
children aged 1 – 10, add twice their
age to 90 mm/Hg, to determine
systolic hypotension, add twice their
age to 70 mm Hg.
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Certified Emergency Nurse (CEN) Exam Review
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Jeff Solheim
Cardiovascular pharmacology
o Bradycardia
 Atropine (reverses cholinergic-mediated decreases in heart rate)
 Use with caution in cases of coronary ischemia and MI
 Unlikely to be effective after cardiac transplantation
 Not useful in Type II second-degree or third degree heart block
 Epinephrine (positive inotrope, dromotrope and chronotrope)
 Dopamine - Doses between 2 and 10 mcg/kg/minute effective to increase heart rate.
 Pacemaker therapy - pacemakers are used when the heart’s intrinsic pacemaking system is inadequate.
Most effective for bradycardia, heart block and idioventricular rhythms. Two methods of pacing in ED:
 External (transcutaneous) –Large electrodes are placed on the skin, one on the back at the
midthoracic level of the spine and a second on the front at the chest lead level of V 3.
 Transvenous – involves threading a catheter electrode into the right atrium or ventricle via the
subclavian, internal jugular, brachial, or femoral vein.
o Pacemaker settings
 Heart rate (how often the pacemaker fires)
 Pacemaker output (strength of pacemaker impulse)
 Sensitivity (degree which pacemaker senses intrinsic impulses)
 Implanted pacemaker: Problem solving
o Failure to output
 Possible causes
 Battery failure
 Lead problem (lead fracture or fractured lead insulation)
 Oversensing
 Management: medications to increase intrinsic heart rate, temporary pacemaker.
o Failure to capture
 Possible causes
 Failing battery
 Lead issue (lead fracture, dislodgement, fractured lead insulation)
 Exit block
o Ischemia/infarction at endocardium site
o Hyperkalemia
o Class III antiarrhythmic drugs (e.g. amiodarone)
 Treatment: correct the problem, temporary pacing
o Oversensing
 Causes
 Muscular activity
 Outside interference (MRI, electrocautery, digital cellular phone)
 Management – magnet application
 Tachycardia
 Cardioversion
o If time allows:
 Assess potassium, magnesium and digoxin levels
 Remove dentures
 Allow patient to go to the bathroom
 Remove transdermal medication and patches
 Provide conscious sedation
o Set to “sync”, assure sync is working
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Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
o
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Do not give
calcium
channel
blockers or
beta-blockers to
patients with
bradycardia,
heart blocks,
heart failure,
etc.
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Set energy level
 Narrow and regular QRS complexes: 50 to 100 Joules (J)
 Narrow but irregular QRS complexes: 120 to 200 J (biphasic waveform) or 200
J (monophasic waveform)
 Wide and regular QRS complexes: 100 J
 Wide but irregular QRS complexes: Patient will require defibrillation
(nonsynchronized)
 Pediatric: 0.5 – 1 Joule/kg increased to 2 Joule/kg
o Deliver shock after “all clear”
 Under breasts of large breasted woman
 Shave hairy chests
 Do not cardiovert over pacemaker or ICD
o Increase energy if unsuccessful and repeat
Internal cardiac defibrillator
o Malfunctions
 Continuous unneeded firing: apply a magnet
 Firing during cardiac arrest
 Allow ICD to work
 Apply magnet if ICD continues to fire but does not convert the rhythm.
 Wait 30 seconds after final firing to manually defibrillate
 Keep paddles/patches 10 cm away from ICD.
Narrow Complex
o Vagal maneuvers
o Adenosine
 Rapid IV push followed by 20 cc saline bolus
 May cause transient heart block or asystole
o Calcium channel blockers (-depine)
 Vasodilators, negative inotrope, negative chronotrope, negative dromotrope.
o Beta-blockers (-lol)
 Vasodilators, negative inotrope, negative chronotrope, negative dromotrope.
 Cardioselective beta-blockers – Beta-one blockers only (ideal for patients with
pre-existing pulmonary conditions) E.g. – Propranolol, Nadolol, Timolol,
Pindolol, Carteolol, Penbutolol
 Non-cardioselective beta-blockers - beta-one and beta two blocking. E.g. –
Acebutolol, Atenolol, Metoprolol, Esmolol, Betaxolol, Bisoprolol
Wide complex
o Unstable: cardioversion and/or precordial thump (for witnessed arrest on a monitor in the
absence of immediate defibrillation)
o Stable
 Procainamide IV
 Monitor for:
o Hypotension
o Widening of the QRS complex more than 50%
 Amiodarone – may cause nausea, bradycardia, hypotension
 Sotalol
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Certified Emergency Nurse (CEN) Exam Review
o
Drug
Epinephrine (Adrenalin)
Isoproterenol (Isuprel)
Dopamine (Intropin, Dopastat)
Norepinephrine bitartrate
(Levophed)
Phenylephrine (NeoSynephrine)
o
Nitroglycerin
Diazoxide (Hyperstat)
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Notes
Positive inotrope, dromotrope and chronotrope as well as vasoconstrictor
 alpha, beta-one and beta-two stimulation – can increase myocardial
workload, can cause myocardial ischemia.
