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STEMI: INITIAL MANAGEMENT ORDER TEMPLATE
(Referenced Version)
This template lists initial elements, drugs, doses, and strategies that should be highly considered when creating admission order sets based upon recent clinical practice guidelines, medication package inserts, and emerging evidence.
DEMOGRAPHICS
Top of Form
Age ___________ years Weight __________ kg
DIET ORDERS
( NPO
( 2 gm sodium restricted/low cholesterol/low fat
( Diabetic _________________ calorie ADA
( Other (specify) _____________________________
ACTIVITY ORDERS
( Bed rest
NURSING ADDIN EN.CITE Antman20047717Antman, E. M.Anbe, D. T.Armstrong, P. W.Bates, E. R.Green, L. A.Hand, M.Hochman, J. S.Krumholz, H. M.Kushner, F. G.Lamas, G. A.Mullany, C. J.Ornato, J. P.Pearle, D. L.Sloan, M. A.Smith, S. C., Jr.Alpert, J. S.Anderson, J. L.Faxon, D. P.Fuster, V.Gibbons, R. J.Gregoratos, G.Halperin, J. L.Hiratzka, L. F.Hunt, S. A.Jacobs, A. K.Ornato, J. P.ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction)J Am Coll CardiolJ Am Coll CardiolE1-E2114432004Aug 415358047http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15358047 1(pg e35)
( Continuous ECG monitoring
( Supplemental O2 to keep arterial saturation > 90%
( Nitroglycerin Protocol: PRN use of 0.4mg q5 min for chest pain
MEDICATION ALLERGIES
( Specify: _______________________________________ Reaction (if known): ___________________________
DIAGNOSTIC STUDIES
( 12-lead ECG FOR RECURRENT CHEST PAIN
( 12-lead ECG IN AM (____/___/___ ___:___ AM)
LABORATORY STUDIES
ROUTINE LABS
Chemistry panel: ( NOW ( DAILY IN AM
CBC: ( NOW ( DAILY IN AM
Fasting lipid panel: ( IN AM
HbA1c: ( IN AM
Calculate creatinine clearance (CrCl): _______ml/min
CrCl ml/min = (140 - age) X weight (kg)/(serum creatinine X 72) multiply by 0.85 if female
SELECT REPERFUSION STRATEGY
( Fibrinolytic Therapy: Within 12 hours of symptom onset and primary PCI cannot be achieved in <90 minutes of 1st medical contact OR who cannot be transferred to primary PCI center with anticipated time from 1st medical contact to balloon to be < 90 minutes
( FIBRINOLYTIC THERAPY ORDERS (Goal is Door to Needle <30 min)
( Primary PCI: Within 12 hours of symptom onset, with primary PCI facility available, with anticipated 1st medical contact to balloon time < 90 minutes
( PRIMARY PCI ORDERS (Goal is Door to Balloon <90 min)
( Medical management: Contraindications to reperfusion therapy.
( MEDICAL MANAGEMENT STRATEGY ORDERS
MEDICATIONS FOR ALL STEMI PATIENTS
( Aspirin: Initial dose 162 mg to 325 mg chewed orally even if already taking aspirin, then daily dose of 81 mg to 162 mg orally if fibrinolytic or no reperfusion and 162 mg to 325 mg daily if primary PCI with stenting performed
Initial: ___________ mg orally.
Daily: ___________ mg orally.
( Clopidogrel: Fibrinolytic or No Reper f u s i o n P a t i e n t s : I n i t i a l D o s e o f 3 0 0 m g o r a l l y a n d m a i n t e n a n c e d o s e o f 7 5 m g . P C I P a t i e n t s : I n i t i a l D o s e o f 3 0 0 - 6 0 0 m g o r a l l y a n d m a i n t e n a n c e d o s e o f 7 5 m g .
I n i t i a l : _ _ _ _ _ _ _ _ _ _ _ m g o r a l l y . ( N o e v i d e n c e f o r l o a d i n g d o s e i f a g e e"7 5 y e a r )
D a i l y : _ _ _ _ _ _ _ _ ___ mg orally.
(Continue for 14 days and potentially to 1 year in fibrinolytic and no reperfusion patients and for 1 year in PCI and stent patients (may be 1 month if bare metal) ;hold if CABG is planned for at least 5-7 days)
BETA BLOCKERS (Hold if signs of heart failure, evidence of low-output state, high risk for cardiogenic shock* or contraindications to beta blocker therapy**)
( Oral Beta-blocker:
Drug: ____________________ _______ mg _____ times day
( IV Beta-Blockers (Optional; recommended if persistent ischemic symptoms, hypertension, or tachycardia and no signs of hemodynamic instability)
Drug: ___________________ _____ mg IV for ____ doses every ___ minutes
*Risk factors for shock (greater number of risk factors, the greater the risk): age > 70 years, SBP < 120 mmHg, sinus tachycardia with HR > 110 bpm or < 60 mmHg, or increased time since onset of symptoms.
