Introduction
Cardiology and Resuscitation represents one of the most critical and heavily tested domains on the NREMT Paramedic certification exam, accounting for approximately 19-20% of all exam questions and serving as the cornerstone of advanced life support interventions. As a paramedic, your expertise in cardiovascular emergencies directly impacts patient survival rates, making this domain essential not only for certification success but for saving lives in the field. This high-yield area encompasses a comprehensive range of topics including cardiac rhythm interpretation, advanced cardiac life support (ACLS) protocols, pharmacological interventions, defibrillation procedures, and post-resuscitation care management. Mastery of cardiology and resuscitation requires a deep understanding of cardiac anatomy and physiology, pathophysiology of cardiovascular diseases, and the ability to make rapid, evidence-based decisions under extreme pressure. The questions in this domain frequently test your knowledge of myocardial infarction recognition and treatment, arrhythmia management, cardiac arrest protocols, and the proper use of advanced airway management during resuscitation efforts. Understanding the intricate relationship between cardiac function and other body systems is crucial, as cardiovascular emergencies often present with complex multi-system involvement requiring comprehensive assessment and intervention strategies. The American Heart Association guidelines form the foundation of many exam questions, emphasizing the importance of high-quality CPR, early defibrillation, and appropriate medication administration in specific sequences. Additionally, this domain integrates closely with other exam areas such as airway management and pharmacology, requiring candidates to demonstrate proficiency in multi-tasking and prioritization during cardiac emergencies. Success in this area demands not only memorization of protocols and drug dosages but also the ability to adapt these guidelines to various patient presentations and clinical scenarios. The practice questions that follow are designed to challenge your critical thinking skills and test your ability to apply evidence-based cardiology and resuscitation principles in realistic emergency situations that mirror both the exam format and real-world paramedic practice.
Practice Questions
Question 1
A 58-year-old male presents with crushing chest pain radiating to his left arm. His 12-lead ECG shows ST elevation in leads II, III, and aVF. What is the most likely location of his myocardial infarction?
- Anterior wall
- Lateral wall
- Inferior wall
- Posterior wall
Correct Answer: C) Inferior wall
Explanation: ST elevation in leads II, III, and aVF indicates an inferior wall myocardial infarction. These leads view the inferior (bottom) portion of the left ventricle. The inferior wall is typically supplied by the right coronary artery. Anterior wall MIs show changes in V1-V4, lateral wall MIs in I, aVL, V5-V6, and posterior wall MIs require posterior leads or reciprocal changes in V1-V2.
Question 2
During a cardiac arrest, you deliver the first shock and immediately resume CPR. How long should you perform CPR before checking the rhythm again?
- 30 seconds
- 1 minute
- 2 minutes
- 5 minutes
Correct Answer: C) 2 minutes
Explanation: According to current AHA guidelines, after delivering a shock, CPR should be performed for 2 minutes (approximately 5 cycles of 30:2) before checking the rhythm again. This minimizes interruptions in chest compressions and maximizes perfusion. The 2-minute interval allows for adequate circulation and potential rhythm conversion while maintaining continuous perfusion pressure.
Question 3
A patient in ventricular fibrillation has been shocked three times with continued VF. What medication should be administered next?
- Atropine 1 mg IV
- Epinephrine 1 mg IV
- Amiodarone 300 mg IV
- Lidocaine 1.5 mg/kg IV
Correct Answer: B) Epinephrine 1 mg IV
Explanation: In persistent VF/VT after the first shock, epinephrine 1 mg IV should be given as soon as possible and then every 3-5 minutes during the arrest. Epinephrine increases coronary and cerebral perfusion pressure during CPR. Amiodarone is considered after epinephrine in refractory VF/VT. Atropine is not indicated in VF, and lidocaine is no longer first-line for VF/VT.
Question 4
A 45-year-old female presents with a heart rate of 180 bpm, blood pressure 80/50 mmHg, and altered mental status. The monitor shows a narrow complex tachycardia. What is the most appropriate immediate treatment?
