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A. Protocol
1. Patient arrives with ischemic chest pain/suspected MI:
2. lf patient is highly suspicious for MI, triage directly without assessment. Otherwise, complete triage assessment as usual.
3. Immediately upon arrival obtain 12-lead ECG. Convey ECG directly to Emergency Medicine Attending Physician.
4. Place patient on oxygen (2 liters by nasal cannula, or more, ff clinically indicated), establish peripheral IV access, and perform other nursing interventions appropriate for the patient with presumed ischemic chest pain.
5. Emergency Department Attending Physician assesses patient for:
a. ST segment elevation for 0.1 mV in at least 2 leads, or new LBBB; and
b. Ischemic chest pain syndrome of duration >20 minutes.
If no, proceed to non-thrombolysis protocol, page 4.
If yes, continue:
6. Assess patient for contraindications to thrombolysis:
A. Absolute
a. Active bleeding,
b. Any history of stroke,
c. Major surgery or trauma in past 2 months,
d. Confirmed BP >180/100,
e. Coumadin Rx with known PT >14 sec or IN >1.4,
f. Other major illness (eg, active metastatic cancer),
g. Pregnancy
B. Relative
a. History of peptic ulcer disease, especially within 6 months,
b. Diabetic retinopathy of the hemorrhagic type,
c. Serious advanced illness such as malignancy.
d. CPR > 5 minutes involving extensive chest compression within 2 weeks,
e. Known pericarditis.
OR: Streptokinase (For MI >4 hours, Age >75 years, inferior wall Mr)
h. Thrombolytic therapy with streptokinase (SK):
1. Reconstitute 1.5 MU of SK
2. Infuse over 60 minutes.
i. Thrombolytic therapy with retavase (r-PA):
1. Retavase is administered as a 10 + 10 U double-bolus injection.
2. Each bolus is administered as an intravenous injection over 2 minutes.
3. The second bolus is given 30 minutes after initiation of the first bolus injections.
4. Each bolus injection should be given via an intravenous line in which no other medication is being simultaneously injected of infused.
5. No other medication should be added to the injection solution contained retavase.
6. There is no experience with patients receiving repeat courses of therapy with retavase.
7. Heparin - give IV heparin 5000 units bolus; start continuous infusion of 1000 U/hr with t-PA (with SK, heparin use is optional).
8. Metoprolol: evaluate for any contraindications, including:
a. Heart rate <60/rain, or SBP <90 mmHg,
b. History of asthma or COPD requiring chronic medication,
c. History of LV ejection fraction <30%,
d. PR > 0.24.
If not contraindications, administer intravenous metoprolol 5 mg bolus q2 minutes X 3, or until ttR <55. Check BP between boluses. Administer oral metoprolol 50 mg, 15 minutes after last dose of IV metoprolol.