KH00544 Rev. 4/8/03
Patient ID Area
ACUTE CORONARY SYNDROME ADMISSION ORDER
ALLERGIES Height: Actual Weight:
ORDERSHEETS
អ Buffalo General Hospital
អ Women and Children's Hospital of Buffalo អ DeGraff Memorial Hospital
អ Millard Fillmore Gates Circle អ Millard Fillmore Suburban អ Other:
White - Chart Yellow - Nursing Copy
Admit to Dr. Diagnosis អ Unstable Angina អ NSTEMI អ STEMI អ Other Condition
Advanced Directives discussed with patient/family and documented in chart អ Yes អ No Resuscitation Status: DNR/DNI Other Limitations
Vital sign frequency Special Considerations អ Bedrest with commode privileges អ BRP
អ Oxygen at 2L/min Nasal Cannula Other អ Cardiac diet
អ IV - 0.9 NS: អ Trap អ KVO ml/hr
អ Cardiac profile q8h x 3 (with troponin I obtained 12 hours after initial determination) អ EKG qd X 3
អ Urinalysis
អ CBC អ BMP អ CMP On អ Old Records to floor
ANTI-THROMBOTIC THERAPY (reference table on back of form) អ ECASA 325 mg po qd
អ Clopidogrel (Plavix) 75 mg po qd
Glycoprotein IIb/IIIa Inhibitor (see ED orders for risk stratification) អ Eptifibatide (Integrilin) (dosing nomogram on back of form)
180 mcg/kg Eptifibatide IV bolus (unless bolus is given in ED)
2.0 mcg/kg/min Eptifibatide IV infusion (half infusion rate if serum creatinine is between 2 - 4 mg/dl) Anticoagulant
អ Unfractionated heparin (Note: When using a GP IIb/IIIa inhibitor or fibrinolytic: use Cardiac Unfractionated Heparin Dosing Nomogram (on back of form), otherwise use weight based heparin nomogram - form KH00271)
units heparin IV bolus (1000 units/ml) (unless bolus given in ED)
units heparin IV/hr infusion (use 100 units/ml bag) (dosing nomogram on back of form) aPTT in 6hrs. (refer to dosing nomogram on back of form for further dosing and lab draws) -OR-
អ Enoxaparin (Lovenox) mg sq q12h (recommended dose is 1 mg/Kg q 12 h sq)
(verify when initial dose was given in ED, before proceeding with administration) (Note: Use unfractionated heparin in severe renal impairment (creatinine clearance < 30 ml/min) and morbidly obese patients)
ANTI-ISCHEMIC THERAPY
Nitroglycerin Therapy (Hold if patient has taken Sildenafil (Viagra) within 24 hours) អ Nitroglycerin 0.4mg SL prn q5min X 3 doses or until pain relief or SBP < 100 mmHg អ Nitroglycerin paste inch(es) topically q6h
អ Nitroglycerin IV infusion at mcg/min, then titrate as per protocol B-Blocker Therapy:
អ Metoprolol (Lopressor) mg po q h (Hold for SBP < 90, HR < 50, AV block >1st -degree decompensated CHF, severe COPD/Asthma)
ACE Inhibitor Therapy:
អ mg q h (Hold for SBP < 90 or Creatinine > 3)
Statin Therapy:
អ mg po q hs
អ Initiate Lidocaine
អ Initiate Atropine mg for symptomatic heart rate below .
អ Acetaminophen (Tylenol) 650mg po q 4-6h prn for headache អ Senna - S (Senokot - S) 1 po bid
អ Antacid (Maalox) 30 cc po q 2 - 3 h prn
អ Yes អ No Telemetry may be discontinued for ordered tests Sedation:
Analgesia:
Consults:អ
Referrals:፤ Cardiac rehab to seeអ Physical Therapy អ Nutritional Services អ Social Services អ Patient Management អ Pastoral Care អ Palliative Care អ Other
Physician/NP/PA Signature Date Time
KH00544 Rev. 4/8/03
ANTI-THROMBOTIC TREATMENT GUIDELINES
• Obtain aPTT q6h after initial dosing
• For aPTTs obtained <12 hours after fibrinolytic administration do not change heparin infusion unless significant bleeding or aPTT > 150 s or < 50 s.
PATIENT WEIGHT (lbs)
PATIENT WEIGHT (kg)
180 mcg/kg bolus via IV push (ml)
2 mcg/kg/min infusion (ml/hr) Normal Renal Function
1 mcg/kg/min infusion (ml/hr)*
Creatinine 2-4 mg/dl aPTT(s) Bolus Dose (Units) Stop Infusion
(min)
Rate Change (mL/h)
Repeat aPTT
<40 40-49 50-70 71-85 86-100 101-150
>150
3000 0 0 0 0 0 0
0 0 0 0 30 60 60
+2 +1 0 (no change)
-1 -2 -3 -6
6hr 6hr Next AM Next AM
6h 6h 6h
81-91 92-102 103-117 118-130 131-143 144-157 158-172 173-185 186-198 199-212 213-227 228-240 241-253 254-267
>267
37-41 42-46 47-53 54-59 60-65 66-71 72-78 79-84 85-90 91-96 97-103 104-109 110-115 116-121
>121
3.4 4 4.5
5 5.6 6.2 6.8 7.3 7.9 8.5 9 9.5 10.2 10.7 11.3
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
3 3.5
4 4.5
5 5.5
6 6.5
7 7.5
8 8.5
9 9.5
10 Likely/Definite ACS
Aspirin + Clopidogrel
+ Enoxaparin Class I/IIa
Possible ACS Aspirin
ACUTE CORONARY SYNDROME ADMISSION ORDER
Definite ACS with continuing Ischemia or Other High-Risk Features or planned PCI
Aspirin + Clopidogrel
+ IV heparin
+
IV platelet GP IIb/ IIIa antagonist
Dosing Nomogram for Eptifibatide (Integrilin)
Bolus: 2mg/ml vial Infusion: 0.75 mg/ml vial Wt (lbs)
81-91 92-102 103-117 118-130 131-143 144-157 158-172
> 173-185
Wt (kg)
37-41 42-46 47-53 54-59 60-65 66-71 72-78
> 79-84
Bolus Dose (Units)
2300 2600 3000 3400 3800 4100 4500 5000
BOLUS (ml) (1000 Units/ml vial)
2.3 2.6 3 3.4 3.8 4.1 4.5 5
Infusion (Units/hr)
470 530 600 680 750 820 900 1000
INFUSION (ml/hr)*
(100 Units/ml bag) 4.7 5.3 6 6.8 7.5 8.2 9 10 Cardiac Unfractionated Heparin Nomogram (for patients receiving a GP Ilb/IIIa inhibitor or fibrinolytic)
(60 Units/kg BOLUS (max- 5,000 Units), 12 Units/kg/hr INFUSION (max- 1,000 Units/hr))
*If infusion pump model cannot deliver to the nearest 0.1 ml, round to the nearest ml (e.g. 5.5 to 6.0 ml/hr)
*If infusion pump cannot deliver to the nearest 0.1 ml - round to the nearest 1.0 ml (e.g. 5.3 ml to 5.0 ml, 6.8 ml to 7.0 ml) For patients NOT receiving a concomitant GP IIB/IIIa inhibitor or fibrinolytic: Initiate Heparin dosing form: Adult unfractionated heparin weight based physician's order (for non-stroke patients) #KH00271.
Heparin Adjustment Nomogram (for patients receiving a GP IIb/IIIa inhibitor or fibrinolytic) based on normal aPTT values of 26-36 s.
SAME AS 1
SAME AS 1
