Stemi alert physician Checklist

Kansas

STEMI ALERT Physician Checklist

Apply Patient Sticker Here

Apply Patient Sticker Here

Date	ED Provider:
Patient Name (if no sticker)	Hospital: Add your Hospital NAME here

STEMI reperfusion “Time to treatment goals”
Door to ECG complete and read by provider: <10 minutes

Door in door out of your facility: < 30 minutes

Fibrinolytic Therapy < 30 minutes

First medical contact (FMC) to device < 120 minutes

	Activate the STEMI ALERT. (customize per facility) Write time when you reviewed the ECG on top of printed ECG and initial. (If unsure of STEMI, talk to Interventional Cardiologist at receiving facility first).
	Immediately call for EMS transport availability. If air is available, notify them of transport STAT. If air is not IMMEDIATELY available, assess other transport options! Add name and contact of your facilities 1^st choice in air and ground transport here, remember to add additional options.
	Have staff call ____________@_____________(PCI receiving facility). Tell operator, “We have a STEMI ALERT at your Hospital name here and need to speak to the Interventional Cardiologist.”
	Please have this information available for Cardiologist, this may impact treatment! Obtain following history from patient and EMS -if possible. Age and DNR status Time of onset of patient’s pain? History of dye or contrast allergy? Primary doctor and / or cardiologist Coumadin use? History of prior MI / stent / CABG / renal failure or current dialysis? CPR, intubation or multiple defibrillations in route? Patient age, weight and height Brief report of Tx and EKG findings
	Have you heard from your transport team? If not, call them again. Have you heard from receiving cardiologist within 10 minutes? If not, call them again.
	In absence of contraindications, fibrinolytics therapy should be administered to STEMI patients within 30 minutes of arrival WHEN the anticipated time between first medical contact to device time exceeds 120 minutes. Consider delays such as; inclement weather or transport not immediately available. Review Thrombolytics Guide Sheet attached to physician blue sheet.
	Order medications. All STEMI patients should be considered for the following: ASA:-325 PO or rectal (only contraindication is true aspirin allergy) Heparin Bolus: 60 units/kg, max 4000 units Plavix 600 mg PO Oxygen to maintain Sa02 > 90% Nitroglycerin 0.4mg SL q 5 min prn (No nitrates in patients who have taken Viagra, Cialis or Levitra within last 72 hours) (If giving lytics refer to lytics sheet for more information on meds) Order pertinent lab
	If you have not heard from your PCI facilities’ INTERVENTIONAL CARDIOLOGIST after 10 minutes and 2 attempts, call the PCI facility (or transfer center) and ask to speak to the GENERAL ON-CALL CARDIOLOGIST.
	Make sure EMTALA forms are done.
	Provide Patient information to STEMI scribe to be copied and sent to receiving hospital with patient: ECG (historical, current and EMS) pertinent lab ED visit physician and nursing notes, including medications given CXR Don’t delay transfer for lab or CXR results – follow with fax
	Write your name on this sheet at top and return (via STEMI packet) to: (add name of person at your facility responsible for STEMI data collection and EMS follow up)

ATTENTION: After STEMI alert is over, place completed Data Sheet A, Physician, Nurse, Scribe checklists back in STEMI alert packet Send Data Sheet B to receiving facility

Resource Numbers: ED Shift Mgr _________ STEMI data collected by: ______________________ Contact number:__________ Physician responsible for review of STEMI patients: ________________________ Contact number: __________ Receiving facility contact/ fax numbers:_____________ EMS contact number to provide patient feedback\ _______________________

Please provide feedback/comments here, for example, what went well, what went wrong in order to improve the next STEMI ALERT. RT -collect and place in mail

Thrombolytics Assessment Worksheet / Checklist

STEMI patients presenting to (your hospital name here) without reasonable expectation of PCI within 90 minutes of presentation should undergo thrombolysis within 30 minutes unless contraindicated” (this recommendation based on AHA/ACC Class I evidence 2013)

In general, short symptom duration, age <75, large infarcts, anterior ST elevation, large reciprocal changes and clear ECG evidence of STEMI indicate patients who may derive the greatest benefit from early administration of thrombolytics if delay to PCI exceeds 1 hour.

