1. Chest Pain ( R/O ACS)
1. Admit to LSU medicine, Telemetry Attending Dr: _________________ , resident: _________, intern: _________
2. Dx: Chest Pain – R/O MI Contributing Dx:
3. Condition: [ ] Stable [ ] Fair [ ] Serious [ ] Critical 4. VS: Q 4 hr with pulse ox checks Call MD if: P < 50 or > 110, BP < 90/60 or > 150/90, R > 25, chest pain unrelieved with 3 NTG or CP with telemetry changes.
4. Activity: Bed rest with bedside commode
5. Nursing: strict I's/O's Q shift; O2 via NC to keep sats > 93, weight on arrival and each am; STAT EKG for significant chest pain or arrhythmia.
6. Diet: AHA step I cardiac diet without caffeine.
7. IV: Hep-Lock
8. Meds: ASA 325 mg PO now (if not given yet in ER) and Q am. NTG 0.4mg SL prn CP, may repeat Q 5 min until pain free or max 3 Tylenol 500 mg PO Q 4 hr prn HA or pain. Ambien 5 mg PO QHS prn insomnia. Nexium 40mg PO qD
9. Other Meds to consider now: statin, antihypertensives, Lovenox (1mg/kg BID)
10. Labs:1. Cardiac enzymes (CK, CK-MB, troponin) with EKGs on admission (if not done in ER) and 6 hr later for total of 3 (put exact time the blood draws should occur). 2. CBC, BMP, MG, phos, qAM 3. TSH with next blood draw 4. fasting Lipid profile in am. 5. CXR (portable) if not done in ER.
11. potential further cardiac tests in AM:
2. Community-Acquired Pneumonia
3. HF exacerbation
4. Asthma/ COPD exacerbation
5. GI bleed
6. DKA
1. Fluids – Correct fluid deficit rapidly by giving 1-2 Liters bolus and high IVF rate after that. Starte with NS then change to 1/2NS as glucose falls. Finally switch to D51/2NS when glucose falls <200.
2. Insulin – 0.1-0.4 units/kg bolus IV regular insulin followed by 0.1-0.2 units/kg/hr. Aim for a 75-100 drip in serum glucose per hour. Continue insulin drip until acidosis has resolved, AG closes and glucose<200.
3. Electrolytes – Expect them to become abnormal. Stay on top of electrolytes (K & Phos especially) with frequent BMP’s q 2-4 hours initially. Expect K to fall with IVF and insulin. This will likely have to be repleted. Sodium needs to be corrected for level of glucose.
Corrected Na = 0.016(measured glucose-100) + measured Na.
4. Acidosis – due to ketones. Expect that this will gradually resolve with above measures. If there is a persistent serum ketosis as measured by the AG, suspect an ongoing insulin deficit.
7. etc.