**Contraindications for beta-blockers: PR interval > 0.24 sec, second or third degree AV block, active asthma, or reactive airway disease.
( ACE-I or ARB: Drug: ____________________ _______ mg _____ times day (start 12 hours after admission).
( Statin: Drug: __________________________ ________ mg once daily (regardless of LDL)
( Stop NSAIDS (except aspirin)
( GI Prophylaxis (with history of GI bleeding)
Drug: _________________________ ___________ mg _____________ times day
FIBRINOLYTIC THERAPY ORDERS (Goal Door to Needle <30 min)
Absolute Contraindications: Relative Contraindications:
Prior hemorrhagic CVA Blood pressure > 180/110 mm Hg
Any cerebrovascular events < 1 year Use of anticoagulants with INR > 2.0
Active internal bleeding Noncompressible vascular punctures
Known intracranial neoplasm Prolonged CPR (> 10 minutes)
Suspected aortic dissection Prior gastrointestinal hemorrhage
Pregnancy or Menstruation
Trauma < 2 to 4 weeks prior
Major Surgery <3 weeks prior
FIBRINOLYTIC THERAPY (Choose ONE):
( Streptokinase: 1.5 MU IV over 30-60 minutes
OR
( Alteplase: Bolus: 15 mg IV
Infusion: 0.75 mg/kg IV over 30 minutes (not to exceed 50 mg); then 0.5 mg/kg over the next 60 minutes (not to exceed 35 mg over the next 60 minutes)
OR
( Reteplase: 10 U IV over 2 minutes, repeat after 30 minutes
OR
( Tenecteplase: if weight < 60 kg, give 30 mg single IV bolus;
if weight 60-69 kg, give 35 mg single IV bolus;
if weight 70-79 kg, give 40 mg single IV bolus;
if weight 80-89 kg, give 45 mg single IV bolus;
if weight > 90 kg, give 50 mg single IV bolus.
ANTICOAGULANT THERAPY (Choose ONE with fibrinolytics):
( Unfractionated Heparin:
Bolus: 60 U/kg IV (not to exceed 4000 U regardless of weight)
Infusion: 12 U/kg/hr IV (not to exceed 1000U/hr regardless of weight) to goal PTT 1.5 to 2.0 times local reference standard; check PTT in 6 hours and adjust heparin as indicated
Note: Not to be continued for > 48 hours unless otherwise indicated.
OR
( Enoxaparin*: Bolus: 30 mg IV (no IV bolus if age >75 years)
Maintenance: 1mg/kg subcutaneously every 12 hours, first dose 15 minutes after bolus (if age >75 years give 0.75 mg/kg every 12 hours with no bolus; if CrCl <30 mL/min, give 1 mg/kg every 24 hours after bolus)
OR
( Fondaparinux*: 2.5 mg IV initial dose, then 2.5mg subcutaneously daily thereafter (av o i d i f C r C l d"3 0 m L / m i n )
* A n t i c o a g u l a n t t h e r a p y f o r a t l e a s t 4 8 h o u r s , a n d p r e f e r a b l y f o r d u r a t i o n o f h o s p i t a l i z a t i o n , u p t o 8 d a y s .
P R I M A R Y P C I S T R A T E G Y O R D E R S ( G o a l D o o r t o B a l l o o n < 9 0 m i n )
G L Y C O P R O T E I N I I B / I I I A T H E R A P Y ( C h o o s e o n e ( C l a s s I I a ) o r u s e clopidogrel as above)
( Abciximab Loading: 0.25 mcg/kg IV bolus
Infusion 0.125 mcg/kg/min IV for 12 hours
OR
( Eptifibatide: Loading: 180 mcg/kg IV bolus, repeat bolus after 10 minutes
Infusion: 2.0 mcg/kg/min IV for 12-18 hours (Reduce to 1.0 mcg/kg/min if CrCl <50 mL/min)
OR
( Tirofiban: Loading: 0.4 mcg/kg/min for 30 minutes IV ( R e d u c e t o 0 . 2 m c g / k g / m i n f o r C r C l d"3 0 m L / m i n )
I n f u s i o n : 0 . 1 m c g / k g / m i n I V f o r 1 2 - 1 8 h o u r s ( R e d u c e t o 0 . 0 5 m c g / k g / m i n i f C r C l d"3 0 m L / m i n ) A D D I N E N . C I T E < E n d N o t e > < C i t e E x c l u d e A u t h = " 1 " > < Y e a r > 2 0 0 7 < / Y e a r > < R e c N u m > 6 < / R e c N u m > < r e c o r d > < r e c - n u m b e r > 6 < / r e c - n u m b e r > < r e f-type name="Electronic Source">12Aggrastat (Tirofiban) Package Insert2008June 122007http://www.medicure.com/aggrastat/Aggrastat_PI_HiRes.pdf6
*Can be started prior to or in cardiac catheterization lab. As supplement to clopidogrel.
