Expanded competencies for the nuclear medicine advanced associate (nmaa) introduction


Participate in image guided biopsy at the discretion of the supervising physician



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Participate in image guided biopsy at the discretion of the supervising physician.


  1. Prepare sterile field and biopsy area using aseptic/sterile technique.

  2. Obtain informed consent for biopsy.

  3. Evaluate for complications prohibiting safe biopsy.

    1. Impaired coagulation

    2. Poor window to biopsy site

  4. Identify appropriate instruments and use according to recommended standards of practice.

  5. Prepare biopsied tissue for pathological examination according to guidelines for specific tissue type, include appropriate transport media slide preparation and documentation.

  6. Close and dress wound according to recommended standards of practice.

  7. Order appropriate follow-up imaging studies appropriate to biopsy site and procedure.

  8. Conduct a Joint Commission recommended “time out” procedure.

  9. Appropriately intervene for complications.

    1. Pneumothorax

    2. Bleeding

    3. Unintended damage to surrounding structures due to extravasations

  10. Advise patient of needed follow-up care.




  1. Manage pain and sedation for patients receiving diagnostic testing or therapeutic treatment.

    1. Prescribe pharmacologic and nonpharmacologic interventions as allowable by state and federal statues.

    2. Monitor patient response to sedation and provide intervention according to accepted standards of practice.

Overview for the Nuclear Cardiology Curriculum

The knowledge and skills of Nuclear Medicine Advanced Associates will be tested and utilized to their capacity in the nuclear cardiology arena. Communication skills on many levels will be essential as the NMAA obtains informed consent from patients, discusses image acquisition with the technologists and clinical staff, and relays outcomes to physicians. It is likely that the actual duties of NMAAs working in nuclear cardiology will vary depending on whether they are employed in a nuclear medicine department within the hospital or in an outpatient cardiology clinic. Many who work in cardiology clinics may have already assumed expanded role responsibilities, and very often these individuals have advanced credentials as nuclear cardiology technologists.

The NMAA will work under the direction of the supervising physician, taking responsibility for all phases involved in obtaining an appropriate and technically accurate test in a safe and professional manner for each individual patient. Although nuclear cardiology can be assumed to cover all aspects of cardiac imaging with radiopharmaceuticals, the emphasis of this aspect of the curriculum will be on myocardial perfusion imaging. Knowledge of cardiac physiology and pathology, stress testing techniques and effects, drug interactions, emergency procedures, ECG and image interpretation, and clinical pathways will be emphasized. The NMAA will build on the clinical skills learned during technologist training such as establishing intravenous lines, ECG lead placement, and image acquisition to obtain advanced proficiencies including but not limited to ECG and image interpretation, outcomes management, and advanced life support.
Clinical Nuclear Medicine:

Cardiology Competencies and Content


  1. Successfully complete and maintain Advanced Cardiac Life Support credentialing.




    1. Assess normal ECG to determine patient safety for stress testing.

      1. Identify the leads are associated with the various arteries and walls of the heart.

      2. Understand the conduction systems within the heart.\




    1. Assess abnormal ECG conduction in preparation for stress testing.

      1. New or old left bundle branch block

      2. New or old ST elevations or ST depressions


  1. Develop procedural policies and standards for pre-cardiac emergencies that might occur within the department as directed by institutional policy and practice standards.





    1. Identify the signs and symptoms of symptomatic bradycardia and symptomatic tachycardia.

      1. Lightheadedness

      2. Dizziness

      3. Fainting

      4. Near syncope

      5. Palpitations

      6. Chest pain

      7. Diaphoresis

      8. Chest pressure

      9. Arrhythmic heart beats

      10. Shortness of breath

      11. Nausea/vomiting

      12. Disturbances in vision

      13. New onset of confusion

      14. Changes in level of consciousness (LOC)

      15. Hypo or hypertension (unstable patient)




    1. Follow a step-by-step course of action for patients who develop asymptomatic bradycardia or tachycardia while in office (before, during or after stress test).

      1. Immediately stop the stress test, if applicable

      2. Administer appropriate oxygen therapy

      3. Obtain intravenous access, if applicable

      4. Assess vital signs frequently (i.e., blood pressure as required)

      5. Activate cardiac assistance team if necessary Call 911, if applicable



    1. Follow a step-by-step course of action for patients who develop signs and symptoms of bradycardia or tachycardia while in office (before, during or after stress test).

