Emergency Department
Chest Pain Non-STEMI Moderate-High Risk Orders
A. PATIENT CARE
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Cardiac Monitor
Vital signs per chest pain routine
Pulse Oximeter checks
IV access
Activity: bedrest with bathroom privileges as tolerated
For all Patients receiving Eptifibatide (Integrilin):
 Neurological Assessment - One time only. Obtain baseline neurological exam before starting Eptifibatide (Integrilin)
 Vital Signs and Neuro checks- q2H during infusion of Eptifibatide (Integrilin). Assess for headache, level of consciousness,
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B.
orientation, and Glascow Coma Scale. If motor weakness, headache present or other changes noted, a more complete neurological
assessment must be performed.
Assess all venous/arterial puncture sites, urine, stool, emesis for bleeding and monitor for hypotension, unusual leg or back pain for
patients receiving Eptifibatide (Integrilin)
Try to avoid / defer venous or arterial punctures during Eptifibatide (Integrilin) infusion. Apply direct pressure or pressure dressing to
any compressible site if access required. Avoid automatic blood pressure cuffs.
NUTRITION
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NPO
C. PHARMACY
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C.
Sodium Chloride 0.9% flush 3mL q8h
Aspirin 162 mg PO (2 baby chewed) one time only OR  If allergic give, Clopidogrel (Plavix) 300 mg PO one time only
Enoxaparin (Lovenox) 1 mg/kg SQ q12h. (Continue upon transfer to floor)
Eptifibatide (Integrilin) 180 mcg/kg bolus over 1-2 minutes (max 22.6 mg) THEN 2 mcg/kg /min infusion (max 15 mg/hr) if dynamic
ST-T changes with pain or positive Troponin I. If SCr  2, decrease maintenance dose to 1 mcg/kg/min. Cardiology consult
recommended prior to usage in ED.
Heparin __________units IV bolus. Dose @ 60 units/kg, THEN IV drip at __________units Dose @ 12 units/kg/hr
Heparin drip per pharmacy dosing: CV/Vascular Protocol
Metoprolol (Lopressor) 5 mg IV over 2 min x 3 doses at 5 minutes intervals (total 15 mg over 15 min)
Metoprolol (Lopressor) 50 mg PO BID. First PO dose to be given 10 minutes after final intravenous dose. (Continue upon transfer to floor)
Morphine Sulfate 2-4 mg IV q10min PRN chest pain
Nitroglycerin (1/150) 0.4 mg SL q5 min x 3 PRN chest pain
Nitrogylcerin 0.4 mg/hr patch one time only for chest pain
Nitroglycerin Infusion 10 mcg/min titrate to pain & SBP > 90 mm Hg (Continue upon transfer to floor)
LABS
STAT collect
 Troponin I
 Myoglobin
 Hemogram (CBC) platelet count
 INR/PTT
 Basic Metabolic Panel (includes: sodium, potassium, CO2, glucose, BUN, Creatinine, calcium, anion gap)
 Troponin I in 4 hours after first draw
 Myoglobin in 4 hours after first draw
E. DIAGNOSTIC IMAGING
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Chest X-Ray PA/Lat STAT
F. PROCEDURES
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EKG 12 lead STAT and repeat q30min while in Emergency Room per MD
Stress Echo if Troponin I / Myoglobin negative at least 6 hours after the onset of chest pain or with cardiology approval. Return to the
Emergency Department following Stress Echo.
G. RESPIRATORY THERAPY
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Nasal O2 at 2-4 L/min to keep O2 sats >94%
H. CONSULTS
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Consult Cardiology for consideration of early cath
I. DISPOSITION
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Admit to CSC/CCU with old chart.
MD SIGNATURE____________________________PAGER #__________________DATE:________________
FORM #476558
FAIRVIEW HEALTH SYSTEM-PHYSICIAN ORDERS
EMERGENCY DEPARTMENT CHEST PAIN NON-STEMI MODERATE-HIGH RISK ORDERS
SEP/2003
ORIGINAL: Medical Record
COPY: Pharmacy
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