1. Is this a CMS inpatient only procedure? Yes, admit as inpatient, proceed to # 3 No, proceed to # 2 2. Do you expect that the patient s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission? Yes, admit as inpatient, proceed to # 3 No, place in observation 3. If admitted as inpatient, Inpatient Physician Certification: Diagnosis: Level of Care: Critical Intermediate Acute Care Location/Specialty Unit Preference 4. Telemetry: If patient Medical/Surgical, must complete Telemetry Orders (form # 36084) 5. Isolation: Contact Droplet Airborne For: 6. Diagnostics: STAT labs if not already drawn: CBC, CMP, baseline Myoglobin, Troponin I PT/INR if patient on Coumadin (warfarin) PTT Other: Repeat Troponin I at 6 hrs 7. Portable CXR on admission STAT 8. STAT EKG Time Completed: 9. EKG PRN for chest pain unrelieved by Nitroglycerin sublingual x 3 doses 10. Repeat EKG 20 min after initial EKG if pain still present 11. Continuous rhythm monitoring with ST monitoring. May be removed for tests/transport 12. Vital signs with blood pressures in both arms 13. O 2 per Protocol (form # 34431) 14. NPO except for medications 15. Activity: Bedrest x 12 hrs Bedside commode Bathroom privileges 16. INT SCHEDULED MEDICATIONS: 17. Aspirin 324 mg (four x 81 mg chewable) po STAT If unable to swallow, Aspirin 300 mg suppository per rectum STAT 18. Nitroglycerin 0.4 mg SL q 5 min x 3 doses if systolic BP > 100 or not pain free 19. Nitroglycerin (200 mcg/ml) Alleviation of Chest Pain Initiate infusion at 10 mcg/min Titrate to maintain chest pain relief and SBP > 100 by 10 mcg/min q 5 min to a max dose of ED/ICU 200 mcg/min, CVICU 100 mcg/min, IMCU 50 mcg/min, Med-Tele 20 mcg/min ICU-If unable to achieve chest pain relief at 100 mcg/min notify Provider 20. TNKase (tenecteplase) IV stat over 5 sec, then flush line with NS (No dextrose solution) Assess for contraindications prior to administration (see # 18) *3-15888* FORM 3-15888 REV. 02/2019 Page 1 of 4
Patient Weight (kg) TNKase (tenecteplase) Volume TNKase (tenecteplase) (mg) to be administered (ml) < 60 kg 30 mg 6 ml 60-69 kg 35 mg 7 ml 70-79 kg 40 mg 8 ml 80-89 kg 45 mg 9 ml > 89 kg 50 mg 10 ml 21. If TNKase (tenecteplase) ordered, assess for TNKase (tenecteplase) Contraindications Absolute Contraindications: If any Yes, do not administer TNKase (tenecteplase) Yes No History of intracranial hemorrhage Yes No Known structural cerebral vascular lesion (e.g., A-V malformation) Yes No Known malignant intracranial neoplasm (primary or metastatic) Yes No Ischemic stroke within 3 months Yes No Suspected aortic dissection Yes No Active bleeding or bleeding diathesis (excluding menses) Yes No Significant closed-head or facial trauma within 3 months Relative Contraindications: (Physician to exercise professional judgment. Benefits should exceed risk.) Yes No History of chronic, severe, or poorly controlled HTN Yes No Uncontrolled hypertension on presentation (SBP > 180 or DBP > 110) Yes No History of prior ischemic stroke > 3 months, dementia, or known intracranial pathology not covered in contraindications Yes No Traumatic or prolonged (> 10 min) CPR or major surgery within < 3 weeks Yes No Internal bleeding within 2-4 weeks Yes No Non-compressible vascular punctures Yes No Pregnancy Yes No Active peptic ulcer disease Yes No Current use of anticoagulants: High INRs increase bleeding risk 22. Anticoagulants: Heparin Infusion Protocol: LOW Intensity (form # 39815) Bolus with 60 units/kg (maximum bolus 4,000 units) Begin Heparin infusion at 12 units/kg/hr (maximum initial rate 1,000 units/hr) Lovenox (enoxaparin): Give between 15 min before to 30 min after the start of TNKase (tenecteplase) If < 75 y/o: 30 mg IV bolus plus 1 mg/kg SQ (max 100 mg) x 1 dose If > 75 y/o: No IV bolus, give 0.75 mg/kg SQ (max 80 mg) x 1 dose FORM 3-15888 REV. 02/2019 Page 2 of 4
23. Beta Blocker (for hypertensive patients only) without the following contraindications: High risk for cardiogenic shock 2 nd or 3 rd degree AV block Severe COPD or active asthma Evidence pf low output state Inferior MI Bradycardia Signs of heart failure Lopressor (metoprolol) 5 mg IV over 2 min W and repeat dose q 5 min x 2 more doses (Hold if systolic BP < 90 or HR < 60) 24. Aggrastat (tirofiban) Protocol (form # 35422) PRN MEDICATIONS Nurses may administer an ordered pain medication in a different pain category (mild, moderate, severe) than the patient stated pain level based on other assessment criteria included in Provider Order policy # 520-06. 25. Chest Pain: Chest pain: Nitroglycerin 0.4 mg sublingual q 5 min x 3 doses prn Severe Pain: per nursing assessment (policy 520-06), or Chest pain unrelieved with 3 doses of SL or max IV Nitroglycerin Morphine 2 mg IV q 5 min prn (up to a max of 10 mg in 2 hrs), Hold for excessive sedation. DC if CrCl < 30. DC if Dilaudid ordered. or Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 15 min prn (max 2 mg in 30 min). If CrCl < 30, dose at 0.25 mg). Hold for excessive sedation. DC if Morphine ordered. 26. Electrolyte Replacement Protocol (form # 21340) 27. Mild Pain per nursing assessment (policy 520-06), Temp >100.5 F, HA: Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn 28. Moderate Pain per nursing assessment (policy 520-06): Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered. or If patient cannot take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn instead of Norco. DC if Percocet ordered. or Percocet (oxycodone/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered. and/or Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or < 50 kg) or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30. FORM 3-15888 REV. 02/2019 Page 3 of 4
PRN MEDICATIONS (Continued): 29. Severe Pain per nursing assessment (policy 520-06), (Begin when Epidural or PCA has been discontinued) or Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered. Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for excessive sedation. DC if Morphine ordered. 30. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV or po q 6 hrs prn If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o) 31. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn ADDITIONAL : Date Time Physician Signature PID Number FORM 3-15888 REV. 02/2019 Page 4 of 4
Reference Page Decision Tree STEMI/New LBBB Does EKG show STEMI or new LBBB? See NSTEMI Decision Tree and AMI/Non-thrombolytic order set TNK Indicated? ER MD gives order for TNK Page on call Cardiologist. Will return call < 10 minutes Page on call Cardiologist. Will return call < 10 minutes Transfer for Rescue PCI. TNK given * EKG and patient presentation indicate reperfusion? Admit to CC unit on Post TNK Order set Transfer for Rescue PCI. * If TNK is not given within 30 Minutes of Pt arrival, document reasons per CART guidelines for delay CART Reason for Delay in Fibrinolytic Therapy Patient refused lytics CT needed to rule out bleed Patient wants to speak to family/clergy before making decision Need to consult cardiology Lytic therapy not indicated. Other Indications for Rescue PCI (JACC) Persistent Ischemic symptoms Hemodynamic or electrical Instability Severe CHF (Class 3) or pulmonary edema and onset of symptoms <12 hours FORM 3-15888 REV. 02/2019 REFERENCE PAGE