"
"
ST-Segment Elevation Myocardial
Infarction
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 immediately,
then aspirin EC 162 mg PO qd OR Clopidogrel
(Plavix) 75 mg PO qd (if allergic to aspirin).
-Nitroglycerin 10 mcg/min infusion (50 mg in 250-500
mL D5W, 100-200 mcg/mL). Titrate to control symp-
toms in 5-10 mcg/min steps, up to 1-3 mcg/kg/min;
maintain systolic BP >90 OR
-Nitroglycerin 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; may repeat x 2.
-Heparin 60 U/kg IV (max 4000 U) push, then 12
U/kg/hr (max 1000 U/hr) by continuous IV infusion
for 48 hours to maintain aPTT of 50-70 seconds.
Check aPTTq6h x 4, then qd. Repeat aPTT 6 hours
after each heparin dosage change.
Thrombolytic Therapy (within first 6 hours of onset of
chest pain)
Absolute Contraindications to Thrombolytics: Active
internal bleeding, suspected aortic dissection, known
intracranial neoplasm, previous intracranial
hemorrhagic stroke at any time, other strokes or
cerebrovascular events within 1 year, head trauma,
pregnancy, recent non-compressible vascular puncture,
uncontrolled hypertension (>180/110 mm Hg).
Relative Contraindications to Thrombolytics: Severe
hypertension, cerebrovascular disease, recent surgery
(within 2 weeks), cardiopulmonary resuscitation.
A.Alteplase (tPA, tissue plasminogen activator,
Activase):
1. 15 mg IV push over 2 min, followed by 0.75 mg/kg
(max 50 mg) IV infusion over 30 min, followed by 0.5
mg/kg (max 35 mg) IV infusion over 60 min (max
total dose 100 mg).
2.Labs: INR/PTT, CBC, fibrinogen.
B. Reteplase (Retavase):
1.10 U IV push over 2 min; repeat second 10 U IV
push after 30 min.
2. Labs: INR, aPTT, CBC, fibrinogen.
C.Tenecteplase (TNKase):
<60 kg30 mg IVP
60-69 kg35 mg IVP
70-79 kg40 mg IVP
80-89 kg 45 mg IVP 90 kg50 mg IVP
C. 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 baseline fibrinogen level and q6h for 24h until
level >100 mg/dL.
3. No IM or arterial punctures, watch IV for bleeding.
Beta-Blockers (within the first 12 hours of onset of
chest pain): 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;
hold if heart rate <60/min or systolic BP <100 mm
Hg OR
-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes,
followed by 50-100 mg PO qd OR
-Esmolol (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).
Angiotensin Converting Enzyme Inhibitor (within the
first 24 hours of onset of chest pain):
-Lisinopril (Zestril, Prinivil) 2.5-5 mg PO qd; titrate to 10-
20 mg qd.
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,
Infarction
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 immediately,
then aspirin EC 162 mg PO qd OR Clopidogrel
(Plavix) 75 mg PO qd (if allergic to aspirin).
-Nitroglycerin 10 mcg/min infusion (50 mg in 250-500
mL D5W, 100-200 mcg/mL). Titrate to control symp-
toms in 5-10 mcg/min steps, up to 1-3 mcg/kg/min;
maintain systolic BP >90 OR
-Nitroglycerin 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; may repeat x 2.
-Heparin 60 U/kg IV (max 4000 U) push, then 12
U/kg/hr (max 1000 U/hr) by continuous IV infusion
for 48 hours to maintain aPTT of 50-70 seconds.
Check aPTTq6h x 4, then qd. Repeat aPTT 6 hours
after each heparin dosage change.
Thrombolytic Therapy (within first 6 hours of onset of
chest pain)
Absolute Contraindications to Thrombolytics: Active
internal bleeding, suspected aortic dissection, known
intracranial neoplasm, previous intracranial
hemorrhagic stroke at any time, other strokes or
cerebrovascular events within 1 year, head trauma,
pregnancy, recent non-compressible vascular puncture,
uncontrolled hypertension (>180/110 mm Hg).
Relative Contraindications to Thrombolytics: Severe
hypertension, cerebrovascular disease, recent surgery
(within 2 weeks), cardiopulmonary resuscitation.
A.Alteplase (tPA, tissue plasminogen activator,
Activase):
1. 15 mg IV push over 2 min, followed by 0.75 mg/kg
(max 50 mg) IV infusion over 30 min, followed by 0.5
mg/kg (max 35 mg) IV infusion over 60 min (max
total dose 100 mg).
2.Labs: INR/PTT, CBC, fibrinogen.
B. Reteplase (Retavase):
1.10 U IV push over 2 min; repeat second 10 U IV
push after 30 min.
2. Labs: INR, aPTT, CBC, fibrinogen.
C.Tenecteplase (TNKase):
<60 kg30 mg IVP
60-69 kg35 mg IVP
70-79 kg40 mg IVP
80-89 kg 45 mg IVP 90 kg50 mg IVP
C. 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 baseline fibrinogen level and q6h for 24h until
level >100 mg/dL.
3. No IM or arterial punctures, watch IV for bleeding.
Beta-Blockers (within the first 12 hours of onset of
chest pain): 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;
hold if heart rate <60/min or systolic BP <100 mm
Hg OR
-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes,
followed by 50-100 mg PO qd OR
-Esmolol (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).
Angiotensin Converting Enzyme Inhibitor (within the
first 24 hours of onset of chest pain):
-Lisinopril (Zestril, Prinivil) 2.5-5 mg PO qd; titrate to 10-
20 mg qd.
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.
pFOX (partial fatty acid oxidation) inhibitors
-Ranolazine (Ranexa) 500 mg twice daily, which can be
increased to a maximum of 1000 mg twice daily as
needed; contraindicated in hepatic impairment or
pre-existing QT prolongation.
Aldosterone Receptor Blocker if EF <40%:
-Eplerenone (Inspra) 24 mg PO qd
-Spironolactone (Aldactone) 25 mg PO qd
Statins:
-Rosuvastatin (Crestor) 10 mg PO qhs OR
-Atorvastatin (Lipitor) 10 mg PO qhs OR
-Pravastatin (Pravachol) 40 mg PO qhs OR
-Simvastatin (Zocor) 40 mg PO qhs OR
-Lovastatin (Mevacor) 20 mg PO qhs OR
-Fluvastatin (Lescol)10-20 mg PO qhs.
11. Symptomatic Medications:
-Morphine sulfate 2-4 mg IV push prn chest pain.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
-Docusate (Colace) 100 mg PO bid.
-Ondansetron (Zofran) 2-4 mg IV q4h prn nausea or
vomiting.
-Famotidine (Pepcid) 20 mg IV/PO bid OR
-Lansoprazole (Prevacid) 30 mg qd.