I. Consider thrombolytics as the preferred therapy if all the following are “yes”:

• Y / N Transportation time to (your hospital’s designated PCI facility) is likely more than 1 hour

(Usually the case if air transport is not immediately available)

• Y / N Symptoms started less than 3 hours ago?

• Y / N Clear ST elevation in 2 or more contiguous leads >1mm or new LBBB?

(A questionable dx of STEMI-consult Interventional Cardiologist at Receiving facility)

• Y / N Patient has no absolute contraindications to thrombolytics? (listed below)

• Y / N Patient is stable w/o signs of cardiogenic shock? (for shock, PCI is preferred)

II. *Absolute contraindications: Avoid thrombolytics if any answer is “yes”

• 
  Y / N Any prior intracranial hemorrhage (ICH)
  
• 
  Y / N Known structural cerebral vascular lesion (i.e. AVM)
  
• 
  Y / N Know malignant intracranial neoplasm (primary or metastatic)
  
• 
  Y / N Ischemic stroke within 3 months (except acute ischemic stroke within 4.5 hrs.)
  
• 
  Y / N Suspected aortic dissection
  
• 
  Y / N Active bleeding or bleeding diatheses (excluding menses)
  
• 
  Y / N Significant closed head or facial trauma within 3 months?
  
• 
  Y / N Intracranial or intraspinal surgery within 2 months
  
• 
  Y / N Severe uncontrolled hypertension (unresponsive to emergency therapy)?
  

III. *Relative contraindications: benefit of PCI may be > thrombolytics, particularly if multiple factors are present. Reasonably assess combined factors.

• 
  History of chronic severe, poorly controlled hypertension
  
• 
  Severe hypertension on presentation (SBP >180mm Hg or DBP >110 mm Hg)
  
• 
  History of prior ischemic stroke > 3 months
  
• 
  Dementia
  
• 
  Known intracranial pathology not covered in absolute contraindications
  
• 
  Traumatic or prolonged (>10 min) CPR
  
• 
  Recent (within 2-4 weeks) internal bleeding
  
• 
  Internal bleeding within 2-4 weeks but not currently
  
• 
  Noncompressible vascular punctures
  
• 
  Pregnancy
  
• 
  Active peptic ulcer
  
• 
  Oral anticoagulant therapy
  

*2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction
IV. If patient clearly fits criteria for thrombolytic therapy, proceed immediately! If you are not sure, prepare for thrombolysis (mix drug) while waiting to talk to PCI Interventional Cardiologist. Continue to work on transport options. Stable post-lytic patients may not need air transport.

Note: Choice of thrombolytic agent is site dependent. Specific instructions for your site are placed on back of the Thrombolytics Assessment Worksheet

(For example, TNK or tPA)

TNK (Tenecteplase)

tissue plasminogen activator instructions and dosing

Remember, Time = Muscle! Door to needle goal <30 minutes!

Dosing;

TNK is weight based.

TNK is a single bolus injection only.

Patient's Weight TNK dose TNK Volume

a. < 60 Kg 30 mg 6 ml

b. 60-70 Kg 35 mg 7 ml

c. 70-80 Kg 40 mg 8 ml

d. 80-90 Kg 45 mg 9 ml

e. >90 Kg 50 mg 10 ml

Preparation

1. Patient should have an IV of N saline.

2. Remove "shield assembly" from 10cc syringe. Note; do not discard.

3. Withdraw 10 ml of sterile water from (provided) vial using "red hub" device.

4. Gently inject sterile water into TNK vial onto TNK powder.

5. Gently swirl contents; do not shake or agitate. Concentration is 5 mg/ml.

It should be colorless to clear - pale yellow.

6. When the decision to give TNK is made, Heparin should be administered before

or concurrently with TNK.

Administration

1. Withdraw appropriate patient dose from TNK mixture.

2. Stand "shield assembly" vertical on countertop (green cap down) and recap red hub

3. Remove entire shield assembly including red hub.

4. TNK is ready to inject as a bolus through a needleless hub into a saline solution IV line.

5. Inject TNK as bolus over 5 seconds.

6. Discard remaining TNK if physician concurs.

Remember to give Heparin or Lovenox in addition to TNK

ACTIVASE® (Alteplase)

Remember, Time = Muscle! Door to needle goal <30 minutes!
Acute Myocardial Infarction

Administer Activase as soon as possible after the onset of symptoms.

There are two Activase dose regimens for use in the management of acute myocardial

infarction; controlled studies to compare clinical outcomes with these regimens have not

been conducted.

A DOSE OF 150 mg OF ACTIVASE SHOULD NOT BE USED FOR THE TREATMENT OF ACUTE

MYOCARDIAL INFARCTION BECAUSE IT HAS BEEN ASSOCIATED WITH AN INCREASE IN

INTRACRANIAL BLEEDING.

Accelerated Infusion

The recommended total dose is based upon patient weight, not to exceed 100 mg. For patients weighing > 67 kg, the recommended dose administered is 100 mg as a 15 mg intravenous bolus, followed by 50 mg infused over the next 30 minutes, and then 35 mg infused over the next 60 minutes.

For patients weighing <67 kg, the recommended dose is administered as a 15 mg intravenous bolus, followed by 0.75 mg/kg infused over the next 30 minutes not to exceed 50 mg, and then 0.50 mg/kg over the next 60 minutes not to exceed 35 mg. The safety and efficacy of this accelerated infusion of Alteplase regimen has only been investigated with concomitant administration of heparin and aspirin as described in

CLINICAL PHARMACOLOGY.

a. The bolus dose may be prepared in one of the following ways:

1. By removing 15 mL from the vial of reconstituted (1 mg/mL) Activase using a syringe and needle. If this method is used with the 50 mg vials, the syringe should not be primed with air and the needle should be inserted into the Activase vial stopper. If the 100 mg vial is used, the needle should be inserted away from the puncture mark made by the transfer device.

2. By removing 15 mL from a port (second injection site) on the infusion line after the infusion set is primed.

3. By programming an infusion pump to deliver a 15 mL (1 mg/mL) bolus at the initiation of the infusion.

b. The remainder of the Activase dose may be administered as follows:

50 mg vials—administer using either a polyvinyl chloride bag or glass vial and infusion set.

100 mg vial—insert the spike end of an infusion set through the same puncture site created by the transfer device in the stopper of the vial of reconstituted Activase. Peel the clear plastic hanger from the vial label. Hang the Activase vial from the resulting loop.

3-Hour Infusion

The recommended dose is 100 mg administered as 60 mg in the first hour (of which 6 to 10 mg is administered as a bolus), 20 mg over the second hour, and 20 mg over the third hour. For smaller patients (< 65 kg), a dose of 1.25 mg/kg administered over 3 hours, as described above, may be used. Although the value of the use of anticoagulants during and following administration of Activase has not been fully studied, heparin has been administered concomitantly for 24 hours or longer in more than 90% of patients.

Aspirin and/or dipyridamole have been given to patients receiving Alteplase during and/or following heparin treatment.

a. The bolus dose may be prepared in one of the following ways:

1. By removing 6 to 10 mL from the vial of reconstituted (1 mg/mL) Activase using a syringe and needle. If this method is used with the 50 mg vials, the syringe should not be primed with air and the needle should be inserted into the Activase vial stopper. If the 100 mg vial is used, the needle should be inserted away from the

puncture mark made by the transfer device.

2. By removing 6 to 10 mL from a port (second injection site) on the infusion line after the infusion set is primed.

3. By programming an infusion pump to deliver a 6 to 10 mL (1 mg/mL) bolus at the initiation of the infusion.

b. The remainder of the Activase dose may be administered as follows:

50 mg vials—administer using either a polyvinyl chloride bag or glass vial and infusion set.

100 mg vial—insert the spike end of an infusion set through the same puncture site created by the transfer device in the stopper of the vial of reconstituted Activase. Peel the clear plastic hanger from the vial label. Hang the Activase vial from the resulting loop.
Reconstitution and Dilution

Activase should be reconstituted by aseptically adding the appropriate volume of the

accompanying Sterile Water for Injection, USP, to the vial. It is important that Activase be

reconstituted only with Sterile Water for Injection, USP, without preservatives. Do not use

Bacteriostatic Water for Injection, USP. The reconstituted preparation results in a colorless

to pale yellow transparent solution containing Activase 1 mg/mL at approximately pH 7.3.

The osmolality of this solution is approximately 215 mOsm/kg.