 alpha, beta-one and beta-two stimulation
 2 – 10 mcg/kg/minute   cardiac output
 > 10 mcg/kg/minute  BP
Peripheral venous and arterial vasoconstrictor and cardiac stimulant
considered in the treatment of hypotension or shock.
Pure alpha-agonist
Vasodilators (monitor for hypotension)
Drug
Angiotensin Converter Enzymes
(ACE Inhibitors). End in –pril
Milrinone/Amrinone
Sodium Nitroprusside (Nipride)
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Jeff Solheim
Vasoconstrictors (monitor for hypertension. May cause local necrosis in cases of infiltration. Infiltration treated
with phentolamine)
Pharmacology
 preload and afterload through
vasodilation and diuresis
Vasodilator/positive inotrope
Potent venous AND arterial dilator
Venous dilator (arterial dilator in higher
doses)
Coronary artery dilator
Arterial dilator for significant hypertension
Notes
Monitor for dry cough, hyperkalemia and
angioedema
Treatment for heart failure
Protect from light (aluminum foil or opaque plastic)
Give IV in glass bottles through PVC tubing.
Inhibits release of insulin (can cause hyperglycemia)
Hypertension
o Severe elevations in blood pressure can lead to:
 Hypertensive encephalopathy (altered LOC, dizziness, headache, stroke seizures)
 Retinal hemorrhages with visual complaints
 Renal damage (hematuria, oliguria)
 Chest pain and ischemia
 Heart failure (enlarged heart, S3/S4 heart sounds)
 Epistaxis
Acute Aortic Dissection (tear in the intimal layer of the aorta, which exposes the degenerated medial layer to the forces of
blood pressure. These forces cleave or dissect the two layers of the arterial wall)
o Ascending Dissection (A)
 Most common and lethal
o Descending Dissection (B)
C
o
Descending into Ascending (C)
o
Risk factors
 Hypertension
 Connective tissue disease (e.g. Marfan’s syndrome)
 Pregnancy
 Trauma
A
B
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Certified Emergency Nurse (CEN) Exam Review
o
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Ascending dissection - pain in the substernal area, throat, jaw or face
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Descending dissection - pain in the intrascapular or lower back areas, abdomen, flank and
lower extremities.
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Changes in blood pressure (Difference of more then 10 mm Hg when comparing SBP of
various limbs).
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Symptoms of spinal cord hypoxia such paresthesia, hemiplegia and paraplegia.
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Signs of hypovolemia,  hct,  WBC ( BUN and creatinine if renal arteries affected)
Treatment
 Prepare for rapid deterioration (oxygen, large bore IV)
 Blood products and fluid resuscitation as needed.
 Narcotics (pain)
 Anti-hypertensives
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Jeff Solheim
Clinical manifestations
 Pain (may be described as a sudden onset tearing, ripping, sharp, knife-like pain not relieved by
analgesics)
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Nitroprusside (Nipride)
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Labetalol (Normadyne, Trandate)
 Calcium channel blockers such as verapamil (Isoptin, Calan) or diltiazem (Cardizem)
Surgical repair/ open thoracotomy
Heart failure[Occurs when the heart can no longer produce sufficient cardiac output at normal filling pressures to meet metabolic
demands (usually when the left ventricular ejection fraction falls below 40%)]
o Clinical manifestations
Right-sided failure
Left-sided failure
o Treatment:
 Peripheral edema  Hemoptysis
 Vasodilators (morphine, Nitroprusside,
 Hepatomegaly
 Progressive dyspnea
 ACE inhibitors)
  JVD
 Crackles on auscultation
 Diuretics
  CVP
 Increased pulmonary artery pressures
 Positive inotropes (lanoxin, dobutamine)
 Dopamine to support blood pressure
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Coronary artery disease
 Symptom progression
Event
Stable angina
Easily relieved by
Pain
rest/NTG
EKG changes
Cardiac
Enzymes
Transient ST
depression
Normal
Unstable angina
Lasts longer than 20
minutes
Transient ST
depression/ T wave
inversion
NSTEMI
Continuous chest
pain
ST segment
depression and T
wave abnormalities
STEMI
Pain described as worse than
angina
ST segment elevation > 2 mm in
leads V , V and V and > 1 mm in
Normal
Elevated
Elevated
1
2
3
all other leads
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Certified Emergency Nurse (CEN) Exam Review
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M