12.Extras: ECG stat and in 12h and in AM, portable
CXR, impedance cardiography, echocardiogram.
Cardiology consult.
13.Labs: SMA7 and 12, magnesium. Cardiac enzymes:
CPK, CPK-MB, troponin T, myoglobin STAT and q8h
x 3. CBC, INR/PTT, UA.
Non-ST Segment Elevation
Myocardial Infarction (NSTEMI)
and Unstable Angina
1.Admit to: Coronary care unit
2.Diagnosis: Acute coronary syndrome
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. 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 immediately,
then aspirin EC 162 mg PO qd OR
-Clopidogrel (Plavix) 75 mg PO qd (if allergic to aspirin)
OR
-Aspirin 325 mg to chew and swallow, then 81-162 mg
PO qd PLUS clopidogrel 300 mg PO x 1, then 75
mg PO qd.
-Nitroglycerin infusion 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 1-3
mcg/kg/min; maintain systolic BP >90 OR
-Nitroglycerin SL, 0.4 mg 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; may repeat 2 times.
-Heparin 60 U/kg IV push, then 15 U/kg/hr by
continuous IV infusion for 48 hours to maintain aPTT
of 50-70 seconds. Check aPTTq6h x 4, then qd.
Repeat aPTT 6 hours after each dosage change.
Glycoprotein II
/III Blockers in High-Risk Patients and
b a
Those with Planned Percutaneous Coronary
Intervention (PCI):
-Eptifibatide (Integrilin) 180 mcg/kg IVP, then 2
mcg/kg/min for 48-72 hours OR
-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 During PCI:
-Abciximab (ReoPro) 0.25 mg/kg IVP, then 0.125
mcg/kg/min IV infusion for 12 hours OR
-Eptifibatide (Integrilin) 180 mcg/kg IVP, then 2
mcg/kg/min for 18-24 hours.
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 mm Hg
OR
-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes,
followed by 50-100 mg PO qd OR
-Esmolol (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).
Angiotensin Converting Enzyme Inhibitors:
-Lisinopril (Zestril, Prinivil) 2.5-5 mg PO qd; titrate to
10-20 mg qd.
-Benazepril (Lotensin) 10 mg qd OR
-Rampril (Altace) 5-10 mg qd OR
-Perindopril (Aceon) 4-8 mg qd.
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.
pFOX (partial fatty acid oxidation) inhibitors
-Ranolazine (Ranexa) 500 mg twice daily, which can be
increased to a maximum of 1000 mg twice daily as
needed; contraindicated in hepatic impairment or
pre-existing QT prolongation.
Aldosterone Receptor Blocker if EF <40%:
-Eplerenone (Inspra) 24 mg PO qd
-Spironolactone (Aldactone) 25 mg PO qd
Statins:
-Rosuvastatin (Crestor) 10 mg PO qhs OR
-Atorvastatin (Lipitor) 10 mg PO qhs OR
-Pravastatin (Pravachol) 40 mg PO qhs OR
-Simvastatin (Zocor) 40 mg PO qhs OR
-Lovastatin (Mevacor) 20 mg PO qhs OR
-Fluvastatin (Lescol)10-20 mg PO qhs.
11. Symptomatic Medications:
-Morphine sulfate 2-4 mg IV push prn chest pain.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
-Docusate (Colace) 100 mg PO bid.
-Ondansetron (Zofran) 2-4 mg IV q4h prn nausea or
vomiting.
-Famotidine (Pepcid) 20 mg IV/PO bid OR
-Lansoprazole (Prevacid) 30 mg qd.
12.Extras: ECG stat and in 12h and in AM, portable
CXR, impedance cardiography, echocardiogram.
Cardiology consult.
13.Labs: SMA7 and 12, magnesium. Cardiac enzymes:
CPK, CPK-MB, troponin T, myoglobin STAT and q8h
x 3. CBC, INR/PTT, UA.
Non-ST Segment Elevation
Myocardial Infarction (NSTEMI)
and Unstable Angina
1.Admit to: Coronary care unit
2.Diagnosis: Acute coronary syndrome
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. 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 immediately,
then aspirin EC 162 mg PO qd OR
-Clopidogrel (Plavix) 75 mg PO qd (if allergic to aspirin)
OR
-Aspirin 325 mg to chew and swallow, then 81-162 mg
PO qd PLUS clopidogrel 300 mg PO x 1, then 75
mg PO qd.
-Nitroglycerin infusion 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 1-3
mcg/kg/min; maintain systolic BP >90 OR
-Nitroglycerin SL, 0.4 mg 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; may repeat 2 times.
-Heparin 60 U/kg IV push, then 15 U/kg/hr by
continuous IV infusion for 48 hours to maintain aPTT
of 50-70 seconds. Check aPTTq6h x 4, then qd.
Repeat aPTT 6 hours after each dosage change.
Glycoprotein II
/III Blockers in High-Risk Patients and
b a
Those with Planned Percutaneous Coronary
Intervention (PCI):
-Eptifibatide (Integrilin) 180 mcg/kg IVP, then 2
mcg/kg/min for 48-72 hours OR
-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 During PCI:
-Abciximab (ReoPro) 0.25 mg/kg IVP, then 0.125
mcg/kg/min IV infusion for 12 hours OR
-Eptifibatide (Integrilin) 180 mcg/kg IVP, then 2
mcg/kg/min for 18-24 hours.
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 mm Hg
OR
-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes,
followed by 50-100 mg PO qd OR
-Esmolol (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).
Angiotensin Converting Enzyme Inhibitors:
-Lisinopril (Zestril, Prinivil) 2.5-5 mg PO qd; titrate to
10-20 mg qd.
-Benazepril (Lotensin) 10 mg qd OR
-Rampril (Altace) 5-10 mg qd OR
-Perindopril (Aceon) 4-8 mg qd.
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.
Statins:
-Rosuvastatin (Crestor) 10 mg PO qd OR
-Atorvastatin (Lipitor) 10 mg PO qhs OR
-Pravastatin (Pravachol) 40 mg PO qhs OR
-Simvastatin (Zocor) 40 mg PO qhs OR
-Lovastatin (Mevacor) 20 mg PO qhs OR
-Fluvastatin (Lescol)10-20 mg PO qhs.
11. Symptomatic Medications:
-Morphine sulfate 2-4 mg IV push prn chest pain.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
-Docusate (Colace) 100 mg PO bid.
-Ondansetron (Zofran) 2-4 mg IV q4h prn N/V.
-Famotidine (Pepcid) 20 mg IV/PO bid OR
-Lansoprazole (Prevacid) 30 mg qd.
