Addressograph La Crosse, WI 54601 EPIC ORDER # 1531 ADULT TEC POST CARDIAC ARREST HYPOTHERMIA ORDER Instructions for use: Check the box in front of each applicable order and sign at the bottom of the order set. If a default order (box is checked) does not apply, draw a single line through the order and initial. Blank spaces within orders must be completed. Nursing Interventions Place/maintain Nasogastric tube, STAT, one time – today. Suction setting: no suction low medium high Type of suction: no suction intermittent continuous Do not use this order for Nasojejunal feeding tube placement, see orderset 232. Consider placing NG under fluoroscopy for patient with history of gastric surgery. Place/maintain Foley catheter with temperature probe, STAT, one time – today. Nursing to select latex free product if patient has latex allergy. Place/maintain Peripheral IV catheter, STAT, one time – today. Labs Blood Gases Blood Gas – Arterial, STAT, one time – today. Lab collect. Calcium – Ionized, STAT, one time – today. Lab collect. Chemistry AST, STAT, one time – today. Lab collect. Lipase, STAT, one time – today. Lab collect. Lactate, STAT, one time – today. Lab collect. HCG – serum, (Pregnancy test), STAT, one time – today. Lab collect. Electrolytes, STAT, one time – today. Lab collect. Phosphorus, STAT, one time – today. Lab collect. Magnesium, STAT, one time – today. Lab collect. BUN, STAT, one time – today. Lab collect. Glucose, STAT, one time – today. Lab collect. Creatinine, STAT, one time – today. Lab collect. Troponin T, STAT, one time – today. Lab collect. ALT, STAT, one time – today. Lab collect. LDH, STAT, one time – today. Lab collect. Coagulation INR, STAT, one time – today. Lab collect. PTT, STAT, one time – today. Lab collect. Hematology CBC, STAT, one time – today. Lab collect. Imaging Chest x-ray PA or AP, STAT, one time imaging. Reason for exam: _______________________________________________________ Is the patient pregnant: Yes No Uncertain Bedside: Yes No Weight bearing restrictions: non-weight bearing partial weight bearing full weight bearing Page 1 of 2 Addressograph La Crosse, WI 54601 EPIC ORDER # 1531 ADULT TEC POST CARDIAC ARREST HYPOTHERMIA ORDER Diagnostics EKG, 12 – lead, STAT, one time – today. Reason for EKG: ___Post Cardiac Arrest_______________________________________ IV Fluids sodium chloride 0.9% **CHILLED** bolus infusion. 2,000 mL, IV, infused over 30 minutes, times one dose. **Chilled saline is stored in Pyxis refrigerator** Fluid cooled to four degrees centigrade. Infuse 2 liters (2,000 mL) over 30 minutes. Follow fluid bolus with normal temperature Normal Saline at 125 mL per hr. sodium chloride 0.9 % IV infusion. 125 mL per hour, IV, continuous. Start after fluid bolus given. Medications NO BENZODIAZEPINES aspirin suppository, 300 mg, rectal, STAT, times one dose. For rectal use only. fentanyl (SUBLIMAZE) 50 mcg bolus every 30 minutes as needed for sedation while in TEC. Look alike/sound alike drug, use with care. propofol (DIPRIVAN): ** Patient must be on ventilator** Titrate in increments of 5 – 10 mcg/kg/min every 3 – 5 minutes until adequate sedation is achieved. If hemodynamically stable, may bolus from bottle 10 – 20 mg every 3 – 5 minutes for no more than three doses per agitated episode. If greater than three doses are necessary, contact physician for additional sedation orders. (Note: infusion greater than 50 mcg/kg/min must be approved by Pulmonary). Maximum rate of infusion: __________ 50 mcg/kg/min (absolute maximum 80 mcg/kg/min) acetaminophen (TYLENOL) 650 mg solution, STAT, per nasogastric tube, times one dose. busPIRone (BUSPAR) 30 mg tablet, STAT, per nasogastric, times one dose. Do not give to patients who are also taking a monoamine oxidase inhibitor or who have an allergy to buspirone. cisatracurium (NIMBEX) 0.1 mg/kg, times one dose as needed for shivering (must be on ventilator.) No benzodiazepines should be ordered, routine, one time – today. Consults Consult to Cardiology, STAT, one time – today. Reason for Consult: ___Post Cardiac Arrest______________________________________ Signature: _______________________________________ Pager: _______ Date: _______ Time: _______ July 2011 Page 2 of 2