- Adenosine 6 mg IV push
- Synchronized cardioversion starting at 50-100 J
- Amiodarone 150 mg IV over 10 minutes
- Diltiazem 0.25 mg/kg IV
Correct Answer: B) Synchronized cardioversion starting at 50-100 J
Explanation: This patient has unstable supraventricular tachycardia with signs of hemodynamic compromise (hypotension and altered mental status). Immediate synchronized cardioversion is indicated for unstable tachycardia. For narrow complex tachycardia, start with 50-100 J. Adenosine and other medications are used for stable SVT, not when the patient is hemodynamically unstable.
Question 5
What is the correct compression-to-ventilation ratio for adult CPR with an advanced airway in place?
- 30:2
- 15:2
- Continuous compressions at 100-120/min with 1 breath every 6 seconds
- Continuous compressions at 100-120/min with 1 breath every 10 seconds
Correct Answer: C) Continuous compressions at 100-120/min with 1 breath every 6 seconds
Explanation: Once an advanced airway (endotracheal tube, supraglottic airway) is in place, chest compressions should be continuous at 100-120 per minute without pausing for ventilations. Ventilations should be delivered at 1 breath every 6 seconds (10 breaths per minute). This approach maximizes perfusion while providing adequate ventilation.
Question 6
A patient presents with bradycardia at 35 bpm, blood pressure 70/40 mmHg, and chest pain. After establishing IV access, what is the first-line medication?
- Epinephrine 2-10 mcg/min infusion
- Atropine 1 mg IV
- Dopamine 5-20 mcg/kg/min infusion
- Transcutaneous pacing
Correct Answer: B) Atropine 1 mg IV
Explanation: For symptomatic bradycardia, atropine 1 mg IV is the first-line treatment, which can be repeated every 3-5 minutes up to 3 mg total. Atropine blocks parasympathetic stimulation and increases heart rate. If atropine is ineffective, then consider transcutaneous pacing or chronotropic agents like epinephrine or dopamine infusions.
Question 7
During CPR, what is the recommended depth of chest compressions for an adult patient?
- At least 1 inch (2.5 cm)
- At least 2 inches (5 cm) but no more than 2.4 inches (6 cm)
- At least 2.5 inches (6.5 cm)
- At least 3 inches (7.5 cm)
Correct Answer: B) At least 2 inches (5 cm) but no more than 2.4 inches (6 cm)
Explanation: Current AHA guidelines recommend chest compressions of at least 2 inches (5 cm) but no more than 2.4 inches (6 cm) for adults. This depth ensures adequate blood flow while avoiding excessive force that could cause injury. Compressions should be delivered at 100-120 per minute with complete chest recoil between compressions.
Question 8
A patient with a suspected acute MI is experiencing cardiogenic shock. Which medication is contraindicated?
- Dopamine
- Nitroglycerin
- Morphine
- Aspirin
Correct Answer: B) Nitroglycerin
Explanation: Nitroglycerin is contraindicated in cardiogenic shock because it causes vasodilation and can further reduce preload and blood pressure in an already hypotensive patient. Cardiogenic shock requires medications that increase contractility and blood pressure, such as dopamine or dobutamine. Aspirin and morphine (in small doses) may still be appropriate with careful monitoring.
Question 9
What is the initial energy setting for biphasic defibrillation in an adult patient with ventricular fibrillation?
- 120-200 J
- 200 J
- 300 J
- 360 J
Correct Answer: A) 120-200 J
Explanation: For biphasic defibrillators, the initial energy dose for VF/VT is 120-200 J, depending on the manufacturer’s recommendations. If the initial shock is unsuccessful, the energy should be increased for subsequent shocks. Biphasic waveforms are more effective than monophasic and require lower energy levels. Monophasic defibrillators require 360 J for all shocks.
Question 10
A 62-year-old male presents with chest pain and the following rhythm on the monitor: regular, narrow QRS complexes at 45 bpm with a PR interval of 0.28 seconds. What is this rhythm?