12.Extras: ECG stat and in 12h and in AM, portable
CXR, impedance cardiography, echocardiogram.
Cardiology consult.
13.Labs: SMA7 and 12, magnesium. Cardiac enzymes:
CPK, CPK-MB, troponin T, myoglobin STAT and q6h
for 24h. CBC, INR/PTT, UA.
Congestive Heart Failure
1.Admit to:
2.Diagnosis: Congestive Heart Failure
3.Condition:
4.Vital Signs: q1h. Call physician if P >120; BP >150/100
<80/60; T >38.5 C; R >25, <10.
5.Activity: Bed rest with bedside commode.
6.Nursing: Daily weights, measure inputs and outputs.
Head-of-bed at 45 degrees, legs elevated.
7.Diet: 1-2 gm salt, cardiac diet.
8.IV Fluids: Heparin lock with flush q shift.
9.Special Medications:
-Oxygen 2-4 L/min by NC.
Diuretics:
-Furosemide (Lasix) 10-160 mg IV qd-bid or 20-80 mg
PO qAM-bid [20, 40, 80 mg] or 10-40 mg/hr IV
infusion OR
-Torsemide (Demadex) 10-40 mg IV or PO qd; max 200
mg/day [5, 10, 20, 100 mg] OR
-Bumetanide (Bumex) 0.5-1 mg IV q2-3h until response;
then 0.5-1.0 mg IV q8-24h (max 10 mg/d); or 0.5-2.0
mg PO qAM.
-Metolazone (Zaroxolyn) 2.5-10 mg PO qd, max 20
mg/d; 30 min before loop diuretic [2.5, 5, 10 mg].
ACE Inhibitors:
-Quinapril (Accupril) 5-10 mg PO qd x 1 dose, then 20-
80 mg PO qd in 1 to 2 divided doses [5, 10, 20, 40
mg] OR
-Lisinopril (Zestril, Prinivil) 5-40 mg PO qd [5, 10, 20, 40
mg] OR
-Benazepril (Lotensin) 10-20 mg PO qd-bid, max 80
mg/d [5, 10, 20, 40 mg] OR
-Fosinopril (Monopril) 10-40 mg PO qd, max 80 mg/d
[10, 20 mg] OR
-Ramipril (Altace) 2.5-10 mg PO qd, max 20 mg/d [1.25,
2.5, 5, 10 mg].
-Captopril (Capoten) 6.25-50 mg PO q8h [12.5,
25,50,100 mg] OR
-Enalapril (Vasotec) 1.25-5 mg slow IV push q6h or 2.5-
20 mg PO bid [5,10,20 mg] OR
-Moexipril (Univasc) 7.5 mg PO qd x 1 dose, then 7.5-
15 mg PO qd-bid [7.5, 15 mg tabs] OR
-Trandolapril (Mavik) 1 mg qd x 1 dose, then 2-4 mg qd
[1, 2, 4 mg tabs].
Angiotensin-II Receptor Blockers:
-Irbesartan (Avapro) 150 mg qd, max 300 mg qd [75,
150, 300 mg].
-Losartan (Cozaar) 25-50 mg bid [25, 50 mg].
-Valsartan (Diovan) 80 mg qd; max 320 mg qd [80, 160
mg].
-Candesartan (Atacand) 8-16 mg qd-bid [4, 8, 16, 32
mg].
-Telmisartan (Micardis) 40-80 mg qd [40, 80 mg].
Adosterone Receptor Blockers:
-Spironolactose (Aldactone) 25 mg PO qd
-Eplerenone (Inspra) 25 mg PO qd.
Beta-Blockers:
-Carvedilol (Coreg) 1.625-3.125 mg PO bid, then slowly
increase the dose every 2 weeks to target dose of 25-
50 mg bid [tab 3.125, 6.25, 12.5, 25 mg] OR
-Metoprolol (Lopressor) start at 12.5 mg bid, then slowly
increase to target dose of 100 mg bid [50, 100 mg]
OR
-Bisoprolol (Zebeta) start at 1.25 mg qd, then slowly
increase to target of 10 mg qd [5,10 mg] OR
-Metoprolol XL (Toprol XL) 50-100 mg PO qd.
Digoxin (Lanoxin) 0.125-0.25 mg PO or IV qd [0.125,
0.25, 0.5 mg].
Inotropic Agents:
-Dobutamine (Dobutrex) 2.5-10 mcg/kg/min IV, max of
14 mcg/kg/min (500 mg in 250 mL D5W, 2 mcg/mL)
OR
-Dopamine (Intropin) 3-15 mcg/kg/min IV (400 mg in
250 cc D5W, 1600 mcg/mL), titrate to CO >4, CI >2;
systolic >90 OR
-Milrinone (Primacor) 0.375 mcg/kg/min IV infusion (40
mg in 200 mL NS, 0.2 mg/mL); titrate to 0.75
mgc/kg/min; arrhythmogenic; may cause hypotension.
Vasodilators:
Statins:
-Rosuvastatin (Crestor) 10 mg PO qd OR
-Atorvastatin (Lipitor) 10 mg PO qhs OR
-Pravastatin (Pravachol) 40 mg PO qhs OR
-Simvastatin (Zocor) 40 mg PO qhs OR
-Lovastatin (Mevacor) 20 mg PO qhs OR
-Fluvastatin (Lescol)10-20 mg PO qhs.
11. Symptomatic Medications:
-Morphine sulfate 2-4 mg IV push prn chest pain.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
-Docusate (Colace) 100 mg PO bid.
-Ondansetron (Zofran) 2-4 mg IV q4h prn N/V.
-Famotidine (Pepcid) 20 mg IV/PO bid OR
-Lansoprazole (Prevacid) 30 mg qd.
12.Extras: ECG stat and in 12h and in AM, portable
CXR, impedance cardiography, echocardiogram.
Cardiology consult.
13.Labs: SMA7 and 12, magnesium. Cardiac enzymes:
CPK, CPK-MB, troponin T, myoglobin STAT and q6h
for 24h. CBC, INR/PTT, UA.
Congestive Heart Failure
1.Admit to:
2.Diagnosis: Congestive Heart Failure
3.Condition:
4.Vital Signs: q1h. Call physician if P >120; BP >150/100
<80/60; T >38.5 C; R >25, <10.
5.Activity: Bed rest with bedside commode.
6.Nursing: Daily weights, measure inputs and outputs.
Head-of-bed at 45 degrees, legs elevated.
7.Diet: 1-2 gm salt, cardiac diet.
8.IV Fluids: Heparin lock with flush q shift.
9.Special Medications:
-Oxygen 2-4 L/min by NC.
