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Chest Pain Cardiac Syncope Orders Emergency Department

By Judy Walker,2014-05-11 21:38
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Chest Pain Cardiac Syncope Orders Emergency Department

     PLACE LABEL HERE

    CHEST PAIN / CARDIAC SYNCOPE

    ORDERS

    Emergency Department

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

    Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

1. Place: Observation for chest pain, rule out myocardial infarction

    2. Consults: ____________________________________________________________________________ 3. Private physician notified: None _________________________________ Time notified ________

    4. Diagnostics:

     Fasting lipid profile if patient has not eaten in 6 hrs

     Repeat Troponin I and Myoglobin at 90 min post baseline

     Repeat EKG in 20 min if chest pain is unresolved and with 90 min markers

     D-Dimer

     Echocardiogram

     PA & Lateral CXR

     CT angiogram of chest to rule out pulmonary embolus

     Venous Doppler Right Upper Extremity

     Left Lower Extremity

    5. Repeat Troponin I at 6 hrs

    6. Vital signs: q 4 hrs q _________ hrs

    7. Continuous cardiac monitoring

    8. Remove continuous cardiac monitoring

     If patient leaves Emergency Department for cardiac testing

    9. Repeat EKG PRN for chest pain

    10. Contact ED physician for recurrent chest pain or EKG changes

    11. Notify ED physician if all cardiac markers are negative at the end of 90-min marker protocol; print EKG

    12. Notify ED physician of all results of positive cardiac markers

    13. Notify ED physician if Troponin I is negative at the end of 6-hr marker protocol: Print EKG 14. Diet: Keep NPO 6 hrs prior to anticipated stress testing Cardiac 1800 Cal ADA

     Full liquid diet (caffeine free/no decaffeinated) after midnight before stress test 15. Activity: Bedrest Bedside Commode Up ad lib Up with assistance

    16. Assess cardiac risk factors

    17. Offer educational handouts/videos as appropriate and record material utilized/smoking cessation 18. INT

HOME MEDICATION ORDERS: to be administered while in the Emergency Department:

    ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Send copy to pharmacy Order writer’s Initials___________

    *3-16341* FORM 3-16341 REV. 03/2012 Page 1 of 3

    PLACE LABEL HERE

    CHEST PAIN / CARDIAC SYNCOPE

    ORDERS

    Emergency Department

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

    Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

SCHEDULED MEDICATION:

    19. Nitroglycerin (NTG) ointment:

     ? inch topically q 6 hrs, remove NTG ointment prior to transport to Cardiology Dept for stress testing

     1 inch topically q 6 hrs, remove NTG ointment prior to transport to Cardiology Dept for stress testing 20. Aspirin 324 mg (four x 81 mg chewables) po STAT if not done in ED. If unable to swallow, Aspirin 300 mg

    suppository per rectum STAT

    21. Plavix (clopidogrel) 300 mg 600 mg po x 1 dose NOW

    22. Anticoagulation:

    ;; Heparin Infusion, HIGH Cardiac Dose (complete form # 28554)

     Lovenox (enoxaparin) 1 mg/kg SQ q 12 hrs (refer to Lovenox Dosing Rounding Chart below)

    Dose Rounding for 1 mg/kg, Give

     if patient weighs: Lovenox (enoxaparin)

    < 50 kg 40 mg q 12 hrs

    50-69 kg 60 mg q 12 hrs

    70-89 kg 80 mg q 12 hrs

    90-109 kg 100 mg q 12 hrs

    110-129 kg 120 mg q 12 hrs

    130-144 kg 140 mg q 12 hrs

    145-154 kg 150 mg q 12 hrs

    155-169 kg 160 mg q 12 hrs

    > 170 kg 180 mg q12 hrs (maximum dose), notify Clinical RPh

    23. Beta Blocker:

     Lopressor (metoprolol) 25 mg po two times daily (hold if systolic BP < 90 or HR < 60)

     Lopressor (metoprolol) 12.5 mg po two times daily (hold if systolic BP < 90 or HR < 60)