      1. Immediately stop the stress test, if applicable

      2. Place patient flat on floor

      3. Elevate lower extremities above heart

      4. Administer appropriate oxygen therapy

      5. Obtain intravenous access

      6. Initiate intravenous fluid bolus of normal saline (NS) or lactated ringers (LR)
      7. Obtain blood sugar level if appropriate


      8. Activate cardiac assistance team if necessary Call 911, if applicable




    1. Identify the proper medications and dosages for stable cardiac rhythms.

      1. Bradycardia

        1. Atropine

          1. Usual dose

          2. Maximum dose

          3. Dose rate

      2. Sinus tachycardia

        1. Normal saline or lactated ringers

          1. Usual dose

          2. Maximum dose

          3. Dose rate

      3. Narrow complex tachycardia of unknown etiology or supraventricular tachycardia (SVT)

        1. Adenosine (therapeutic)

          1. Usual dose

          2. Maximum dose

          3. Dose rate

        2. Calcium channel blockers

          1. Diltiazem

            1. Usual dose

            2. Maximum dose

            3. Dose rate

          2. Verapamil

            1. Usual dose

            2. Maximum dose

            3. Dose rate

        3. Beta-blockers

          1. Metoprolol

            1. Usual dose

            2. Maximum dose

            3. Dose rate

          2. Labetalol

            1. Usual dose

            2. Maximum dose

            3. Dose rate


        1. Amiodarone

            1. Usual dose

            2. Maximum dose

            3. Dose rate

      1. Narrow complex tachycardia of unknown etiology or supraventricular tachycardia (SVT) non-medicine.

        1. Valsalva maneuver

        2. Ice to face

        3. Blow into an occluded straw

        4. Carotid massage
      2. Atrial fibrillation/atrial flutter


        1. Diltiazem

          1. Usual dose

          2. Maximum dose

          3. Dose rate

        2. Beta-blockers

          1. Metoprolol

            1. Usual dose

            2. Maximum dose

            3. Dose rate

          2. Labetalol

            1. Usual dose

            2. Maximum dose

            3. Dose rate

        3. Amiodarone

          1. Usual dose

          2. Maximum dose

          3. Dose rate

      3. Ventricular tachycardia - monomorphic etiology

        1. Amiodarone

          1. Usual dose

          2. Maximum dose

          3. Dose rate

        2. Lidocaine

          1. Usual dose

          2. Maximum dose

          3. Dose rate

          4. Use lidocaine only if amiodarone not available or patient is allergic to amiodarone.

      4. Ventricular tachycardia – polymorphic etiology

        1. Magnesium

          1. Usual dose

          2. Maximum dose

          3. Dose rate

        2. Amiodarone

          1. Usual dose

          2. Maximum dose

          3. Dose rate



        1. Lidocaine

          1. Usual dose

          2. Maximum dose

          3. Dose rate

          4. Use lidocaine only if amiodarone not available or patient is allergic to amiodarone




    1. List contraindications and precautions of common cardiac medications.

      1. Atropine

        1. Myocardial infarct

        2. Ventricular escape rhythm (HR<40 with wide complex)

      2. Calcium channel blockers

        1. Wolff-Parkinson-White (WPW)

        2. Lown-Ganong-Levine (LGL)


        3. Sick sinus syndrome (SSS)

      3. Beta blockers

        1. Wolff-Parkinson-White (WPW)

        2. Sick sinus syndrome (SSS)

        3. Heart block, 2nd and 3rd degree

      4. Verapamil

        1. Wolff-Parkinson-White (WPW)

        2. Lown-Ganong-Levine (LGL)

        3. Sick sinus syndrome (SSS)

        4. Poor LV (left ventricular) function (EF< 30%)

      5. Adenosine

        1. Known or suspected bronchoconstrictive or bronchospastic lung disease

        2. Poor LV function

      6. Amiodarone

        1. Myocardial infarction




    1. Follow a step-by-step approach to handling an ST elevated myocardial infarction (STEMI).

      1. Oxygen 2 to 4L nasal cannula

      2. Aspirin 325mg (non-EC aspirin) or 2 to 4 81mg chewable aspirins

      3. Nitroglycerin 0.4mg tablets every 5 minutes for maximum of 3 tables or 3 nitro-sprays

      4. Morphine




    1. Follow a step-by-step approach to handling a stroke situation.

      1. Provide proper oxygen therapy

      2. Obtain intravenous access

      3. Determine precise time of symptom onset

      4. Perform Cincinnati Pre-hospital Stroke Scale

        1. Facial droop (ask patient to show teeth and smile)

        2. Arm drift (ask patient to extend arms, palms down, with eyes closed
        3. Speech (ask patient to say “You can’t teach an old dog new tricks”)



