Download ER CHEST PAIN PROTOCAL

EMS HEART ALERT CALL: __________ EKG TRANSMITTED: Y / N EMS / WALK-IN ARRIVALTIME: __________ *EKG < 5 MIN OF ARRIVAL (AS A GOAL) TIME:_________
* PHYSICIAN READS EKG (< 10MIN AS A GOAL) TIME/INT: __________/__________
DIAGNOSIS:
STEMI / LBBB:
YES / NO
ACTIVATE CATH LAB: TIME__________
CARDIOLOGIST: ____________________
PAGED: __________
CALL BACK: ___________ * > 10 MINS: Y / N
DELAYS: ____________________________________
CARDIOLOGIST: ____________________
PAGED: __________
CALL BACK: ___________ * > 10 MINS: Y / N
DELAYS: ____________________________________
CATH TEAM PAGER:
266-1222
PAGED: __________
CALL BACK: ____________
TORB: ADMISSION ORDER TO CATH LAB UNDER DR. ____________________
DEPARTURE TO CATH LAB __________
INITIAL
CASE START: __________
READY FOR TRANSFER TO CATH LAB: TIME___________________
DIAGNOSIS:
ACUTE MI
CONSENT SIGNED: TIME____________________
BALLOON INFLATION: __________
RN CATH LAB: ____________________________
** (GOAL IS TO BE COMPLETED WITHIN 10 MINUTES OF ARRIVAL) **
TIME:__________ ASSIGNED BED AND PLACE ON CARDIAC MONITOR:
WT : ______KG
HT: ______/______
ALLERGIES:
HISTORY: MI CABAG CAD CHF DM HTN CVA RENAL DIALYSIS
VITAL SIGNS: TIME: __________ TEMP__________ PULSE__________ RESP__________ O2 SAT__________% B/P__________/__________
VITAL SIGNS: TIME: __________ TEMP__________ PULSE __________ RESP__________ O2 SAT__________% B/P__________/__________
*OXYGEN AT 2 L/MIN PRN; O2 SAT MONITORING (MAINTAIN Sa02 GREATER THAN OR EQUAL TO 92%)
TIME: __________ LITERS: __________
NASAL CANULA
NRB (MASK)
*START SALINE LOCK; IF SBP LESS THAN 90, NOTIFY MD AND THEN HANG NS AT 100ML/HR
1) TIME: _____ SITE: _____ GAUGE: _____ INITIAL: _____ 2) TIME: _____ SITE: _____ GAUGE: _____ INITIAL: _____
*DRAW HEART PANEL : CBC, CMP, Troponin, CPK-MB/CPK, PT, PTT, Lipid Profile, Liver Profile, D-Dimer, Lactic Acid, Ketones, Mg++
*LABS: TIME DRAWN: __________ RESULTS TIME: __________
*PORTABLE CHEST X-RAY: TIME __________
*ASA: 325 MG PO OR __________MG / PO CHEWED: TIMED: __________ IF NOT GIVER PRIOR TO ARRIVAL
ASA GIVEN PRIOR TO ARRIVAL: Y / N TIME: __________ DOSE: __________ EMS / HOME / MD OFFICE
NITRO: 0.4MG SL Q 5 MIN X 3 DOSES: TIME: (1) ______ (2) ______ (3) ______ EMS / HOME / MD OFFICE: __________
***MEDICATIONS***: (DOCUMENT TIME AND DOSE GIVEN):
HEPARIN BOLUS (Without a drip - 60 Units/kg (max 5,000 Units): TIME __________ / DOSE __________
DRIP: TIME ________ / DOSE __________ / RATE _________
An ADP antagonist is given prior to catheterization in the following order unless contraindications
1ST LINE AGENT- TICAGRELOR (BRILINTA) 180mg PO: Time __________
Loading dose (regardless of whether the patient was already taking clopidogrel, prasugrel or ticagrelor) unless contraindications are present as listed below.
2ND LINE AGENT- PRASUGREL (EFFIENT) 60 mg PO: Time __________
Loading dose should be used rather than ticagrelor if the patient has any of the following contraindications to ticagrelor (which are not contraindications for prasugrelor):
known allergy to ticagrelor , second degree or greater heart block, or concomitant oral or IV therapy with reverse transcriptase inhibitors, or strong CYP3A inhibitors (e.g.
ketoconazole, clarithromycin), CYP3A substrates (e.g. cyclosporine, quinidine), or strong (e.g. rifampin/rifampicin, phenytoin).
3RD LINE AGENT- Clopidogrel (PLAVIX) 600mg PO: Time __________
Loading dose should be given instead of ticagrelor or prasugrel if the patient has any of the following contraindications to both ticagrelor and prasugrel:
Contraindications to both ticagrelor and Prasugrel;
Dialysis, known moderate or severe liver disease, known hemoglobin<10 g/dL or known platelet count <100,000 cells/mm3, major bleed within 2 months, major
surgery within 1 month, oral anticoagulation therapy that cannot be stopped, fibrinolytic therapy planned or given within the previous 24 h; will refuse blood
transfusions. Note: No ADP antagonists should be given if the patient is actively bleeding.
Additional absolute contraindication to Prasugrel
Prior transient ischemic attack (TIA) or cerebrovascular accident (CVA)
MORPHINE: TIME/DOSE (1) __________/__________ (2) _________ /__________ (3) _________/__________
METOPROLOL: 5 MG IV Q 5 MIN X 3 DOSES: Time: (1) __________ (2) __________ (3) __________
NITRO PASTE: TIME: __________
DRIP: TIME: __________ / DOSE: __________ / RATE: __________
OTHER MEDS: _________________________________________________________________________________________________________________________
NOTES: ____________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
Physician Signiture:__________________________________________________________ /ED Nurse __________________ / CATH LAB Nurse _______________________
PATIENT TRANS TO: ____________ SHEATH PULLED BY: ____________ HEMATOMA: Y/N PATIENT DC: _____________
*DENOTES ACC/AHA GUIDELINES/TIMES SET AS GOALS
REVISED: 11/2014
SOUTHWEST GENERAL HOSPITAL
Emergency Department ACS CHECKLIST STEMI TRACK I