Because Activase contains no antibacterial preservatives, it should be reconstituted

immediately before use. The solution may be used for intravenous administration within 8

hours following reconstitution when stored between 2–30°C (36–86°F). Before further

dilution or administration, the product should be visually inspected for particulate matter

and discoloration prior to administration whenever solution and container permit.

Activase may be administered as reconstituted at 1 mg/mL. As an alternative, the

reconstituted solution may be diluted further immediately before administration in an equal

volume of 0.9% Sodium Chloride Injection, USP, or 5% Dextrose Injection, USP, to yield a

concentration of 0.5 mg/mL. Either polyvinyl chloride bags or glass vials are acceptable.

Activase is stable for up to 8 hours in these solutions at room temperature. Exposure to light

has no effect on the stability of these solutions. Excessive agitation during dilution should

be avoided; mixing should be accomplished with gentle swirling and/or slow inversion.

Do not use other infusion solutions, eg, Sterile Water for Injection, USP, or preservativecontaining

solutions for further dilution.

50 mg Vials

Reconstitution should be carried out using a large bore needle (eg, 18 gauge) and a syringe,

directing the stream of Sterile Water for Injection, USP, into the lyophilized cake. DO NOT

USE IF VACUUM IS NOT PRESENT. Slight foaming upon reconstitution is not unusual;

standing undisturbed for several minutes is usually sufficient to allow dissipation of any

large bubbles.

No other medication should be added to infusion solutions containing Activase. Any

unused infusion solution should be discarded.

100 mg Vial

Reconstitution should be carried out using the transfer device provided, adding the contents

of the accompanying 100 mL vial of Sterile Water for Injection, USP, to the contents of the

100 mg vial of Activase powder. Slight foaming upon reconstitution is not unusual; standing

undisturbed for several minutes is usually sufficient to allow dissipation of any large bubbles.

Please refer to the accompanying Instructions for Reconstitution and Administration.

100 mg VIALS DO NOT CONTAIN VACUUM.

100 mg VIAL RECONSTITUTION

1. Use aseptic technique throughout.

2. Remove the protective flip-caps from one vial of Activase and one vial of Sterile Water

for Injection, USP (SWFI).

3. Open the package containing the transfer device by peeling the paper label off the package.

4. Remove the protective cap from one end of the transfer device and keeping the vial of SWFI

upright, insert the piercing pin vertically into the center of the stopper of the vial of SWFI.

5. Remove the protective cap from the other end of the transfer device. DO NOT INVERT

THE VIAL OF SWFI.

6. Holding the vial of Activase upside-down, position it so that the center of the stopper is

directly over the exposed piercing pin of the transfer device.

7. Push the vial of Activase down so that the piercing pin is inserted through the center of

the Activase vial stopper.

8. Invert the two vials so that the vial of Activase is on the bottom (upright) and the vial of

SWFI is upside-down, allowing the SWFI to flow down through the transfer device. Allow

the entire contents of the vial of SWFI to flow into the Activase vial (approximately 0.5 cc

of SWFI will remain in the diluent vial). Approximately 2 minutes are required for this procedure.

9. Remove the transfer device and the empty SWFI vial from the Activase vial. Safely discard

both the transfer device and the empty diluent vial according to institutional procedures.

10.Swirl gently to dissolve the Activase powder. DO NOT SHAKE.

No other medication should be added to infusion solutions containing Activase.

Any unused infusion solution should be discarded.

HOW SUPPLIED

Activase®(Alteplase) is supplied as a sterile, lyophilized powder in 50 mg vials containing

vacuum and in 100 mg vials without vacuum.

Each 50 mg Activase vial (29 million IU) is packaged with diluent for reconstitution (50 mL

Sterile Water for Injection, USP): NDC 50242-044-13.

Each 100 mg Activase vial (58 million IU) is packaged with diluent for reconstitution

(100 mL Sterile Water for Injection, USP), and one transfer device: NDC 50242-085-27.

Storage

Store lyophilized Activase at controlled room temperature not to exceed 30°C (86°F), or

under refrigeration (2–8°C/36–46°F). Protect the lyophilized material during extended

storage from excessive exposure to light.

Do not use beyond the expiration date stamped on the vial.

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NOT PART OF THE MEDICAL RECORD 08.07.13