Unique Plan Description: ED Chest Pain
Plan Selection Display: ED Chest Pain
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2011-11-30 14:22:27
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-05-09 11:49:03
Available at all facilities: Yes

ED Chest Pain
Laboratory
	CBC with Diff
		Stat, spec type = Blood
	Comprehensive Metabolic Panel
		Stat, spec type = Blood
	hs Troponin T - MH/WH/JE
		Stat, spec type = Blood
		T;N+180, Timed, spec type = Blood
	D-Dimer - MH/WH/JE
		Stat, spec type = Blood
	ProBNP
		Stat, spec type = Blood
	hsCRP
		Stat, spec type = Blood
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
	Urinalysis
		T;N, Stat, Stat, spec type = Urine
	UA (Culture if Positive)
		Stat, Stat, spec type = Urine
			Comment: change the indwelling catheter prior to obtaining specimen if catheter in place greater than 2 weeks, or unknown.
	Basic Metabolic Panel
		Stat, spec type = Blood
	Blood Gases Arterial (ABG) - MH/WH/JE
		Stat, spec type = Blood
	Amylase Level
		Stat, spec type = Blood
	Lipase Level
		Stat, spec type = Blood
	Heparin Anti-Xa Heparin
		Stat, spec type = Blood
		T;N+360, Routine, Q6H, spec type = Blood
	Order Lab
		Enter orders for anti factor Xa UFH q6h after initiation of therapy or any dosage change until 2 consecutive anti factor Xa UFH in therapeutic range, then q24h WHILE IN ED.
	Glucose POC - RN
		T;N
Diagnostic Tests
Diagnostics
	ECG in ED
		Stat, Indication: Chest Pain
		Timed, Indication: Chest Pain
			Comment: to be done 15 minutes after previous ECG
Radiology
	Chest 1 View
		Stat, Pain/Chest
	Chest 2 View
		Stat, Pain/Chest
	CTA Chest
		Stat, Dissection of Aorta
	CTA Chest Pulmonary Arteries
		Stat, Pulmonary Emboli
	CTA Abd
		Stat, Aortic Dissection
IV Solutions