O
Medication
Morphine
Sulfate
Dose
2 -4 mg IV push, repeat q5-30
minutes as needed
Oxygen
Nitroglycerin
4 L/min via nasal cannula
 S/L or spray q3-5 minutes
up to 3 doses
 12.5 – 25 mcg bolus IV
followed by an infusion 1020 mcg/minute
160 – 325 mg PO (chewable)
N
Aspirin
A
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Comments
  pain
  preload
  myocardial oxygen demand
Titrate to keep oxygen saturation above 95%
 Limit SBP changes to <10% if normotensive or < 30% if
hypertensive
 Hold if SBP < 90 mmHg
 Contraindicated for people who have taken Viagra or
Levitra within 24 hours
Maybe repeated in patients who have already taken ASA or
are on daily doses
Location of MI based on changes in various leads
o
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Jeff Solheim
Treatment considerations for a myocardial infarction
Location of MI
Anterior
Expected lead changes
V , V and V
Anterior/Septal
V,V
Lateral
I, AVL, V , V
Inferior
Right Ventricle
II, III, AVF
RV , RV , RV
Posterior
Tall R waves and ST depression in V and V
2
3
4
1
2
5
4
5
6
6
1
2
Thrombolytics
Contraindications
Recent internal bleeding (less than one month prior to arrival)
Known bleeding diathesis
History of cerebrovascular accident
Recent surgery
Intracranial arteriovenous malformations
Uncontrolled hypertension (SBP > 180 mm Hg, DBP > 110 mm Hg)
Trauma within the past ten days
Recent cardiopulmonary resuscitation efforts
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Relative Contraindications
Minor trauma
Diabetic retinopathy
Pregnancy
Concurrent anticoagulation
Severe trauma in the past six months
Any previous central nervous system
event
Unsuccessful central venous puncture
Monitoring after thrombolytics
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Monitor for bleeding
o Venipuncture/ABG puncture sites
o GCS for intracranial bleeding
o Abdominal girth
o Bruising in the flanks
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Reduce risk for bleeding
o Minimize movement
o Limit venipunctures/ABGs
o Minimize invasive blood pressures
Monitor for reperfusion
o Resolution of chest pain
o Normalizing ST segment changes
o Reperfusion arrhythmias
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Certified Emergency Nurse (CEN) Exam Review
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Jeff Solheim
Right Ventricular Infarct
o Move leads to right side of chest
V1R
Fourth intercostal space along the left sternal border. (same as lead V 2)
V2R
Fourth intercostal space along the right sternal border. (Same as lead V 1)
V3R
Midway between leads V2R and V4R
V4R (V7)
Fifth intercostal space at the right midclavicular line
V5R (V8)
Midway between V4R and V6R in the fifth intercostal space
V6R (V9)
Right midaxillary line at the fifth intercostal space
Symptom
Right side
Left side
Nausea and vomiting
Dyspnea/Orthopnea
Diaphoresis
Tachycardia
Bradycardia
Hypertension
Hypotension
JVD
o Treatment
 Fluid loading
 Inotropic support
 Avoid vasodilators (morphine, nitroglycerin, diuretics)
 All other treatments as per MI protocols
Variant angina (also known as variable angina, Prinzmetal’s angina or coronary artery spasms – caused by ischemia secondary
to a spasm in the coronary artery.)
o Often occurs in younger individuals who may have no coronary heart disease
o Causes chest pain that is often more severe than typical angina pain.
 Pain tends to be cyclical
 Often occurs between midnight and 8 AM
o EKG may show ST elevation that resolves with resolution of pain.
o Treated with nitroglycerin or calcium channel blockers
Infections involving the heart
o Infective Endocarditis (general term used to describe inflammation of the endocardium, especially the cardiac valves)
 Clinical manifestations
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Signs of infection (Fever, anorexia, weight loss, night sweats, myalgia, fatigue, malaise)
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Pain (Pleuritic chest pain, abdominal or back pain
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Signs of Embolization (stroke signs, hemoptysis, splinter hemorrhages, petechiae of the conjunctiva,
palate, neck, upper trunk, or extremities, Osler’s nodes, Janeway lesions)
Diagnosis
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 WBC
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 ESR

Blood cultures
 Echocardiogram
Treatment
Definition: Osler’s
nodes – tender,
subcutaneous nodules,
often in the pulp of the
digits.