    1. Follow a step-by-step approach to handling other patient incidents.

      1. Exercise induced hypotension or hypertension

      2. Vaso-vagal

      3. Asystole

      4. Ventricular tachycardia




    1. Identify and delegate personnel to perform various tasks in preparation for cardiac emergencies.

      1. Crash cart checks: see competency #5

      2. Required training or drills




    1. Incorporate the appropriate federal, state, and institutional guidelines into departmental policies and procedures.



  1. Develop procedural policies and standards for cardiac arrest emergencies that occur within the department as directed by institutional policy and practice standards and provide indicated intervention for a cardiac emergency event.




    1. Establish IV access.




    1. Identify and administer the appropriate medications for commonly occurring cardiac arrythmias under the direction of the supervising physician.

      1. Asystole

        1. Epinephrine

          1. Usual dose

          2. Maximum dose

          3. Dose rate

        2. Atropine

          1. Usual dose

          2. Maximum dose

          3. Dose rate

      2. PEA

        1. Epinephrine

          1. Usual dose

          2. Maximum dose

          3. Dose rate

        2. Atropine

          1. Usual dose

          2. Maximum dose

          3. Dose rate
      3. Ventricular fibrillation


        1. Epinephrine

          1. Usual dose

          2. Maximum dose

          3. Dose rate



        1. Vasopressin

          1. Usual dose

          2. Maximum dose

          3. Dose rate

        2. Amiodarone

          1. Usual dose

          2. Maximum dose

          3. Dose rate

        3. Lidocaine

          1. Usual dose

          2. Maximum dose

          3. Dose rate

          4. Use only if amiodarone not available

      1. Pulseless ventricular tachycardia

        1. Epinephrine

          1. Usual dose

          2. Maximum dose

          3. Dose rate

        2. Vasopressin

          1. Usual dose

          2. Maximum dose

          3. Dose rate

        3. Amiodarone

          1. Usual dose

          2. Maximum dose

          3. Dose rate

        4. Lidocaine

          1. Usual dose

          2. Maximum dose

          3. Dose rate

          4. Use only if amiodarone not available




    1. Perform cardiac compression or defibrillate patient if required.

      1. Placement location of defibrillating pads on a patient needing to be cardioverted, defibrillated or transcutaneously paced

      2. Manual and automated defibrillators

      3. Cardiac compression methodology




    1. Facilitate the ordering of labs or other tests as needed for a cardiac arrest event under the direction of the supervising physician.

