2. Diagnosis: Rule out myocardial infarction
3 Condition:
4. Vital Signs: q1h. Call physician if pulse >90,<60; BP>150/90, <90/60;R>25, <12; T >38.5/C.
5. Activity: Bed rest with bedside commode.
7. Nursing: Guaiac stools. If patient has chest pain,obtain 12-lead ECG and call physician.
8. Diet: Cardiac diet, 1-2 gm sodium, low fat, low cholesterol diet.
No caffeine or temperature extremes.
9. IV Fluids: D5W at TKO
10. Special Medications:
-Oxygen 2-4 L/min by NC.-Aspirin 325 mg PO, chew and swallow, then aspirin EC 162 mg PO qd OR
Clopidogrel (Plavix) 75 mg PO qd (if allergic to aspirin).
-Nitroglycerine 10 mcg/min infusion (50 mg in 250-500mL D5W, 100-200 mcg/mL).
Titrate to control symptoms in 5-10 mcg/min steps, up to 200-300mcg/min;
maintain systolic BP >90 OR
-Nitroglycerine SL, 0.4 mg (0.15-0.6 mg) SL q5min until pain free (up to 3 tabs) OR
-Nitroglycerin spray (0.4 mg/aerosol spray)1-2 sprays under the tongue q 5min;
may repeat x 2.
-Heparin 60 U/kg IV push, then 12 U/kg/hr by continuous IV infusion for
48 hours to maintain aPTT of 50-70 seconds. Check aPTTq6h x 4, then qd.
Repeat aPTT 6 hours after each heparin dosage change.
Thrombolytic Therapy
Absolute Contraindications to Thrombolytics: Active internal bleeding,
suspected aortic dissection, known intracranial neoplasm,
previous intracranial hemorrhagic stroke at any time,
other strokes or cerebrovascular events within 1 year,
head trauma,pregnancy, recent non-compressible vascular puncture,
uncontrolled hypertension (>180/110 mmHg).
Relative Contraindications to Thrombolytics: Absence of ST-segment elevation,
severe hypertension,cerebrovascular disease, recent surgery (within 2weeks),
cardiopulmonary resuscitation.
A. Alteplase (tPA, tissue plasminogen activator,Activase):
1. 15 mg IV push over 2 min, followed by 0.75 mg/kg (max 50 mg) IV infusion
over 30 min, followed by0.5 mg/kg (max 35 mg) IV infusion
over 60 min (max total dose 100 mg).
2. Labs: INR/PTT, CBC, fibrinogen.
B. Reteplase (Retavase):
1. 10 U IV push over 2 min; repeat second 10 U IV push after 30 min.
2. Labs: INR, aPTT, CBC, fibrinogen.
C. Tenecteplase (TNKase):
<60 kg 30 mg IVP
60-69 kg 35 mg IVP
70-79 kg 40 mg IVP
80-89 kg 45 mg IVP
$90 kg 50 mg IVP
C. Streptokinase (Streptase):
1. 1.5 million IU in 100 mL NS IV over 60 min.
Pretreat with diphenhydramine (Benadryl) 50 mg IV push AND
Methylprednisolone (Soln-Medrol) 250 mg IV push.
2. Check fibrinogen level now and q6h for 24h until level >100 mg/dL.
3. No IM or arterial punctures, watch IV for bleeding.
Angiotensin Converting Enzyme Inhibitor:
-Lisinopril (Zestril, Prinivil) 2.5-5 mg PO qd; titrate to 10-20 mg qd.
Long-acting Nitrates:
-Nitroglycerin patch 0.2 mg/hr qd.
Allow for nitrate-free period to prevent tachyphylaxis.
-Isosorbide dinitrate (Isordil) 10-60 mg PO tid [5,10,20,30,40 mg] OR
-Isosorbide mononitrate (Imdur) 30-60 mg PO qd.
Beta-Blockers: Contraindicated in cardiogenic shock.
-Metoprolol (Lopressor) 5 mg IV q2-5min x 3 doses;
then 25 mg PO q6h for 48h, then 100 mg PO q12h; hold if heart rate <60/min
or systolic BP <100 mmHg OR
-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes,
followed by 50-100 mg PO qd OR
-Esmolol hydrochloride (Brevibloc) 500 mcg/kg IV over 1 min,
then 50 mcg/kg/min IV infusion, titrated to heart rate >60 bpm (max 300 mcg/kg/min).
Statins:
-Atorvastatin (Lipitor) 10 mg PO qhs OR
-Pravastatin (Pravachol) 40 mg PO qhs OR
-Simvastatin (Zocor) 20 mg PO qhs OR
-Lovastatin (Mevacor) 20 mg PO qhs OR
-Fluvastatin (Lescol)10-20 mg PO qhs.
11. Symptomatic Medications:
-Morphine sulfate 2-4 mg IV push prn chest pain.-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache.
-Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
-Docusate (Colace) 100 mg PO bid.
-Dimenhydrinate (Dramamine) 25-50 mg IV over 2-5 min q4-6h or
50 mg PO q4-6h prn nausea.
-Famotidine (Pepcid) 20 mg IV/PO bid.
12. Extras: ECG stat and in 12h and in AM, portable CXR,
impedance cardiography, echocardiogram.Cardiology consult.
13. Labs: SMA7 and 12, magnesium. Cardiac enzymes:
CPK-MB, troponin T, myoglobin STAT and q6h for24h. CBC, INR/PTT, UA.
