Unique Plan Description: ED GI Bleed
Plan Selection Display: ED GI Bleed
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-04-19 21:00:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-07-24 12:59:49
Available at all facilities: Yes

ED GI Bleed
Vital Signs
	BP and Pulse, Orthostatic
		T;N, Once
Diet
	NPO
		T;N
Laboratory
STAT Lab
	Emergency Release RBC
		
	Type and Crossmatch (Product Available)
		T;N, Stat, For Possible Transfusion
	CBC with Diff
		Stat, spec type = Blood
	Comprehensive Metabolic Panel
		Stat, spec type = Blood
	INR - MH/WH/JE
		Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Stat, spec type = Diagnostic Blood
	Blood Gases Arterial (ABG) - MH/WH/JE
		Stat, spec type = Blood
	Blood Gases Arterial (ABG) - FH
		T;N, Stat, spec type = Blood
	Occult Blood Stool - JE
		Stat, spec type = Stool
	Occult Blood Stool - MH/WH/FH
		Stat, spec type = Stool
	Type and Screen (No Product on hold)
		Stat, spec type = Blood
	Lactate
		Stat, spec type = Blood
	Urinalysis
		T;N, Stat, Stat, spec type = Urine
	UA (Culture if Positive)
		Stat, Stat, spec type = Urine
	Pregnancy Test Urine
		Stat, Stat, Urine Random, spec type = Urine
	Pregnancy Test Whole Blood - JE
		Stat, spec type = Blood
	Beta-HCG Quantitative - Pregnancy
		Stat, spec type = Blood
	Hemoglobin and Hematocrit
		Stat, spec type = Blood
Diagnostic Tests

	CT Abd Pelvis w Contrast
		Stat, Nausea
	CT Abd Pelvis w/o Contrast
		Stat, GI Bleed
	ECG in ED
		Stat, Indication: Weakness
	Abd & Upright w Chest
		Stat, Blood Loss
IV Solutions
	Sodium Chloride 0.9%
		1,000 mL, IV, STAT, 999 ml/hr
		1,000 mL, IV, STAT, 500 ml/hr
		1,000 mL, IV, STAT, 125 ml/hr
		1,000 mL, IV, STAT, 100 ml/hr
		1,000 mL, IV, STAT, 75 ml/hr
	SandoSTATIN 500mcg/NS 250mL
		250 mL, IV
			Comment: Rate: 25 mcg/hr
		500 mcg, EVERY BAG, 25 mcg/hr
		250 mL, IV
			Comment: Rate: 50 mcg/hr
		500 mcg, EVERY BAG, 50 mcg/hr
		250 mL, IV
			Comment: Rate: 100 mcg/hr
		500 mcg, EVERY BAG, 100 mcg/hr
Medications
	Pepcid
		40 mg, Injection, IV PUSH, Once, NOW
	Phenergan (FH)
		6.25 mg, INT, IVPB, Once, STAT
	ondansetron
		4 mg, Injection, IV Push, Once, STAT
	ondansetron (MH/WH)
		8 mg, Injection, IV Push, Once, STAT
	Vitamin K
		5 mg, Solution, By Mouth, Once, STAT
	Vitamin K IVPB
		10 mg, Injection, IVPB, Once, STAT
	pantoprazole IV
		40 mg, Injection, IV Push, Once, STAT
			Comment: Reconstitute with 10mL normal saline and infuse over 2 minutes.  Does NOT require filtration.
	SandoSTATIN
		50 mcg, Injection, IV Push, Once
		100 mcg, Injection, IV Push, Once
	Rocephin IVPB
		1,000 mg, Injection-Premix, IVPB, Once, STAT
	Rocephin IVPB (FH)
		1,000 mg, INT, IVPB, Once, STAT
Patient Care
	Continuous Pulse Oximetry by Nurse
		T;N, Once
	Glucose POC - RN
		T;N, Once
	Foley Catheter
		T;N, Insert, Once
	Straight Catheter
		T;N, Insert, Once
	Enteral Tube
		T;N, Per Nasogastric Tube (NG), Connect to low continuous suction | Insert, X Ray, Once
	Oxygen Therapy, Nurse to Administer
		T;N
	No NSAIDS (non steroidal anti-inflamatory)
		T;N
	ED Cardiac Telemetry Monitoring
		T;N, Once
	No Coumadin
		T;N
	No Anticoagulants
		T;N
Consults/Follow-up
	Consult Gastroenterologist
		Reason for Referral: GI bleed
	Consult General Surgery
		Reason for Referral: GI bleed
	Consult Hospitalist
		Reason for Referral: GI bleed

Transfuse (Administer) Blood Products EKM
Vital Signs
		Refer to Transfusion Guidelines for Blood Components(NOTE)*
	Vital Signs
		T;N
			Comment: VS within 30 minutes before starting the transfusion, within 5-15 minutes after starting infusion, whenever a suspected adverse reaction occurs, and within 30 minutes of when transfusion complete
Laboratory
Packed Cells
	Crossmatch Red Blood Cells
		T;N, Routine
		T;N, Stat
	Administer blood products
		T;N, Packed cells
Plasma
	Frozen Plasma
		T;N, Routine
	Administer blood products
		T;N, Plasma-fresh frozen
Platelet Pheresis
	Platelet Pheresis
		T;N, Routine
	Administer blood products
		T;N, Platelet
Cryopreciptate
	Cryoprecipitate
		T;N, Routine
	Administer blood products
		T;N, Cryoprecipitate
IV Solutions