	Sodium Chloride 0.9%
		1,000 mL, IV, STAT, 1 Dose(s)/Time(s), 999 ml/hr
		1,000 mL, IV, STAT, 1 Dose(s)/Time(s), 75 ml/hr
		1,000 mL, IV, STAT, 1 Dose(s)/Time(s), 100 ml/hr
		1,000 mL, IV, STAT, 1 Dose(s)/Time(s), 125 ml/hr
		1,000 mL, IV, STAT, 1 Dose(s)/Time(s), 500 ml/hr
	nitroglycerin 50 mg/D5W 250 mL Premix IV
		50 mg, EVERY BAG, 5 mcg/min
		250 mL, drug form: IV Large Volume, route of administration: IV, pharmacy order priority: Routine, requested start date/time T;N, Maintain Parameter: SBP> Parameter Goal: 90, Increment Dose Increase: 5 mcg/min, Increment Dose Decrease: 5 mcg/min, Incremen
			Comment: If no response at 20mcg/min, may increase by 10mcg/min every 5 min.  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
	HEParin 1000 units/mL injectable solution (MH/WH)
		60 units/kg, Injection, IV Push, Once, STAT
			Comment: maximum INITIAL BOLUS=4000 units.
	HEParin 1000 units/mL injectable solution (JE)
		60 units/kg, Injection, IV PUSH, Once, STAT
			Comment: maximum INITIAL BOLUS=4000 units.
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV, STAT, 1 Dose(s)/Time(s)
			Comment: Conc: 100 units/mL. Titrate according to Low Dose Weight Based Heparin Protocol.  Dosing wt/IV Pump  = _______kg.  Maximum weight for dosing 110kg.  MAXIMUM INITIAL RATE IS 1000 units per hour.1) Anti-factor Xa UFH <than 0.2 units/mL, bolus 60 units/kg & increase rate by 4 units/kg/hr.2) Anti-factor Xa UFH = 0.2-0.29 units/mL, bolus 30 units/kg & increase rate by 2 units/kg/hr.3) Anti-factor Xa UFH = 0.3-0.7 units/mL, (therapeutic range) Do not give bolus & do not change rate.4) Anti-factor Xa UFH = 0.71-0.95 units/mL, do not bolus. Decrease rate by 2 units/kg/hr.5) Anti-factor Xa UFH = 0.96 units/mL or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber
		25,000 units, EVERY BAG, 12 unit/kg/hr
		Heparin doses are based on weight  at time of initiation of protocol. Patients >110kg, dosed at weight of 110kg(NOTE)*
Medications
	aspirin
		324 mg, Tablet, Chew, By Mouth, Once, STAT
		300 mg, Suppository, RECTALLY, Once, STAT
	Nitrostat
		0.4 mg, Tab, SUBLINGUAL, Q5MIN, PRN, chest pain, STAT, 1 hr
			Comment: may repeat three times.
	morphine  IV
		2 mg, Syringe, IV PUSH, Once, STAT
		4 mg, Syringe, IV PUSH, Once, STAT
	Dilaudid Injectable
		1 mg, Injection, IV PUSH, Once, STAT
	fentaNYL
		25 mcg, Injection, IV Push, Once, STAT
		50 mcg, Injection, IV Push, Once, STAT
		75 mcg, Injection, IV Push, Once, STAT
		100 mcg, Injection, IV Push, Once, STAT
	ketorolac injectable
		15 mg, Injection, IV PUSH, Once, STAT
			Comment: if CrCl<50, wt <50kg or age>65y/o
		30 mg, Injection, IV PUSH, Once, STAT
		30 mg, Injection, IM-IntraMUSCULAR, Once, STAT
			Comment: if CrCl<50, wt <50kg or age>65y/o
		60 mg, Injection, IM-IntraMUSCULAR, Once, STAT
	Lopressor
		5 mg, Solution-Injection, IV PUSH, Q5MIN, STAT, duration: 3 Dose(s)/Time(s)
			Comment: Hold this Beta-Blocker 12 hours prior to any ordered Dobutamine Stress Echo (DSE).
	Brilinta (ticagrelor)
		180 mg, Tab, By Mouth, Once, STAT
	Plavix
		75 mg, Tab, BY MOUTH, Once, STAT
		600 mg, Tab, BY MOUTH, Once, STAT
	Lasix Injection
		20 mg, IV PUSH, Once, STAT
		40 mg, IV PUSH, Once, STAT
		80 mg, IV PUSH, Once, STAT
	Lovenox
		1 mg/kg, Syringe, SUBCUTANEOUS, Once, STAT
	Cardizem
		15 mg, Injection, IV Push, Once, STAT
		20 mg, Injection, IV Push, Once, STAT
		25 mg, Injection, IV Push, Once, STAT
	Ativan
		0.5 mg, Injection, IV PUSH, Once, STAT
		1 mg, Injection, IV PUSH, Once, STAT
	adenosine IV Push
		6 mg, Injection, IV Push, Once, STAT
		12 mg, Injection, IV Push, Once, STAT
	Tylenol
		1,000 mg, Tab, By Mouth, Once, STAT
	ondansetron
		4 mg, Injection, IV PUSH, Once, STAT
Patient Care
	Avoid IM Injections if possible while on anticoagulants
		
	ED Cardiac Telemetry Monitoring
		T;N, Once
	Oxygen Therapy, Nurse to Administer
		Via Nasal Cannula, O2 @ 2L
	Continuous Pulse Oximetry by Nurse
		T;N, Once
	Foley Catheter
		Insert, Once
	Straight Catheter
		T;N, Straight, Insert, Once
Consults/Follow-up
	Consult Cardiologist
		Reason for Referral: chest pain
	Consult Hospitalist
		Reason for Referral: chest pain

ED Blood Culture with Lactate
Laboratory
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		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.10570.1001(NOTE)*
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	Lactate
		T;N, Stat, spec type = Blood
	.Blood Culture.
		T;N, Stat, spec type = Blood
	.Culture Blood
		T;N, Stat, spec type = Blood

ED Peripheral Lock Insert with Flush
Medications
	sodium chloride 0.9% flush injectable soln
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush, 4 hr
Patient Care
	Peripheral Lock-Insert
		T;N, Once

GI Cocktail Order Set
Medications
	Maalox Plus oral susp
		30 mL, Suspension, Oral, By Mouth, Once, STAT
			Comment: Administer with 15mL of Viscous Lidociane for GI cocktail.
	lidocaine Viscous 2% solution
		15 mL, Soln, By Mouth, Once, STAT
			Comment: Administer with 30mL of Maalox Plus oral susp for GI cocktail.

hs Troponin T - MH/WH/JE
Laboratory
	hs Troponin T - MH/WH/JE
		Stat, spec type = Blood
		T;N+120, Timed, spec type = Blood
		T;N+360, Timed, spec type = Blood

ED Blood Culture Set
	.Blood Culture.
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	.Blood Culture
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
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		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.10570.1001(NOTE)*
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hs Troponin I - FH (Stat and 2hr and 6hr)
	hs Troponin I - FH
		T;N, Stat, spec type = Blood
		T;N+120, Timed, spec type = Blood
		T;N+360, Timed, spec type = Blood

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase