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Amipci flow sheet feb 06.doc.xls

Acute ST Elevation MI/Potential PCI Pathway
Stephens Memorial Hospital
Emergency Services
Action Taken
Time of ES arrival: Pain on arrival /10
Time of chest pain onset _______ Pain at onset /10 ___
CP greater than 12 hr Y N
Hx:
STAT EKG: given to physician @: ______ ST Elevation Y N
New LBBB Y N
Subsequent EKG Times: ____________ ST Elevation Y N
Subsequent EKG Times: ____________ ST Elevation Y N
Subsequent EKG Times: ____________ ST Elevation Y N
Page "Code Purple"
O2 _______ Liters by N/C Mask
Rescue stand-by PACE called to ES @ ____
PACE Arrival @ __________
Cardiac Monitor Rhythm
IV _____ga _____Site SL N/S @ _____ mL/hr
Order ICU Labs Stat
Portable Chest xray stat
325 mg ASA po ordered not ordered contraindicated
allergic unable to swallow Given/taken prehospital Second IV ____ ga ____ Site SL N/S @ ____ mL/hr
Viagra/Livitra/Cialis within 24 hours? Y N
# 1 Nitro SL 1/150, 1 Q 5 minutes prn chest pain
# 2 Nitro SL 1/150, 1 Q 5 minutes prn chest pain
# 3 Nitro SL 1/150, 1 Q 5 minutes prn chest pain
Morphine Sulfate 2-4 mg IV push for pain Dose given ______ mg
Fentanyl 25-50 Mcg IV push for pain Dose given ______ mg
Stated Ht _______ cms Stated Wt ______ kg
Heparin bolus
IV: 60 units x ___ kg=_______units Max=4000 Units
Call to MMC One-Call 1-207-662-2950

Lytic Contraindicated _____ Primary PCI go to page 2
Physician Signature: ____________________RN Signature: _______________ Acute ST Elevation MI/Potential PCI Pathway
Stephens Memorial Hospital
Emergency Services
Action Taken
TNKase according to protocol if ordered. From one vial of TNKase
reconstitute with 10 mL diluent: Final Concentration = 5 mg/mL. To prevent
precipitation administer over 5 seconds into running NS IV

Patient Weight (kg) TNKase (mg) Volume TNKase to be
Administered (mL)
Lytic & PCI Lytic & Observation
Heparin premix
(25000 units/500 mL D5W) infusion: Start at 1000
units/hour (20 mL/min) or as ordered ____________________
(may hold/dc for pts being transferred)
IV nitroglycerin drip on physician order; titrate to Systolic B/P greater
than 100 (consider nitro paste if IV drip likely to delay transport)
Plavix
300 mg PO Stat ordered not ordered
Benadryl 50 mg po now ordered not ordered
# 1 Metoprolol 5 mg IV push Q 5 mins Reason Withheld:
# 2 Metoprolol 5 mg IV push Reason Withheld:
# 3 Metoprolol 5 mg IV push Reason Withheld:
Call MMC for Nurse to Nurse report 1-207-662-3838 (let it ring)
Report given to _____________________ by __________________

EMTALA form completed
Fax demographic face sheet to MMC 1-207-662-3682
Pt/family information sheet given Family not present
Directions to Maine Medical given
Directions to ____________ Hospital given
Voided before transport ______ mL Has not voided
If time, prepare pt for cardiac cath lab:
Remove clothing
Plastic snap johnnie
Transport O2 and monitor
Bag personal belongings and label valuables envelope
sent with pt given to family
If transferred before lab results, FAX results to (207)662-6385
COPY both pages of this form and send COPY with patient in red
rapid transport folder
Disposition: Admit to ICU Transfer to:_________________
Time of Departure from ES
Physician Signature: ____________________RN Signature: _______________

Source: http://www.mainequalityforum.org/Stephens%20amipci%20flow%20sheet.pdf

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