Level 1: Acute Myocardial Infarction by ECG: ST-segment elevation, posterior MI, or LBBB with ischemic symptoms

Transcription

1 PENNSYLVANIA HOSPITAL ED CHEST PAIN STANDING ORDERS Level 1: Acute Myocardial Infarction by ECG: ST-segment elevation, posterior MI, or LBBB with ischemic symptoms Monitoring: Cardiac monitor, oximeter Oxygen via at Notify cath lab Tests: ECG CBC, BMP, PT, PTT CKMB and total CK, Trop I T&S pcxr Medications: ASA mg PO t-pa: 15 mg bolus mg IV (0.75 mg/kg not to exceed 50 mg) over next 30 min mg IV (0.50 mg/kg not to exceed 35 mg) over next 60 min NTG by infusion: 50 mg/250 cc D5W at 3mcg/min, titrate to pain and SBP > torr Heparin _u bolus then infuse at u/hr OR Lovenox mg IV and mg SQ MS mg IV q h PRN chest pain Metoprolol 5mg IV over 5 min, repeat x 2 additional doses (total 15 mg over 15 min) Metoprolol 25 mg PO 60 min after IV metoprolol IV: Start two peripheral lines with 0.9% NaCl at cc/hr

2 Invasive lines: Diet: NPO Activity: complete bedrest bedrest with BRPs Nursing: neuro checks q 1h x 24h; notify admitting physician of any neurologic changes immediately VS q 5 min until after t-pa completed, then q 15 min per protocol obtain old chart

3 PENNSYLVANIA HOSPITAL ED CHEST PAIN STANDING ORDERS Level 2: UA/NQMI: Unstable angina, typical anginal symptoms with ST-segment depression, ischemic T-wave inversion, new onset CHF with ischemic pain Monitoring: Cardiac monitor, oximeter Oxygen via at Notify cath lab Tests: ECG CBC, BMP, PT, PTT CKMB and total CK, Trop I Myoglobin CKMB, total CK, Trop I, myoglobin at 3h CKMB, total CK, Trop I at 6h repeat PTT in 6h if starting heparin T&S pcxr resting sestamibi scan Medications: ASA mg PO NTG by infusion: 50 mg/250 cc D5W at 3mcg/min, titrate to pain and SBP > torr Heparin u bolus then infuse at u/hr OR Lovenox mg IV and mg SQ MS mg IV q h PRN chest pain Integrilin protocol: bolus mcg (180 mcg/kg), then infusion at cc/hr (2 mcg/kg/min) Metoprolol 5mg IV over 5 min, repeat x 2 additional doses (total 15 mg over 15 min) Metoprolol 25 mg PO 60 min after IV metoprolol Notify cath lab If cath management not anticipated or if patient not eligible for CABG, give 300 mg clopidogrel PO now and start clopidogrel 75mg q d

4 IV: Start two peripheral lines with 0.9% NaCl at cc/hr Invasive lines: Diet: NPO Activity: complete bedrest bedrest with BRPs Nursing: VS per protocol obtain old chart

5 PENNSYLVANIA HOSPITAL ED CHEST PAIN STANDING ORDERS Level 3: Moderate to high risk of ACS: typical anginal pain > 30min with normal ECG, or atypical symptoms with nondiagnostic ECG Monitoring: Cardiac monitor, oximeter Oxygen via at Tests: ECG CBC, BMP, PT, PTT CKMB and total CK, Trop I Myoglobin CKMB, total CK, Trop I, myoglobin at 3h CKMB, total CK, Trop I at 6h CKMB, total CK, Trop I at 9h T&S pcxr resting sestamibi scan Medications: ASA mg PO NTG 1/150 SL per protocol NTP 1 inch to ACW Lovenox mg SQ MS mg IV q h PRN chest pain If cath management not anticipated or if patient not eligible for CABG, give 300 mg clopidogrel PO now and start clopidogrel 75mg q d _

6 IV: Start peripheral line with 0.9% NaCl at cc/hr Start second line for Integrilin +/- heparin Diet: NPO cardiac diabetic: cal ADA Activity: complete bedrest bedrest with BRPs Nursing: VS per protocol obtain old chart

7 PENNSYLVANIA HOSPITAL ED CHEST PAIN STANDING ORDERS Level 4: Low risk of ACS: typical anginal pain < 30min with normal ECG, or atypical symptoms with normal ECG, or cocaine-associated symptoms with normal or non-diagnostic ECG Monitoring: Cardiac monitor, oximeter Oxygen via at Tests: ECG CBC, BMP, PT, PTT CKMB and total CK, Trop I Myoglobin CKMB, total CK, Trop I, myoglobin at 3h CKMB, total CK, Trop I at 6h CKMB, total CK, Trop I at 9h pcxr schedule adenosine (time) schedule treadmill (time) Medications: ASA mg PO NTG 1/150 SL per protocol NTP 1 inch to ACW MS mg IV q h PRN chest pain IV: heparin lock Start peripheral line with 0.9% NaCl at cc/hr

8 Diet: cardiac diabetic: cal ADA Activity: bedrest with BRPs Nursing: VS per protocol obtain old chart