    PRN MEDICATIONS (If > one drug is ordered for the same indication, clinical assessment will be used per policy 520-06) 24. Chest pain: Nitroglycerin 0.4 mg sublingual q 5 min x 3 doses prn. Notify Emergency Department

    physician. Hold if systolic BP < 100 mm/Hg

    25. Severe chest pain unrelieved with max dose of Nitroglycerin sublingual x 3 doses

     Dilaudid (hydromorPHONE) 0.5 - 2 mg IV q 15 min prn (up to a max of 4 mg in 30 min)

    Hold for excessive sedation

     Morphine 2 mg IV q 5 min prn (up to a maximum of 10 mg in 2 hrs)

    Hold for excessive sedation

    26. Moderate pain:

     Lortab (HYDROcodone/acetaminophen) 5/500 mg 1-2 tabs or 10/500 mg 1 tab po q 4 hrs prn

     Percocet (oxyCODONE/acetaminophen) 5/325 mg 1-2 tabs or 10/325 mg 1 tab po q 4 hrs prn

     Hycet elixir (HYDROcodone 7.5 mg / acetaminophen 325 mg/15 ml) 15 ml po q 4 hrs prn

    Send copy to pharmacy Order writer’s Initials___________ FORM 3-16341 REV. 03/2012 Page 2 of 4

    PLACE LABEL HERE

    CHEST PAIN / CARDIAC SYNCOPE

    ORDERS

    Emergency Department

    ;; Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if > 65 y/o old or < 50 kg)

    or 10 mg po q 6 hrs prn (max combined duration of IV and po Toradol {ketorolac} is 5 days) Send copy to pharmacy Order writer’s Initials___________ FORM 3-16341 REV. 03/2012 Page 3 of 4

    PLACE LABEL HERE

    CHEST PAIN / CARDIAC SYNCOPE

    ORDERS

    Emergency Department

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

    Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

27. Mild pain/temp >100.5;F/HA: Tylenol (acetaminophen) 650 mg po q 4 hrs

    28. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV q 6 hrs prn

     Reglan (metoclopramide) 10 mg po or IV q 6 hrs prn (5 mg if > 65 y/o)

     Phenergan (promethazine) 12.5-25 mg po or per rectum q 4 hrs prn 29. Sleep: Ambien (zolpidem) 5-10 mg po at HS prn. If 5 mg given, may repeat x 1 dose after 2 hrs

    If > 65 year old, begin with 5 mg po at HS, may repeat x 1 dose after 2 hrs

     Other: _________________________________________________________________ 30. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn 31. Anxiety: Ativan (lorazepam) 0.5 - 1 mg po q 8 hrs prn

     Xanax (alprazolam) 0.25 - 0.5 mg po q 6 hrs prn

    STRESS TESTING: Consult cardiologist Dr. ______________________________________________

     ETT in a.m. ETT NOW

     Lexiscan (regadenoson) DIMPS in am Lexiscan (regadenoson) DIMPS NOW

     Exercise DIMPS in am Exercise DIMPS NOW

     Stress Echo

Stress Test Selection Methodology (AHA/ACC)

    ETT- able to exercise and normal or near normal ECG

    Exclusion criteria: Inability to exercise, LV hypertrophy with repolarization changes, significant ST and T

    wave changes including digoxin effect, biphasic or invertered T waves in anterior leads, LBBB Exercise Stress Echocardiogram or Exercise Stress Nuclear Medicine Study

    May be useful to discuss with local cardiologist for test of choice

    Patient able to exercise but abnormal ECG

    Exclusion Criteria: Inability to exercise, biphasic or invertered T waves in anterior leads

    Pharmacologic Stress Test

    May be useful to discuss with local cardiologist for test of choice

    Patient unable to exercise and abnormal ECG

    Normal Stress Test- follow up with PCP or clinic

    Abnormal Stress Test- consult PCP or Cardiologist

ADDITIONAL ORDERS:

    ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

    ______________ ___________________ _________________________________ __________ Date Time Physician Signature PID Number

    Send copy to pharmacy FORM 3-16341 REV. 03/2012 Page 4 of 4

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