Diuretics:
-Furosemide (Lasix) 10-160 mg IV qd-bid or 20-80 mg
PO qAM-bid [20, 40, 80 mg] or 10-40 mg/hr IV
infusion OR
-Torsemide (Demadex) 10-40 mg IV or PO qd; max 200
mg/day [5, 10, 20, 100 mg] OR
-Bumetanide (Bumex) 0.5-1 mg IV q2-3h until response;
then 0.5-1.0 mg IV q8-24h (max 10 mg/d); or 0.5-2.0
mg PO qAM.
-Metolazone (Zaroxolyn) 2.5-10 mg PO qd, max 20
mg/d; 30 min before loop diuretic [2.5, 5, 10 mg].
ACE Inhibitors:
-Quinapril (Accupril) 5-10 mg PO qd x 1 dose, then 20-
80 mg PO qd in 1 to 2 divided doses [5, 10, 20, 40
mg] OR
-Lisinopril (Zestril, Prinivil) 5-40 mg PO qd [5, 10, 20, 40
mg] OR
-Benazepril (Lotensin) 10-20 mg PO qd-bid, max 80
mg/d [5, 10, 20, 40 mg] OR
-Fosinopril (Monopril) 10-40 mg PO qd, max 80 mg/d
[10, 20 mg] OR
-Ramipril (Altace) 2.5-10 mg PO qd, max 20 mg/d [1.25,
2.5, 5, 10 mg].
-Captopril (Capoten) 6.25-50 mg PO q8h [12.5,
25,50,100 mg] OR
-Enalapril (Vasotec) 1.25-5 mg slow IV push q6h or 2.5-
20 mg PO bid [5,10,20 mg] OR
-Moexipril (Univasc) 7.5 mg PO qd x 1 dose, then 7.5-
15 mg PO qd-bid [7.5, 15 mg tabs] OR
-Trandolapril (Mavik) 1 mg qd x 1 dose, then 2-4 mg qd
[1, 2, 4 mg tabs].
Angiotensin-II Receptor Blockers:
-Irbesartan (Avapro) 150 mg qd, max 300 mg qd [75,
150, 300 mg].
-Losartan (Cozaar) 25-50 mg bid [25, 50 mg].
-Valsartan (Diovan) 80 mg qd; max 320 mg qd [80, 160
mg].
-Candesartan (Atacand) 8-16 mg qd-bid [4, 8, 16, 32
mg].
-Telmisartan (Micardis) 40-80 mg qd [40, 80 mg].
Adosterone Receptor Blockers:
-Spironolactose (Aldactone) 25 mg PO qd
-Eplerenone (Inspra) 25 mg PO qd.
Beta-Blockers:
-Carvedilol (Coreg) 1.625-3.125 mg PO bid, then slowly
increase the dose every 2 weeks to target dose of 25-
50 mg bid [tab 3.125, 6.25, 12.5, 25 mg] OR
-Metoprolol (Lopressor) start at 12.5 mg bid, then slowly
increase to target dose of 100 mg bid [50, 100 mg]
OR
-Bisoprolol (Zebeta) start at 1.25 mg qd, then slowly
increase to target of 10 mg qd [5,10 mg] OR
-Metoprolol XL (Toprol XL) 50-100 mg PO qd.
Digoxin (Lanoxin) 0.125-0.25 mg PO or IV qd [0.125,
0.25, 0.5 mg].
Inotropic Agents:
-Dobutamine (Dobutrex) 2.5-10 mcg/kg/min IV, max of
14 mcg/kg/min (500 mg in 250 mL D5W, 2 mcg/mL)
OR
-Dopamine (Intropin) 3-15 mcg/kg/min IV (400 mg in
250 cc D5W, 1600 mcg/mL), titrate to CO >4, CI >2;
systolic >90 OR
-Milrinone (Primacor) 0.375 mcg/kg/min IV infusion (40
mg in 200 mL NS, 0.2 mg/mL); titrate to 0.75
mgc/kg/min; arrhythmogenic; may cause hypotension.
Vasodilators:
-Nitroglycerin 5 mcg/min IV infusion (50 mg in 250 mL
D5W). Titrate in increments of 5 mcg/min to contro
symptoms and maintain systolic BP >90 mmHg.
-Nesiritide (Natrecor) 2 mcg/kg IV load over 1 min, then
0.010 mcg/kg/min IV infusion. Titrate in increments o
0.005 mcg/kg/min q3h to max 0.03 mcg/kg/min IV
infusion.
-Isosorbide dinitrate/hydralazine (BiDil), 20 mg/37.5
mg tabs, 1-2 tabs tid; shown to decrease mortality
in black patients with heart failure when added to
standard treatment.
Potassium:
-KCL (Micro-K) 20-60 mEq PO qd if the patient is
taking loop diuretics.
Pacing:
-Synchronized biventricular pacing if ejection fraction
<40% and QRS duration >135 msec.
10. Symptomatic Medications:
-Morphine sulfate 2-4 mg IV push prn dyspnea or
anxiety.
-Heparin 5000 U SQ q12h or enoxaparin (Lovenox) 1
mg/kg SC q12h.
-Docusate (Colace) 100-200 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h OR
-Lansoprazole (Prevacid) 30 mg qd.
11. Extras: CXR PA and LAT, ECG now and repeat if
chest pain or palpitations, impedance cardiography,
echocardiogram.
12. Labs: SMA 7&12, CBC; B-type natriuretic peptide
(BNP), cardiac enzymes: CPK, CPK-MB, troponin T,
myoglobin STAT and q6h for 24h. Repeat SMA 7 in
AM. UA.
Supraventricular Tachycardia
1.Admit to:
2.Diagnosis: PSVT
3.Condition:
4.Vital Signs: q1h. Call physician if BP >160/90, <90-
/60; apical pulse >130, <50; R >25, <10; T >38.5 C
5.Activity: Bedrest with bedside commode.
6.Nursing:
7.Diet: Low fat, low cholesterol, no caffeine.
8.IV Fluids: D5W at TKO.
9. Special Medications:
Attempt vagal maneuvers (Valsalva maneuver) before
drug therapy.
Cardioversion (if unstable or refractory to drug therapy)
1.NPO for 6h, digoxin level must be less than 2.4
and potassium and magnesium must be normal.
2.Midazolam (Versed) 2-5 mg IV push.
3.If stable, cardiovert with synchronized 10-50 J,
and increase by 50 J increments if necessary. If
unstable, start with 100 J, then increase to 200 J
and 360 J.