      1. Required lab work
        1. CBC (complete blood count)


        2. Chemistry (Chem-7, SMA-7, BMP, etc)

        3. Cardiac enzyme markers (troponin, CK-MB)

        4. Protime and Partial Protime (PT, PTT, INR)

        5. Arterial pO2

      2. EKG




    1. Facilitate admission of patient to hospital if necessary.



  1. Provide indicated intervention for non-cardiac emergency events.

    1. Diabetic patient

      1. Obtain blood sugar

      2. Indications for administering oral medications/food versus intravenous dextrose

    2. Respiratory distress

      1. Oxygen

      2. Medications as needed

    3. Panic attack

      1. Relaxation techniques

      2. Medications as needed



  1. Manage crash cart for compliance.




    1. Follow the appropriate guidelines in implementing regulation for managing the department’s crash cart.

      1. Institution

      2. Federal

      3. State

      4. Joint Commission

      5. AHA




    1. Inventory crash cart components according to institutional policy.

      1. Personnel responsible for checking the crash cart

      2. Frequency of checks

      3. Items checked

        1. Testing the defibrillator

        2. Medications

        3. Pads on the crash cart

        4. Portable oxygen tank level

        5. Security lock




    1. Properly dispose of expired drugs.




    1. Replace expired drugs.




    1. Perform quality assurance testing on defibrillator and document results.



  1. Take comprehensive patient history and evaluate for patient pathology.




    1. Interview patient and document on department form a complete past and current cardiac history.

      1. Height and weight

      2. Medication history


      1. Family history of known cardiovascular disease

        1. Acute Syndromes

        2. Chronic Syndromes

        3. Heart Failure

      2. Patient history of related disorders

        1. Hyper/hypotension

        2. Thyroid disorders

        3. Diabetes

        4. Stroke

        5. Previous thoracic surgery and/or cardiac intervention

        6. Tobacco abuse

        7. Metabolic syndrome

        8. Glaucoma

        9. Chest/ back/ jaw pain

        10. Dyspnea

        11. New onset of fatigue

        12. Dyslipidemia.




    1. Establish NPO compliance.




    1. Evaluate ambulatory ability.




    1. Review non-cardiac history for prevalence to study requested.




    1. Perform physical assessment

      1. Heart sounds


      2. Lung sounds

      3. Blood pressure and heart rate



  1. Evaluate patient laboratory biochemical markers relevant to cardiac pathology.




    1. Review most recent laboratory test results relevant to cardiovascular diseases.

      1. Relevant laboratory tests

        1. Urine Tests

          1. Glucose Content

          2. Presence of albumin or blood cells

          3. pH

          4. Pregnancy

        2. Blood Tests

          1. Cholesterol

            1. HDL

            2. LDL

          2. Hemoglobin values

          3. Hematocrit Values

          4. Leukocyte Count

          5. Serum Chemistries

          6. Blood Urea Nitrogen (BUN)

          7. Creatinine



          1. Serum Electrolytes

            1. Calcium

            2. Potassium

            3. Sodium

          2. Serum Enzymes

          3. Creatine Phosphokinase (CPK)

          4. Serum Glutamic Oxaloacetic Transaminase (SGOT)

          5. Lactic Dehydrogenase

          6. Glucose

          7. Thyroid

          8. Serum troponin levels

      1. Normal and abnormal results

      2. Relationship to cardiovascular disease




    1. Order relevant blood tests if necessary (including pregnancy testing).


  1. Evaluate patient medications for contraindications to stress testing.





    1. Understand contraindications to each type of stress test and evaluate for each.

      1. Contraindications to exercise Testing

        1. Absolute

    1. Acute myocardial infarction (within 2 d)

    2. Unstable angina not previously stabilized by medical therapy

    3. Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise

    4. Symptomatic severe aortic stenosis

    5. Uncontrolled symptomatic heart failure

    6. Acute pulmonary embolus or pulmonary infarction

    7. Acute myocarditis or pericarditis

    8. Acute aortic dissection

        1. Relative

    1. Left main coronary stenosis

    2. Moderate stenotic valvular heart disease (emphasis on aortic stenosis)

    3. Electrolyte abnormalities

    4. Severe arterial hypertension

    5. Tachyarrhythmias or bradyarrhythmias

    6. Hypertrophic cardiomyopathy and other forms of outflow tract obstruction

    7. Mental or physical impairment leading to inability to exercise adequately

    8. High degree atrioventricular block.

      1. Contraindications to adenosine

  1. Second or third degree AV block (except in patient with a functioning artificial pacemaker)

  2. Sinus node disease, such as sick sinus syndrome or symptomatic bradycardia (except in patients with a functioning artificial pacemaker)
  3. Known or suspected bronchoconstrictive or bronchospastic lung disease (e.g. asthma)


  4. known hypersensitivity to adenosine

  5. Use of methylxanthines

      1. Contraindications to dipyridamole

  1. Known sensitivity to dipyridamole

  2. Known sensitivity to aminophyllin

  3. Use of medications containing methylaxanthine

  4. unstable angina

  5. Acute myocardial infarction

  6. Severe asthma or bronchospasm

  7. Hypotension

  8. Caffeine within 12-24 hours

      1. Contraindications to dobutamine (Bedford Laboratories packet insert)

  1. Idiopathic hypertrophic subaortic stensis

  2. Hypersensitivity to dobutamine

  3. Cardiac arrhythmias




    1. Review patient medications for contraindications to exercise stress testing.

      1. Evaluate medications and understand how they can affect the response to and interpretation of exercise or pharmacologic stress testing.

      2. Recognize the effect medications can have on HR, BP, contractility, LVEFP.

      3. Know recommendations for length of time to discontinue medication if necessary.

      4. Relevant medications

        1. Antiarrhythmics

        2. Beta blockers

        3. Calcium channel blockers

        4. Inotropics

        5. Vasoactive

        6. Diuretics

        7. Analgesics

        8. Caffeine containing medications

        9. Theophylline

        10. Inhalers

        11. Nitrates




    1. Conduct preoperative evaluation for orthopedic or other surgery.

      1. COPD

      2. LBBB

      3. Pacemaker/AICD




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