ANTICOAGULANT THERAPY (Choose one):
( Unfractionated Heparin:
Bolus: 60 U/kg not to exceed 4000 U
Infusion: 12 U/kg/hr not to exceed 1000 U/hr to goal PTT 1.5 to 2.0 times local reference standard (target ACT in catheterization lab: 200-250 sec if concomitant GP IIb-IIIa therapy, 250-300 sec if no concomitant GP IIb-IIIa therapy; re-bolus with heparin to achieve target ACT if measured values below recommended ranges)
OR
( Enoxaparin: Bolus: 30 mg IV (no IV bolus if age >75 years)
Maintenance: 1mg/kg subcutaneously every 12 hours, first dose 15 minutes after bolus (if age >75 years give 0.75 mg/kg every 12 hours with no bolus; if CrCl <30 mL/min, give 1 mg/kg every 24 hours after bolus)
If last subcutaneous dose less than 8 hours prior to PCI, no additional enoxaparin required; if last subcutaneous dose 8-12 hours earlier or never given, intravenous dose of 0.3 mg/kg should be given.
Note: Discontinue after completion of the PCI procedure, unless continued anticoagulation indicated
MEDICAL MANAGEMENT STRATEGY ORDERS (NO REPERFUSION)
ANTICOAGULANT THERAPY (Choose one):
( Unfractionated Heparin:
Bolus: 60 U/kg IV (not to exceed 4000 U regardless of weight)
Infusion: 12 U/kg/hr IV (not to exceed 1000U/hr regardless of weight) to goal PTT 1.5 to 2.0 times local reference standard; check PTT in 6 hours and adjust heparin as indicated
Note: Not to be continued for > 48 hours unless otherwise indicated.
OR
( Enoxaparin*: Bolus: 30 mg IV (no IV bolus if age >75 years)
Maintenance: 1 mg/kg subcutaneously every 12 hours, first dose 3 0 m i n u t e s a f t e r b o l u s ( i f a g e > 7 5 y e a r s , g i v e 0 . 7 5 m g / k g e v e r y 1 2 h o u r s w i t h n o b o l u s ; i f C r C l < 3 0 m L / m i n , g i v e 1 m g / k g e v e r y 2 4 h o u r s a f t e r b o l u s )
O R
( F o n d a p a r i n u x * : 2 . 5 m g I V i n i t i a l d o s e , t h e n 2 . 5 m g s u b c u t a n e o u s l y d a i l y t h e r e a f t e r ( a v o i d i f C r C l d"30 mL/min)
*Anticoagulant therapy for at least 48 hours, and preferably for duration of hospitalization, up to 8 days in patients with no contraindications for anticoagulation.
Bottom of Form
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Endnote:
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Page PAGE 1 of NUMPAGES 5
Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008;51:210-247. (p217).
Antman EM, Hand M, Armstrong PW, et al. 2007, p 217.
Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004;44:E1-E211. (p36).
Antman EM, Anbe DT, Armstrong PW, et al.2004, e73.
Antman EM, Hand M, Armstrong PW, et al. 2007, p 235.
Antman EM, Hand M, Armstrong PW, et al. 2007, p 230.
King SB, 3rd, Smith SC, Jr., Hirshfeld JW, Jr., et al. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol. 2008;51:172-209.
Antman EM, Hand M, Armstrong PW, et al. 2007, p 237
Antman EM, Hand M, Armstrong PW, et al. 2007, p 217.
Antman EM, Hand M, Armstrong PW, et al. 2007, p 237
Antman EM, Hand M, Armstrong PW, et al. 2007, p 215
Antman EM, Hand M, Armstrong PW, et al. 2007, p 215
Antman EM, Hand M, Armstrong PW, et al. 2007, p 215
Antman EM, Hand M, Armstrong PW, et al. 2007, p 215
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