Pharmacologic Therapy of Supraventricular
Tachycardia:
-Adenosine (Adenocard) 6 mg rapid IV over 1-2 sec,
followed by saline flush, may repeat 12 mg IV after
2-3 min, up to max of 30 mg total OR
-Verapamil (Isoptin) 2.5-5 mg IV over 2-3 min (may
give calcium gluconate 1 gm IV over 3-6 min prior
to verapamil); then 40-120 mg PO q8h [40, 80,
120 mg] or verapamil SR 120-240 mg PO qd [120,
180, 240 mg] OR
-Esmolol(Brevibloc) 500 mcg/kg IV over 1 min, then
50 mcg/kg/min IV infusion, titrated to HR of <80
(max of 300 mcg/kg/min) OR
-Diltiazem (Cardizem) 0.25 mg/kg IV over 2-5
minutes, followed by 5 mg/h IV infusion. Titrate to
max 15 mg/h; then diltiazem-CD (Cardizem-CD)
120-240 mg PO qd OR
-Metoprolol (Lopressor) 5 mg IVP q4-6h; then 50-100
mg PO bid, or metoprolol XL (Toprol-XL) 50-100
mg PO qd OR
-Digoxin (Lanoxin) 0.25 mg q4h as needed; up to 1.0-
1.5 mg; then 0.125-0.25 mg PO qd.
10.Symptomatic Medications:
-Lorazepam (Ativan) 1-2 mg PO tid prn anxiety.
11.Extras: Portable CXR, ECG; repeat if chest pain.
Cardiology consult.
12.Labs: CBC, SMA 7 & 12, Mg, thyroid panel. UA.
Ventricular Arrhythmias
1.Ventricular Fibrillation and Tachycardia:
-If unstable (see ACLS protocol): Defibrillate with
unsynchronized 200 J, then 300 J.
-Oxygen 100% by mask.
-Lidocaine (Xylocaine) loading dose 75-100 mg IV,
then 2-4 mg/min IV OR
-Amiodarone (Cordarone) 300 mg in 100 mL of D5W,
IV infusion over 10 min, then 900 mg in 500 mL of
D5W, at 1 mg/min for 6 hrs, then at 0.5 mg/min
thereafter; or 400 mg PO q8h x 14 days, then 200-
400 mg qd.
-Also see “other antiarrhythmics” below.
2.Torsades de Pointes Ventricular Tachycardia:
-Correct underlying causes, including
hypomagnesemia, and hypokalemia, and consider
discontinuing quinidine, procainamide, disopyr-
amide, moricizine, amiodarone, sotalol, ibutilide,
phenothiazine, haloperidol, tricyclic and tetracyclic
antidepressants, ketoconazole, itraconazole,
D5W). Titrate in increments of 5 mcg/min to contro
symptoms and maintain systolic BP >90 mmHg.
-Nesiritide (Natrecor) 2 mcg/kg IV load over 1 min, then
0.010 mcg/kg/min IV infusion. Titrate in increments o
0.005 mcg/kg/min q3h to max 0.03 mcg/kg/min IV
infusion.
-Isosorbide dinitrate/hydralazine (BiDil), 20 mg/37.5
mg tabs, 1-2 tabs tid; shown to decrease mortality
in black patients with heart failure when added to
standard treatment.
Potassium:
-KCL (Micro-K) 20-60 mEq PO qd if the patient is
taking loop diuretics.
Pacing:
-Synchronized biventricular pacing if ejection fraction
<40% and QRS duration >135 msec.
10. Symptomatic Medications:
-Morphine sulfate 2-4 mg IV push prn dyspnea or
anxiety.
-Heparin 5000 U SQ q12h or enoxaparin (Lovenox) 1
mg/kg SC q12h.
-Docusate (Colace) 100-200 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h OR
-Lansoprazole (Prevacid) 30 mg qd.
11. Extras: CXR PA and LAT, ECG now and repeat if
chest pain or palpitations, impedance cardiography,
echocardiogram.
12. Labs: SMA 7&12, CBC; B-type natriuretic peptide
(BNP), cardiac enzymes: CPK, CPK-MB, troponin T,
myoglobin STAT and q6h for 24h. Repeat SMA 7 in
AM. UA.
Supraventricular Tachycardia
1.Admit to:
2.Diagnosis: PSVT
3.Condition:
4.Vital Signs: q1h. Call physician if BP >160/90, <90-
/60; apical pulse >130, <50; R >25, <10; T >38.5 C
5.Activity: Bedrest with bedside commode.
6.Nursing:
7.Diet: Low fat, low cholesterol, no caffeine.
8.IV Fluids: D5W at TKO.
9. Special Medications:
Attempt vagal maneuvers (Valsalva maneuver) before
drug therapy.
Cardioversion (if unstable or refractory to drug therapy)
1.NPO for 6h, digoxin level must be less than 2.4
and potassium and magnesium must be normal.
2.Midazolam (Versed) 2-5 mg IV push.
3.If stable, cardiovert with synchronized 10-50 J,
and increase by 50 J increments if necessary. If
unstable, start with 100 J, then increase to 200 J
and 360 J.
Pharmacologic Therapy of Supraventricular
Tachycardia:
-Adenosine (Adenocard) 6 mg rapid IV over 1-2 sec,
followed by saline flush, may repeat 12 mg IV after
2-3 min, up to max of 30 mg total OR
-Verapamil (Isoptin) 2.5-5 mg IV over 2-3 min (may
give calcium gluconate 1 gm IV over 3-6 min prior
to verapamil); then 40-120 mg PO q8h [40, 80,
120 mg] or verapamil SR 120-240 mg PO qd [120,
180, 240 mg] OR
-Esmolol(Brevibloc) 500 mcg/kg IV over 1 min, then
50 mcg/kg/min IV infusion, titrated to HR of <80
(max of 300 mcg/kg/min) OR
-Diltiazem (Cardizem) 0.25 mg/kg IV over 2-5
minutes, followed by 5 mg/h IV infusion. Titrate to
max 15 mg/h; then diltiazem-CD (Cardizem-CD)
120-240 mg PO qd OR
-Metoprolol (Lopressor) 5 mg IVP q4-6h; then 50-100
mg PO bid, or metoprolol XL (Toprol-XL) 50-100
mg PO qd OR
-Digoxin (Lanoxin) 0.25 mg q4h as needed; up to 1.0-
1.5 mg; then 0.125-0.25 mg PO qd.
10.Symptomatic Medications:
-Lorazepam (Ativan) 1-2 mg PO tid prn anxiety.
11.Extras: Portable CXR, ECG; repeat if chest pain.
Cardiology consult.
12.Labs: CBC, SMA 7 & 12, Mg, thyroid panel. UA.
Ventricular Arrhythmias
1.Ventricular Fibrillation and Tachycardia:
-If unstable (see ACLS protocol): Defibrillate with
unsynchronized 200 J, then 300 J.
-Oxygen 100% by mask.
