Streptokinase Streptase

1. 1.5 million IU in 100 mL NS IV over 60 min. Pretreat with diphenhydramine (Benadryl) 50 mg IV push AND

Methylprednisolone (Soln-Medrol) 250 mg IV push.

2. Check fibrinogen level now and q6h for 24h until level >100 mg/dL.

3. No IM or arterial punctures, watch IV for bleeding. Angiotensin Converting Enzyme Inhibitors:

-Captopril (Capoten) initial dose 6.25 mg PO; after 2 hours, increase to 12.5 mg; after 6-8 hours, increase to 25 mg, then increase to 50 mg bid on day 2 OR

-Lisinopril (Zestril, Prinivil) 5 mg PO x 1 dose, then 10 mg qd, then 10-20 mg bid.

-Enalapril (Vasotec) 2.5 mg PO x 1, then 5 mg qd. Increase dose to max dose of 10-20 mg bid. Long-acting Nitrates:

-Nitroglycerin patch 0.2 mg/hr qd. Allow for nitrate-free period to prevent tachyphylaxis.

-Isosorbide dinitrate (Isordil) 10-60 mg PO tid [5,10,20, 30,40 mg] OR -Isosorbide mononitrate (Imdur) 30-60 mg PO qd. Beta-Blockers: Contraindicated in cardiogenic shock.

-Metoprolol (Lopressor) 5 mg IV q2-5min x 3 doses; then 25 mg PO q6h for 48h, then 100 mg PO q12h; keep HR <60/min, hold if systolic BP <100 mmHg OR

-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes, followed by 50-100 mg PO qd OR

-Esmolol hydrochloride (Brevibloc) 500 mcg/kg IV over 1 min, then 50 mcg/kg/min IV infusion, titrated to heart rate >60 bpm (max 300 mcg/kg/min).

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