PLACE LABEL HERE

tnkase(tenecteplase)/ACUTE STEMI

orders

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. Is this a CMS inpatient only procedure?  Yes, admit as inpatient, proceed to # 3  No, proceed to # 2

2. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission? Yes, admit as inpatient, proceed to # 3No, place in observation

3. If admitted as inpatient, Inpatient Physician Certification:

Diagnosis: ______

Level of Care: Critical  Intermediate  Acute Care Location/Specialty Unit Preference______

4. Telemetry: If patient Medical/Surgical, must complete form # 36084

5. Isolation:  Contact  Droplet  Airborne For: ______

6.Diagnostics: STAT labs if not already drawn: CBC, CMP, baseline Myoglobin, Troponin I

PT/INR if patient on Coumadin (warfarin)

 PTT  Other: ______

Repeat Troponin I at 6 hrs

7.Portable CXR on admission STAT

8.STAT EKG Time Completed: ______

9.EKG PRN for chest pain unrelieved by Nitroglycerin sublingual x 3 doses

10.Repeat EKG 20 min after initial EKG if pain still present

11.Continuous rhythm monitoring with ST monitoring. May be removed for tests/transport

12.Vital signs with blood pressures in both arms

13.O2per Protocol (form # 34431)

14.NPO except for medications

15.Activity:  Bedrest x 12 hrs  Bedside commode  Bathroom privileges

16.INT

SCHEDULED MEDICATIONS:

17.Aspirin 324 mg (four x 81 mg chewable) po STAT

If unable to swallow, Aspirin 300 mg suppository per rectum STAT

18. Nitroglycerin 0.4 mg SL q 5 min x 3 doses if systolic BP100 or not pain free

19.  Nitroglycerin (200 mcg/ml) IV infusion at 10 mcg/min; may titrate up to 100 mcg/min until relief of symptoms. Maintain systolic BP 100 mm Hg

20.TNKase (tenecteplase) IV stat over 5 sec, then flush line with NS (No dextrose solution)

Assess for contraindications prior to administration (see # 18)

Patient Weight (kg) / TNKase (tenecteplase) (mg) / Volume TNKase (tenecteplase)
to be administered (ml)
Less than 60 kg / 30 mg / 6 ml
60-69 kg / 35 mg / 7 ml
70-79 kg / 40 mg / 8 ml
80-89 kg / 45 mg / 9 ml
Greater than 89 kg / 50 mg / 10 ml

Copy to pharmacyOrder writer’s initials ______

*3-15888*FORM 3-15888 REV. 06/2017 Page 1 of 3

PLACE LABEL HERE

tnkase(tenecteplase)/ACUTE STEMI

orders

Copy to pharmacy Order writer’s initials ______

FORM 3-15888 REV. 06/2017 Page 2 of 3

PLACE LABEL HERE

tnkase(tenecteplase)/ACUTE STEMI

orders

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).

21. If TNKase (tenecteplase) ordered, assess for TNKase (tenecteplase) Contraindications

Absolute Contraindications: If any “Yes”, do not administer TNKase (tenecteplase)

 Yes  NoHistory of intracranial hemorrhage

 Yes  NoKnown structural cerebral vascular lesion (e.g., A-V malformation)

 Yes  NoKnown malignant intracranial neoplasm (primary or metastatic)

 Yes  NoIschemic stroke within 3 months

 Yes  NoSuspected aortic dissection

Yes  NoActive bleeding or bleeding diathesis (excluding menses)

 Yes  NoSignificant closed-head or facial trauma within 3 months

Relative Contraindications (Physician to exercise professional judgment. Benefits should exceed risk)

 Yes  NoHistory of chronic, severe, or poorly controlled HTN

 Yes  NoUncontrolled hypertension on presentation (SBP > 180 or DBP > 110)

 Yes  NoHistory of prior ischemic stroke > 3months, dementia, or known intracranial pathology not covered in contraindications

 Yes  NoTraumatic or prolonged (>10 min) CPR or major surgery within <3 weeks

 Yes  NoInternal bleeding within 2-4 weeks

 Yes  NoNon-compressible vascular punctures

 Yes  NoPregnancy

 Yes  NoActive peptic ulcer disease

 Yes  NoCurrent use of anticoagulants: High INRs increase bleeding risk

22.Anticoagulants:

Heparin Infusion Protocol: LOW Intensity (form # 39815)

Bolus with 60 units/kg (maximum bolus 4,000 units)

Begin Heparin infusion at 12 units/kg/hr (maximum initial rate 1,000 units/hr)

 Lovenox (enoxaparin):

Give between 15 min before to 30 min after the start of TNKase (tenecteplase)

If < 75 y/o: 30 mg IV bolus plus 1 mg/kg SQ (max 100 mg) x 1 dose

If 75 y/o: No IV bolus, give 0.75 mg/kg SQ (max 80 mg) x 1 dose

23.Beta Blocker (for hypertensive patients only) without the following contraindications:

  • High risk for cardiogenic shock
  • 2nd or 3rd degree AV block
  • Severe COPD or active asthma
  • Evidence pf low output state
  • Inferior MI
  • Bradycardia
  • Signs of heart failure

Lopressor (metoprolol) 5 mg IV over 2 min NOW and repeat dose q 5 min x 2 moredoses

(Hold if systolic BP < 90 or HR < 60)

24. Aggrastat (tirofiban) Protocol (form # 35422)

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).

PRN MEDICATIONSSee policy 520-06 for range orders and pain intensity guidelines.

  1. Chest Pain:Chest pain: Nitroglycerin 0.4 mg sublingual q 5 minutes x 3 doses prn

Severe Pain or Chest pain unrelieved with 3 doses of SL or max IV Nitroglycerin

Morphine 2 mg IV q 5 min prn (up to a max of 10 mg in 2 hrs), Hold for excessive sedation. DC if CrCl < 30. DC if Dilaudid ordered.

or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 15 min prn (max 2 mg in 30 min). If CrCl < 30, dose at 0.25 mg). Hold for excessive sedation. DC if Morphine ordered.

  1. Electrolyte Replacement Protocol (form # 21340)
  2. Mild Pain, Temp>100.5F, HA:Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
  3. Moderate Pain:

Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn.

DC if Percocet ordered.

or If patient cannot take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml)

15 ml po q 4 hrs prn instead of Norco. DC if Percocet ordered.

or Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn.

DC if Norco ordered.

and/or  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50,

> 65 y/o old or <50 kg) or 10 mg po q 6 hrs prn (max combined duration of IV

and po ketorolac is 5 days). DC if CrCl < 30.

  1. Severe Pain (Begin when Epidural or PCA has been discontinued)

Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation.

DC if Dilaudid ordered.

or Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg.

Hold for excessive sedation. DC if Morphine ordered.

  1. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV or po q 6 hrs prn

If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)

  1. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn

ADDITIONAL ORDERS:

______

______

______

______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-15888 REV.06/2017 Page 3 of 3

PLACE LABEL HERE

tnkase(tenecteplase)/ACUTE STEMI

orders

Copy to pharmacy

FORM 3-15888 REV.06/2017 Page 3 of 3