-Lidocaine (Xylocaine) loading dose 75-100 mg IV,
then 2-4 mg/min IV OR
-Amiodarone (Cordarone) 300 mg in 100 mL of D5W,
IV infusion over 10 min, then 900 mg in 500 mL of
D5W, at 1 mg/min for 6 hrs, then at 0.5 mg/min
thereafter; or 400 mg PO q8h x 14 days, then 200-
400 mg qd.
-Also see “other antiarrhythmics” below.
2.Torsades de Pointes Ventricular Tachycardia:
-Correct underlying causes, including
hypomagnesemia, and hypokalemia, and consider
discontinuing quinidine, procainamide, disopyr-
amide, moricizine, amiodarone, sotalol, ibutilide,
phenothiazine, haloperidol, tricyclic and tetracyclic
antidepressants, ketoconazole, itraconazole,
bepridil.
-Magnesium sulfate 1-4 gm in IV bolus over 5-1
or infuse 3-20 mg/min for 7-48h until QTc int
<440 msec.
-Isoproterenol (Isuprel), 2-20 mcg/min (2 mg in
mL D5W, 4 mcg/mL).
-Consider ventricular pacing and/or cardioversio
3. Other Antiarrhythmics:
Class I:
-Moricizine (Ethmozine) 200-300 mg PO q8h, m
900 mg/d [200, 250, 300 mg].
Class Ia:
-Quinidine gluconate (Quinaglute) 324-648 mg
q8-12h [324 mg].
-Procainamide (Procan, Procanbid)
IV: 15 mg/kg IV loading dose at 20 mg/min,
followed by 2-4 mg/min continuous IV infusio
PO: 500 mg (nonsustained release) PO q2h
doses, then Procanbid 1-2 gm PO q12h [50
1000 mg].
-Disopyramide (Norpace, Norpace CR) 100-300
PO q6-8h [100, 150, mg] or disopyramide C
150 mg PO bid [100, 150 mg].
Class Ib:
-Lidocaine (Xylocaine) 75-100 mg IV, then 2-4
IV
-Mexiletine (Mexitil) 100-200 mg PO q8h, max 1
mg/d [150, 200, 250 mg].
-Tocainide (Tonocard) loading 400-600 mg PO,
400-600 mg PO q8-12h (1200-1800 mg/d) P
divided doses q8-12h [400, 600 mg].
-Phenytoin (Dilantin), loading dose 100-300 mg
given as 50 mg in NS over 10 min IV q5min,
100 mg IV q5min prn.
Class Ic:
-Flecainide (Tambocor) 50-100 mg PO q12h, m
400 mg/d [50, 100, 150 mg].
-Propafenone (Rythmol) 150-300 mg PO q8h, m
1200 mg/d [150, 225, 300 mg].
Class II:
-Propranolol (Inderal) 1-3 mg IV in NS (max 0.1
mg/kg) or 20-80 mg PO tid-qid [10, 20, 40, 6
mg]; propranolol-LA (Inderal-LA), 80-120 mg
qd [60, 80, 120, 160 mg]
-Esmolol (Brevibloc) loading dose 500 mcg/kg o
min, then 50-200 mcg/kg/min IV infusion
-Atenolol (Tenormin) 50-100 mg/d PO [25, 50, 1
mg].
-Nadolol (Corgard) 40-100 mg PO qd-bid [20, 4
120, 160 mg].
-Metoprolol (Lopressor) 50-100 mg PO bid-tid [
100 mg], or metoprolol XL (Toprol-XL) 50-20
PO qd [50, 100, 200 mg].
Class III:
-Amiodarone (Cordarone), PO loading 400-120
in divided doses for 2-4 weeks, then 200-40
PO qd (5-10 mg/kg) [200 mg] or amiodarone
(Cordarone) 300 mg in 100 mL of D5W, IV
infusion over 10-20 min, then 900 mg in 500
D5W, at 1 mg/min for 6 hrs, then at 0.5 mg/
thereafter.
-Sotalol (Betapace) 40-80 mg PO bid, max 320
in 2-3 divided doses [80, 160 mg].
4.Extras: CXR, ECG, Holter monitor, signal avera
ECG, cardiology consult.
5.Labs: SMA 7&12, Mg, calcium, CBC, drug level
Hypertensive Emergencies
1.Admit to:
2.Diagnosis: Hypertensive emergencies
3.Condition:
4.Vital Signs: q30min until BP controlled, then q4
5.Activity: Bed rest
6.Nursing: Intra-arterial BP monitoring, daily weig
inputs and outputs.
7.Diet: Clear liquids.
8.IV Fluids: D5W at TKO.
9.Special Medications:
-Nitroprusside sodium 0.25-10 mcg/kg/min IV (5
in 250 mL of D5W), titrate to desired BP
-Labetalol (Trandate, Normodyne) 20 mg IV bol
(0.25 mg/kg), then 20-80 mg boluses IV q10
15min, titrate to desired BP or continuous IV
sion of 1.0-2.0 mg/min, titrate to desired BP.
in patients with thoracic or aortic abdominal
aneurysm.
-Fenoldopam (Corlopam) 0.01mcg/kg/min IV inf
Adjust dose by 0.025-0.05 mcg/kg/min q15m
max 0.3 mcg/kg/min. [10 mg in 250 mL D5W
-Nicardipine (Cardene IV) 5 mg/hr IV infusion,
increase rate by 2.5 mg/hr every 15 min up t
mg/hr (25 mg in D5W 250 mL).
-Enalaprilat (Vasotec IV) 1.25- 5.0 mg IV q6h. D
use in presence of acute myocardial infarcti
bilateral renal stenosis.
-Esmolol (Brevibloc) 500 mcg/kg/min IV infusion
minute, then 50 mcg/kg/min; titrate by 50
mcg/kg/min increments to 300 mcg/kg/min (
in D5W 250 mL).
-Clonidine (Catapres), initial 0.1-0.2 mg PO follo
by 0.1 mg per hour until DBP <115 (max tot
dose of 0.8 mg).
-Phentolamine (pheochromocytoma), 5-10 mg I
repeated as needed up to 20 mg.
-Trimethaphan (Arfonad [dissecting aneurysm])
-Magnesium sulfate 1-4 gm in IV bolus over 5-1
or infuse 3-20 mg/min for 7-48h until QTc int
<440 msec.
-Isoproterenol (Isuprel), 2-20 mcg/min (2 mg in
mL D5W, 4 mcg/mL).
-Consider ventricular pacing and/or cardioversio
3. Other Antiarrhythmics:
Class I:
-Moricizine (Ethmozine) 200-300 mg PO q8h, m
900 mg/d [200, 250, 300 mg].
Class Ia:
-Quinidine gluconate (Quinaglute) 324-648 mg
q8-12h [324 mg].