- First-degree AV block
- Second-degree AV block Type I (Wenckebach)
- Second-degree AV block Type II
- Third-degree AV block
Correct Answer: A) First-degree AV block
Explanation: First-degree AV block is characterized by a prolonged PR interval (>0.20 seconds) with all P waves conducted to the ventricles. The rhythm is regular with a 1:1 P:QRS ratio. In this case, the PR interval of 0.28 seconds with regular rhythm and narrow QRS indicates first-degree AV block. The bradycardia may require treatment if the patient is symptomatic.
Question 11
During post-resuscitation care, what is the target blood pressure for a patient who achieved return of spontaneous circulation (ROSC)?
- Systolic BP >90 mmHg
- Systolic BP >100 mmHg
- Mean arterial pressure >65 mmHg
- Systolic BP >120 mmHg
Correct Answer: C) Mean arterial pressure >65 mmHg
Explanation: Post-resuscitation guidelines recommend maintaining a mean arterial pressure (MAP) of at least 65 mmHg to ensure adequate organ perfusion, particularly to the brain and kidneys. This target helps optimize neurological outcomes and prevent secondary injury. Vasopressors may be needed to achieve and maintain this target in the post-arrest period.
Question 12
A patient presents with chest pain and ST depression in leads V1-V4. What type of myocardial infarction should you suspect?
- Anterior STEMI
- Inferior STEMI
- Posterior STEMI
- Lateral STEMI
Correct Answer: C) Posterior STEMI
Explanation: ST depression in leads V1-V4 represents reciprocal changes and suggests a posterior wall myocardial infarction. True posterior MIs are often missed because standard 12-lead ECGs don’t directly view the posterior wall. Posterior leads (V7-V9) would show ST elevation. The reciprocal changes in the anterior leads (V1-V4) are often the only clue on a standard 12-lead ECG.
Question 13
What is the maximum total dose of atropine that should be administered for symptomatic bradycardia?
- 1 mg
- 2 mg
- 3 mg
- 5 mg
Correct Answer: C) 3 mg
Explanation: The maximum total dose of atropine for symptomatic bradycardia is 3 mg. Atropine is given in 1 mg doses IV every 3-5 minutes until the desired heart rate is achieved or the maximum dose is reached. Higher doses may cause paradoxical bradycardia or other adverse effects. If 3 mg is ineffective, consider alternative treatments like transcutaneous pacing or chronotropic medications.
Question 14
A patient in cardiac arrest has been in asystole for 10 minutes despite appropriate ACLS interventions. What should be considered at this point?
- Continue resuscitation for another 10 minutes
- Administer sodium bicarbonate
- Consider termination of resuscitation efforts
- Increase epinephrine dose to 2 mg
Correct Answer: C) Consider termination of resuscitation efforts
Explanation: Prolonged asystole (typically >20 minutes) with appropriate ACLS interventions and no reversible causes suggests a poor prognosis. While the exact timing varies by protocol and circumstances, consideration of termination of resuscitation efforts may be appropriate after consulting with medical control. Factors include downtime, response to interventions, and presence of reversible causes.
Question 15
A patient presents with wide-complex tachycardia at 200 bpm and is hemodynamically stable. What is the most appropriate initial treatment?
- Immediate synchronized cardioversion
- Adenosine 6 mg IV push
- Amiodarone 150 mg IV over 10 minutes
- Lidocaine 1-1.5 mg/kg IV
Correct Answer: C) Amiodarone 150 mg IV over 10 minutes
Explanation: For stable wide-complex tachycardia (presumed ventricular tachycardia), amiodarone 150 mg IV over 10 minutes is the preferred first-line treatment. This can be repeated once if needed. Adenosine should not be used for wide-complex tachycardia unless certain it’s SVT with aberrancy. Synchronized cardioversion is reserved for unstable patients. Lidocaine is an alternative but amiodarone is preferred.