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Long term IV antibiotics
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May require admission with cardiac monitoring
Definition: Janeway
Lesions – non-tender
erythematous,
hemorrhagic, or pustular
lesions often on the palms
or soles
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Certified Emergency Nurse (CEN) Exam Review
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Jeff Solheim
Pericarditis (inflammation of the pericardial sac)
o Common causes
 MI (2 – 3 days after the MI)
 Connective tissue disorders
 Renal failure
 Mediastinal injury
 Neoplasms or radiation
 Infectious processes
o Clinical manifestations
 Pain (exacerbated by deep inspiration, coughing, swallowing, supine position, but relieved by leaning forward
or sitting up)
 Indications of infection (malaise, fever, chills, dyspnea and cough)
 Tachycardia and tachypnea
 Auscultation of pericardial friction rub
 EKG changes
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ST segment elevation with upright T waves in all leads except aVR and V 1.

T waves flatten, the ST segment returns to baseline after several days
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T wave inversion (it may take weeks or months for the T waves to return to normal).
o
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Treatment
 Allow patient position of comfort (sitting upright with legs dangling)
Definition: Kussmaul’s
 Anti-inflammatory agents
Sign - Elevation of neck
veins with inspiration
 Antipyretics
during spontaneous
 Antibiotics
breathing
 Colchicine (for cases related to gout)
Pericardial tamponade (accumulation of fluid in the pericardial sac)
o Clinical manifestations
 Beck’s triad (muffled heart tones, hypotension, JVD)
 Kussmaul’s sign
 Obstructive shock (narrowing pulse pressure, cool, moist skin,  urinary output)
o Treatment
 Pericardiocentesis (Emergent cases)
 Surgery
Peripheral vascular occlusions
Provacation of pain
Quality of pain
Region and radiation
of pain
Severity of pain
Timing of pain
Objective findings
SYMPTOMS
Arterial occlusion
Pain is always present, it occurs at rest, with
movement and with exercise
May be described as a burning discomfort
Typically hurts from the area of the occlusion
distally because all tissue distal to the occlusion will
be void of adequate oxygen
Described as excrutiating
Pain starts as soon as the occlusion develops and is
not easily relieved
Cold extremity with decreases pulses that may
progress to paralysis
Venous occlusion
Pain is more common with walking or other
activity and diminishes with rest
Described as a deep ache or throbbing type of
pain
Localized to the area around the occlusion
Described as an aching or throbbing
Pain which evolves
Swelling of the extremity with deep muscle
tenderness, darkened color and a possible fever
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Certified Emergency Nurse (CEN) Exam Review
Positioning
Activity
Treatment
TREATMENT CONSIDERATIONS
Arterial occlusion
Elevate HOB but do not elevated
extremity
Encourage activity
Thrombolytic infusion,
embolectomy , balloon catheter
extraction or bypass grafting
Education
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Jeff Solheim
Venous occlusion
Elevate affected extremity
Absolute bedrest
Anticoagulants or thrombolytics
Warm packs over site
Increase fluids
Monitor for PE, stroke, MI
Blunt cardiac injury (right ventricle most often affected.)
o Clinical manifestations range from mild chest pain to cardiac failure
o Possible EKG changes
 Tachycardia
 PAC
 PVC
 Atrial fibrillation
 SA or AV block
 VF or VT
 ST and T wave abnormalities
o Treatment
 Cardiac monitor
 IV access (fluid restriction to prevent heart failure)
 Interventions for heart failure and dysrhythmias as appropriate
 Admission
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Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
Practice Questions
Which of the following patients carries the highest risk of contracting endocarditis?
a.
b.
c.
d.
An 81-year old patient being treated for acute hypertension
A 39-year-old patient who had a large tattoo engraved two weeks previously
A 22-year old patient who has had two cases of conjunctivitis in the past three weeks
A 51-year old patient who had an inferior wall myocardial infarction four weeks previously
Which of the following assessment findings is more consistent with a peripheral vascular venous occlusion?
a.
b.
c.
d.
A burning discomfort in an extremity
A fever associated with a pale, cool extremity
Excruciating pain which is relieved with activity
An aching pain localized to one area of an extremity
A pediatric patient weighing 12 kg is to be cardioverted. What is the appropriate initial energy level?
a.)
b.)
c.)
d.)
3 Joules
12 Joules
36 Joules
50 Joules
A patient presents to the ED with a blood pressure of 234/144 mm Hg. If pharmacological treatment is undertaken for this disorder,
which of the following blood pressure readings would be optimal within 30 minutes of treatment initiation?
a.
b.
c.
d.
120/80 mm Hg
140/90 mm Hg
164/100 mm Hg
200/100 mm Hg
ANSWERS: B, D, B, C
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