-Procainamide (Procan, Procanbid)
IV: 15 mg/kg IV loading dose at 20 mg/min,
followed by 2-4 mg/min continuous IV infusio
PO: 500 mg (nonsustained release) PO q2h
doses, then Procanbid 1-2 gm PO q12h [50
1000 mg].
-Disopyramide (Norpace, Norpace CR) 100-300
PO q6-8h [100, 150, mg] or disopyramide C
150 mg PO bid [100, 150 mg].
Class Ib:
-Lidocaine (Xylocaine) 75-100 mg IV, then 2-4
IV
-Mexiletine (Mexitil) 100-200 mg PO q8h, max 1
mg/d [150, 200, 250 mg].
-Tocainide (Tonocard) loading 400-600 mg PO,
400-600 mg PO q8-12h (1200-1800 mg/d) P
divided doses q8-12h [400, 600 mg].
-Phenytoin (Dilantin), loading dose 100-300 mg
given as 50 mg in NS over 10 min IV q5min,
100 mg IV q5min prn.
Class Ic:
-Flecainide (Tambocor) 50-100 mg PO q12h, m
400 mg/d [50, 100, 150 mg].
-Propafenone (Rythmol) 150-300 mg PO q8h, m
1200 mg/d [150, 225, 300 mg].
Class II:
-Propranolol (Inderal) 1-3 mg IV in NS (max 0.1
mg/kg) or 20-80 mg PO tid-qid [10, 20, 40, 6
mg]; propranolol-LA (Inderal-LA), 80-120 mg
qd [60, 80, 120, 160 mg]
-Esmolol (Brevibloc) loading dose 500 mcg/kg o
min, then 50-200 mcg/kg/min IV infusion
-Atenolol (Tenormin) 50-100 mg/d PO [25, 50, 1
mg].
-Nadolol (Corgard) 40-100 mg PO qd-bid [20, 4
120, 160 mg].
-Metoprolol (Lopressor) 50-100 mg PO bid-tid [
100 mg], or metoprolol XL (Toprol-XL) 50-20
PO qd [50, 100, 200 mg].
Class III:
-Amiodarone (Cordarone), PO loading 400-120
in divided doses for 2-4 weeks, then 200-40
PO qd (5-10 mg/kg) [200 mg] or amiodarone
(Cordarone) 300 mg in 100 mL of D5W, IV
infusion over 10-20 min, then 900 mg in 500
D5W, at 1 mg/min for 6 hrs, then at 0.5 mg/
thereafter.
-Sotalol (Betapace) 40-80 mg PO bid, max 320
in 2-3 divided doses [80, 160 mg].
4.Extras: CXR, ECG, Holter monitor, signal avera
ECG, cardiology consult.
5.Labs: SMA 7&12, Mg, calcium, CBC, drug level
Hypertensive Emergencies
1.Admit to:
2.Diagnosis: Hypertensive emergencies
3.Condition:
4.Vital Signs: q30min until BP controlled, then q4
5.Activity: Bed rest
6.Nursing: Intra-arterial BP monitoring, daily weig
inputs and outputs.
7.Diet: Clear liquids.
8.IV Fluids: D5W at TKO.
9.Special Medications:
-Nitroprusside sodium 0.25-10 mcg/kg/min IV (5
in 250 mL of D5W), titrate to desired BP
-Labetalol (Trandate, Normodyne) 20 mg IV bol
(0.25 mg/kg), then 20-80 mg boluses IV q10
15min, titrate to desired BP or continuous IV
sion of 1.0-2.0 mg/min, titrate to desired BP.
in patients with thoracic or aortic abdominal
aneurysm.
-Fenoldopam (Corlopam) 0.01mcg/kg/min IV inf
Adjust dose by 0.025-0.05 mcg/kg/min q15m
max 0.3 mcg/kg/min. [10 mg in 250 mL D5W
-Nicardipine (Cardene IV) 5 mg/hr IV infusion,
increase rate by 2.5 mg/hr every 15 min up t
mg/hr (25 mg in D5W 250 mL).
-Enalaprilat (Vasotec IV) 1.25- 5.0 mg IV q6h. D
use in presence of acute myocardial infarcti
bilateral renal stenosis.
-Esmolol (Brevibloc) 500 mcg/kg/min IV infusion
minute, then 50 mcg/kg/min; titrate by 50
mcg/kg/min increments to 300 mcg/kg/min (
in D5W 250 mL).
-Clonidine (Catapres), initial 0.1-0.2 mg PO follo
by 0.1 mg per hour until DBP <115 (max tot
dose of 0.8 mg).
-Phentolamine (pheochromocytoma), 5-10 mg I
repeated as needed up to 20 mg.
-Trimethaphan (Arfonad [dissecting aneurysm])
bepridil.
-Magnesium sulfate 1-4 gm in IV bolus over 5-1
or infuse 3-20 mg/min for 7-48h until QTc int
<440 msec.
-Isoproterenol (Isuprel), 2-20 mcg/min (2 mg in
mL D5W, 4 mcg/mL).
-Consider ventricular pacing and/or cardioversio
3. Other Antiarrhythmics:
Class I:
-Moricizine (Ethmozine) 200-300 mg PO q8h, m
900 mg/d [200, 250, 300 mg].
Class Ia:
-Quinidine gluconate (Quinaglute) 324-648 mg
q8-12h [324 mg].
-Procainamide (Procan, Procanbid)
IV: 15 mg/kg IV loading dose at 20 mg/min,
followed by 2-4 mg/min continuous IV infusio
PO: 500 mg (nonsustained release) PO q2h
doses, then Procanbid 1-2 gm PO q12h [50
1000 mg].
-Disopyramide (Norpace, Norpace CR) 100-300
PO q6-8h [100, 150, mg] or disopyramide C
150 mg PO bid [100, 150 mg].
Class Ib:
-Lidocaine (Xylocaine) 75-100 mg IV, then 2-4
IV
-Mexiletine (Mexitil) 100-200 mg PO q8h, max 1
mg/d [150, 200, 250 mg].
-Tocainide (Tonocard) loading 400-600 mg PO,
400-600 mg PO q8-12h (1200-1800 mg/d) P
divided doses q8-12h [400, 600 mg].
-Phenytoin (Dilantin), loading dose 100-300 mg
given as 50 mg in NS over 10 min IV q5min,
100 mg IV q5min prn.
Class Ic:
-Flecainide (Tambocor) 50-100 mg PO q12h, m
400 mg/d [50, 100, 150 mg].
-Propafenone (Rythmol) 150-300 mg PO q8h, m
1200 mg/d [150, 225, 300 mg].