	Sodium Chloride 0.9%
		500 mL, IV, 1 Dose(s)/Time(s), 20 ml/hr
Medications
	Tylenol
		650 mg, Tab, By Mouth, Once, T;N
Patient Care
	Obtain Consent/Permit for:
		T;N, blood product transfusion
	Patient Education
		T;N, Review education leaflet "When you need a blood transfusion" prior to administering blood.
	Notify MD
		T;N, Temperature >100.0 F prior to transfusion

pantoprazole (Protonix) Infusion Protocol
IV Solutions
	Protonix 80 mg/NS 500 mL infusion IV
		500 mL, IV, Routine, T;N
			Comment: Conc:  0.16 mg/mL.
		80 mg, EVERY BAG, 8 mg/hr
Medications
	pantoprazole IV
		80 mg, Injection, IV Push, Once
			Comment: Dilute each 40mg vial with 10ml NS.  Administer the 80mg dose over 4 minutes.

protamine Reversal of IV and SC heparin
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	protamine
		mg, Injection, IVPB, Once, NOW, 30 ml/hr
			Comment: Nurse to monitor patient continuously for the first 10min; if patient tolerates infusion after 10min (no increased hypotension, bradycardia, anaphylaxis), rate may be increased to 90ml/hr for remainder of the infusion.
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		mg, Injection, IVPB, Once, NOW, 30 ml/hr
			Comment: Nurse to monitor patient continuously for the first 10min; if patient tolerates infusion for 10min (no increased hypotension, bradycardia, anaphylaxis), rate may be increased to 90ml/hr for remainder of the infusion.  VS to be monitored every 5min.
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		mg, Injection, IVPB, Once, NOW, 30 ml/hr
			Comment: Nurse to monitor patient continuously for the first 10min; if patient tolerates infusion for 10min (no increased hypotension, bradycardia, anaphylaxis), rate may be increased to 90ml/hr for remainder of the infusion.  VS to be monitored every 5min.
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	diphenhydrAMINE
		25 mg, Injection, IV Push, Once, PRN for allergy symptoms
			Comment: with protamine
	methylPREDNISolone
		125 mg, Injection, IV Push, Once, PRN for wheezing and/or shortness of breath
			Comment: with protamine
	EPINEPHrine
		0.3 mg, Injection, SUBCUTANEOUS, Once, PRN for wheezing and/or shortness of breath
			Comment: with protamine
Patient Care
	Order Lab
		T;N, PTT to be drawn 2 hours after protamine infusion complete. Nurse to enter lab.
		T;N, Heparin antiXa Heparin" to be drawn 2 hours after protamine infusion complete. Nurse to enter lab.
	Cardiac Telemetry Monitoring
		Telemetry Indications: Other
			Comment: during protamine infusion only, dc when infusion complete

protamine Reversal of enoxaparin
Medications
		     There is not a complete antidote for enoxaparin.  Protamine only reverses approximately 60% of the enoxaparin dose.(NOTE)*
		Reveral for enoxaparin given within the last 8 hours(NOTE)*
		       protamine dose is 1 mg for every 1 mg enoxaparin administered (maximum recommended dose of 50mg).  If bleeding continues and if anti-Xa LMWH and/or PTT is prolonged at 4 hrs after initial infusion, half the original dose may be repeated.(NOTE)*
	protamine
		mg, Injection, IVPB, Once, NOW, 30 ml/hr
			Comment: Nurse to monitor patient continuously for the first 10min; if patient tolerates infusion for 10min (no increased hypotension, bradycardia, anaphylaxis), rate may be increased to 90ml/hr for remainder of the infusion.  VS to be monitored every 5min.
		Reversal for enoxaparin given 8-12 hours ago:(NOTE)*
		     Protamine dose is 0.5 mg for every 1 mg of enoxaparin administered (maximum recommended dose of 50mg).(NOTE)*
		mg, Injection, IVPB, Once, NOW, 30 ml/hr
			Comment: Nurse to monitor patient continuously for the first 10min; if patient tolerates infusion for 10min (no increased hypotension, bradycardia, anaphylaxis), rate may be increased to 90ml/hr for remainder of the infusion.  VS to be monitored every 5min.
		Patients currently on/previously treated with protamine sulfate containing insulin (NPH), have undergone vasectomy, or have known fish allergies may have a greater risk for hypersensitivity reactions.(NOTE)*
	diphenhydrAMINE
		25 mg, Injection, IV Push, Once, PRN for allergy symptoms
			Comment: with protamine
	methylPREDNISolone
		125 mg, Injection, IV Push, Once, PRN for wheezing and/or shortness of breath
			Comment: with protamine
	EPINEPHrine
		0.3 mg, Injection, SUBCUTANEOUS, Once, PRN for wheezing and/or shortness of breath
			Comment: with protamine
Patient Care
	Order Lab
		T;N, PTT to be drawn 4 hours after protamine infusion complete. Nurse to enter lab.
		T;N, Heparin Anti-Xa LMWH Lovenox to be drawn 4 hours after protamine infusion complete. Nurse to enter lab.
	Cardiac Telemetry Monitoring
		Telemetry Indications: Other
			Comment: during protamine infusion only, dc when infusion complete

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

*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