Myocardial Infarction and Unstable Angina

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1. Admit to: Coronary care unit

2. Diagnosis: Rule out myocardial infarction

3 Condition:

4. Vital signs: q1h. Call physician if pulse >90,<60; BP >150/90, <90/60; R>25, <12; T >38.5°C.

5. Activity: Bed rest with bedside commode.

7. Nursing: Guaiac stools. If patient has chest pain, obtain 12-lead ECG and call physician.

8. Diet: Cardiac diet, 1-2 gm sodium, low fat, low cholesterol diet. No caffeine or temperature extremes.

9. IV Fluids: D5W at TKO

10. Special Medications: -Oxygen 2-4 L/min by NC.

-Aspirin 325 mg PO, chew and swallow, then 160 mg PO qd OR -Clopidogrel (Plavix) 300 mg PO x 1, then 75 mg PO qd (if allergic to aspirin). -Nitroglycerine infusion 15 mcg IV bolus, then 10 mcg/min infusion (50 mg in 250-500 mL D5W, 100-200 mcg/mL). Titrate to control symptoms in 5-10 mcg/min steps, up to 200-300 mcg/min; maintain systolic BP >90 OR -Nitroglycerine SL, 0.4 mg (0.15-0.6 mg) SL q5min until pain free (up to 3 tabs) OR

-Nitroglycerin spray (0.4 mg/aerosol spray) 1 -2 sprays under the tongue q 5min; MR x 2.

-Heparin 75 U/kg IV push, then 15 U/kg/hr by continuous IV infusion. -aPTTq6h x 4, then qd. Repeat aPTT 6 hours after each heparin dosage change.

Glycoprotein IIb/IIIa Blockers for Acute Coronary Syndromes:

-Eptifibatide (Integrilin) 180mcg/kg IVP, then 2 mcg/kg/min for 72 hours. -Tirofiban (Aggrastat) 0.4 mcg/kg/min for 30 min, then 0.1 mcg/kg/min for 48-108 hours.

Glycoprotein IIb/IIIa blockers for Use With Angioplasty:

-Abciximab (ReoPro) 0.25 mg/kg IVP, then 0.125 mcg/kg/min IV infusion for 12 hours.

-Eptifibatide (Integrilin) 180 mcg/kg IVP, then 2 mcg/kg/min for 20-24 hours.

Thrombolytic Therapy

Absolute Contraindications to Thrombolytics: Active internal bleeding, history of hemorrhagic stroke, head trauma, pregnancy, surgery within 2 wk, recent non-compressible vascular puncture, uncontrolled hypertension (>180/110 mmHg).

Relative Contraindications to Thrombolytics: Absence of ST-segment elevation, severe hypertension, cerebrovascular disease, recent surgery (within 2 weeks), cardiopulmonary resuscitation.

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