PLACE LABEL HERE
CHEST PAIN / CARDIAC SYNCOPE
ORDERS
Emergency Department
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1.
2.
3.
4.


Place: Observation for chest pain, rule out myocardial infarction
Consults: ____________________________________________________________________________
Private physician notified:  None  _________________________________  Time notified ________
Diagnostics:
 Fasting lipid profile – if patient has not eaten in 6 hrs
 Repeat Troponin I and Myoglobin at 90 min post baseline
 Repeat EKG in 20 min if chest pain is unresolved and with 90 min markers
  D-Dimer
  Echocardiogram
  PA & Lateral CXR
  CT angiogram of chest to rule out pulmonary embolus

 Venous Doppler  Right
 Upper Extremity

 Left
 Lower Extremity
5. Repeat Troponin I at 6 hrs
6. Vital signs:  q 4 hrs
 q _________ hrs
7. Continuous cardiac monitoring
8. Remove continuous cardiac monitoring
 If patient leaves Emergency Department for cardiac testing
9. Repeat EKG PRN for chest pain
10. Contact ED physician for recurrent chest pain or EKG changes
11. Notify ED physician if all cardiac markers are negative at the end of 90-min marker protocol; print EKG
12. Notify ED physician of all results of positive cardiac markers
13. Notify ED physician if Troponin I is negative at the end of 6-hr marker protocol: Print EKG
14. Diet:  Keep NPO 6 hrs prior to anticipated stress testing  Cardiac  1800 Cal ADA
 Full liquid diet (caffeine free/no decaffeinated) after midnight before stress test
15. Activity:  Bedrest
 Bedside Commode
 Up ad lib
 Up with assistance
16. Assess cardiac risk factors
17. Offer educational handouts/videos as appropriate and record material utilized/smoking cessation
18. INT
HOME MEDICATION ORDERS: to be administered while in the Emergency Department:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Order writer’s Initials___________
Send copy to pharmacy
*3-16341*
FORM 3-16341 REV. 03/2012
Page 1 of 3
PLACE LABEL HERE
CHEST PAIN / CARDIAC SYNCOPE
ORDERS
Emergency Department
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
SCHEDULED MEDICATION:
19. Nitroglycerin (NTG) ointment:
  ½ inch topically q 6 hrs, remove NTG ointment prior to transport to Cardiology Dept for stress testing
  1 inch topically q 6 hrs, remove NTG ointment prior to transport to Cardiology Dept for stress testing
20. Aspirin 324 mg (four x 81 mg chewables) po STAT if not done in ED. If unable to swallow, Aspirin 300 mg
suppository per rectum STAT
21.  Plavix (clopidogrel)  300 mg  600 mg po x 1 dose NOW
22. Anticoagulation:
  Heparin Infusion, HIGH Cardiac Dose (complete form # 28554)
 Lovenox (enoxaparin) 1 mg/kg SQ q 12 hrs (refer to Lovenox Dosing Rounding Chart below)
Dose Rounding for 1 mg/kg,
if patient weighs:
< 50 kg
50-69 kg
70-89 kg
90-109 kg
110-129 kg
130-144 kg
145-154 kg
155-169 kg
> 170 kg
Give
Lovenox (enoxaparin)
40 mg q 12 hrs
60 mg q 12 hrs
80 mg q 12 hrs
100 mg q 12 hrs
120 mg q 12 hrs
140 mg q 12 hrs
150 mg q 12 hrs
160 mg q 12 hrs
180 mg q12 hrs (maximum dose),
notify Clinical RPh
23. Beta Blocker:
 Lopressor (metoprolol) 25 mg po two times daily (hold if systolic BP < 90 or HR < 60)
 Lopressor (metoprolol) 12.5 mg po two times daily (hold if systolic BP < 90 or HR < 60)
PRN MEDICATIONS (If > one drug is ordered for the same indication, clinical assessment will be used per policy 520-06)
24.
Chest pain: Nitroglycerin 0.4 mg sublingual q 5 min x 3 doses prn. Notify Emergency Department
physician. Hold if systolic BP < 100 mm/Hg
25.
Severe chest pain unrelieved with max dose of Nitroglycerin sublingual x 3 doses
 Dilaudid (hydromorPHONE) 0.5 - 2 mg IV q 15 min prn (up to a max of 4 mg in 30 min)
Hold for excessive sedation
 Morphine 2 mg IV q 5 min prn (up to a maximum of 10 mg in 2 hrs)
Hold for excessive sedation
26.
Moderate pain:
 Lortab (HYDROcodone/acetaminophen) 5/500 mg 1-2 tabs or 10/500 mg 1 tab po q 4 hrs prn
 Percocet (oxyCODONE/acetaminophen) 5/325 mg 1-2 tabs or 10/325 mg 1 tab po q 4 hrs prn
 Hycet elixir (HYDROcodone 7.5 mg / acetaminophen 325 mg/15 ml) 15 ml po q 4 hrs prn
Send copy to pharmacy
FORM 3-16341 REV. 03/2012
Order writer’s Initials___________
Page 2 of 4
PLACE LABEL HERE
CHEST PAIN / CARDIAC SYNCOPE
ORDERS
Emergency Department

 Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if > 65 y/o old or < 50 kg)
or 10 mg po q 6 hrs prn (max combined duration of IV and po Toradol {ketorolac} is 5 days)
Send copy to pharmacy
FORM 3-16341 REV. 03/2012
Order writer’s Initials___________
Page 3 of 4
PLACE LABEL HERE
CHEST PAIN / CARDIAC SYNCOPE
ORDERS
Emergency Department
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
27.
28.
29.
30.
31.
Mild pain/temp >100.5F/HA: Tylenol (acetaminophen) 650 mg po q 4 hrs
Nausea/Vomiting:
 Zofran (ondansetron) 4 mg IV q 6 hrs prn
 Reglan (metoclopramide) 10 mg po or IV q 6 hrs prn (5 mg if > 65 y/o)
 Phenergan (promethazine) 12.5-25 mg po or per rectum q 4 hrs prn
Sleep:  Ambien (zolpidem) 5-10 mg po at HS prn. If 5 mg given, may repeat x 1 dose after 2 hrs
If > 65 year old, begin with 5 mg po at HS, may repeat x 1 dose after 2 hrs
 Other: _________________________________________________________________
Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
Anxiety:
 Ativan (lorazepam) 0.5 - 1 mg po q 8 hrs prn
 Xanax (alprazolam) 0.25 - 0.5 mg po q 6 hrs prn
STRESS TESTING: Consult cardiologist Dr. ______________________________________________
 ETT in a.m.
 ETT NOW
 Lexiscan (regadenoson) DIMPS in am  Lexiscan (regadenoson) DIMPS NOW
 Exercise DIMPS in am
 Exercise DIMPS NOW
 Stress Echo
Stress Test Selection Methodology (AHA/ACC)
ETT- able to exercise and normal or near normal ECG
Exclusion criteria: Inability to exercise, LV hypertrophy with repolarization changes, significant ST and T
wave changes including digoxin effect, biphasic or invertered T waves in anterior leads, LBBB
Exercise Stress Echocardiogram or Exercise Stress Nuclear Medicine Study
May be useful to discuss with local cardiologist for test of choice
Patient able to exercise but abnormal ECG
Exclusion Criteria: Inability to exercise, biphasic or invertered T waves in anterior leads
Pharmacologic Stress Test
May be useful to discuss with local cardiologist for test of choice
Patient unable to exercise and abnormal ECG
Normal Stress Test- follow up with PCP or clinic
Abnormal Stress Test- consult PCP or Cardiologist
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________
Date
___________________
Time
_________________________________
Physician Signature
__________
PID Number
Send copy to pharmacy
FORM 3-16341 REV. 03/2012
Page 4 of 4