Class II:
-Propranolol (Inderal) 1-3 mg IV in NS (max 0.1
mg/kg) or 20-80 mg PO tid-qid [10, 20, 40, 6
mg]; propranolol-LA (Inderal-LA), 80-120 mg
qd [60, 80, 120, 160 mg]
-Esmolol (Brevibloc) loading dose 500 mcg/kg o
min, then 50-200 mcg/kg/min IV infusion
-Atenolol (Tenormin) 50-100 mg/d PO [25, 50, 1
mg].
-Nadolol (Corgard) 40-100 mg PO qd-bid [20, 4
120, 160 mg].
-Metoprolol (Lopressor) 50-100 mg PO bid-tid [
100 mg], or metoprolol XL (Toprol-XL) 50-20
PO qd [50, 100, 200 mg].
Class III:
-Amiodarone (Cordarone), PO loading 400-120
in divided doses for 2-4 weeks, then 200-40
PO qd (5-10 mg/kg) [200 mg] or amiodarone
(Cordarone) 300 mg in 100 mL of D5W, IV
infusion over 10-20 min, then 900 mg in 500
D5W, at 1 mg/min for 6 hrs, then at 0.5 mg/
thereafter.
-Sotalol (Betapace) 40-80 mg PO bid, max 320
in 2-3 divided doses [80, 160 mg].
4.Extras: CXR, ECG, Holter monitor, signal avera
ECG, cardiology consult.
5.Labs: SMA 7&12, Mg, calcium, CBC, drug level
Hypertensive Emergencies
1.Admit to:
2.Diagnosis: Hypertensive emergencies
3.Condition:
4.Vital Signs: q30min until BP controlled, then q4
5.Activity: Bed rest
6.Nursing: Intra-arterial BP monitoring, daily weig
inputs and outputs.
7.Diet: Clear liquids.
8.IV Fluids: D5W at TKO.
9.Special Medications:
-Nitroprusside sodium 0.25-10 mcg/kg/min IV (5
in 250 mL of D5W), titrate to desired BP
-Labetalol (Trandate, Normodyne) 20 mg IV bol
(0.25 mg/kg), then 20-80 mg boluses IV q10
15min, titrate to desired BP or continuous IV
sion of 1.0-2.0 mg/min, titrate to desired BP.
in patients with thoracic or aortic abdominal
aneurysm.
-Fenoldopam (Corlopam) 0.01mcg/kg/min IV inf
Adjust dose by 0.025-0.05 mcg/kg/min q15m
max 0.3 mcg/kg/min. [10 mg in 250 mL D5W
-Nicardipine (Cardene IV) 5 mg/hr IV infusion,
increase rate by 2.5 mg/hr every 15 min up t
mg/hr (25 mg in D5W 250 mL).
-Enalaprilat (Vasotec IV) 1.25- 5.0 mg IV q6h. D
use in presence of acute myocardial infarcti
bilateral renal stenosis.
-Esmolol (Brevibloc) 500 mcg/kg/min IV infusion
minute, then 50 mcg/kg/min; titrate by 50
mcg/kg/min increments to 300 mcg/kg/min (
in D5W 250 mL).
-Clonidine (Catapres), initial 0.1-0.2 mg PO follo
by 0.1 mg per hour until DBP <115 (max tot
dose of 0.8 mg).
-Phentolamine (pheochromocytoma), 5-10 mg I
repeated as needed up to 20 mg.
-Trimethaphan (Arfonad [dissecting aneurysm])
-Magnesium sulfate 1-4 gm in IV bolus over 5-1
or infuse 3-20 mg/min for 7-48h until QTc int
<440 msec.
-Isoproterenol (Isuprel), 2-20 mcg/min (2 mg in
mL D5W, 4 mcg/mL).
-Consider ventricular pacing and/or cardioversio
3. Other Antiarrhythmics:
Class I:
-Moricizine (Ethmozine) 200-300 mg PO q8h, m
900 mg/d [200, 250, 300 mg].
Class Ia:
-Quinidine gluconate (Quinaglute) 324-648 mg
q8-12h [324 mg].
-Procainamide (Procan, Procanbid)
IV: 15 mg/kg IV loading dose at 20 mg/min,
followed by 2-4 mg/min continuous IV infusio
PO: 500 mg (nonsustained release) PO q2h
doses, then Procanbid 1-2 gm PO q12h [50
1000 mg].
-Disopyramide (Norpace, Norpace CR) 100-300
PO q6-8h [100, 150, mg] or disopyramide C
150 mg PO bid [100, 150 mg].
Class Ib:
-Lidocaine (Xylocaine) 75-100 mg IV, then 2-4
IV
-Mexiletine (Mexitil) 100-200 mg PO q8h, max 1
mg/d [150, 200, 250 mg].
-Tocainide (Tonocard) loading 400-600 mg PO,
400-600 mg PO q8-12h (1200-1800 mg/d) P
divided doses q8-12h [400, 600 mg].
-Phenytoin (Dilantin), loading dose 100-300 mg
given as 50 mg in NS over 10 min IV q5min,
100 mg IV q5min prn.
Class Ic:
-Flecainide (Tambocor) 50-100 mg PO q12h, m
400 mg/d [50, 100, 150 mg].
-Propafenone (Rythmol) 150-300 mg PO q8h, m
1200 mg/d [150, 225, 300 mg].
Class II:
-Propranolol (Inderal) 1-3 mg IV in NS (max 0.1
mg/kg) or 20-80 mg PO tid-qid [10, 20, 40, 6
mg]; propranolol-LA (Inderal-LA), 80-120 mg
qd [60, 80, 120, 160 mg]
-Esmolol (Brevibloc) loading dose 500 mcg/kg o
min, then 50-200 mcg/kg/min IV infusion
-Atenolol (Tenormin) 50-100 mg/d PO [25, 50, 1
mg].
-Nadolol (Corgard) 40-100 mg PO qd-bid [20, 4
120, 160 mg].
-Metoprolol (Lopressor) 50-100 mg PO bid-tid [
100 mg], or metoprolol XL (Toprol-XL) 50-20
PO qd [50, 100, 200 mg].
Class III:
-Amiodarone (Cordarone), PO loading 400-120
in divided doses for 2-4 weeks, then 200-40
PO qd (5-10 mg/kg) [200 mg] or amiodarone
(Cordarone) 300 mg in 100 mL of D5W, IV
infusion over 10-20 min, then 900 mg in 500
D5W, at 1 mg/min for 6 hrs, then at 0.5 mg/
thereafter.
-Sotalol (Betapace) 40-80 mg PO bid, max 320
in 2-3 divided doses [80, 160 mg].
4.Extras: CXR, ECG, Holter monitor, signal avera
ECG, cardiology consult.
5.Labs: SMA 7&12, Mg, calcium, CBC, drug level
Hypertensive Emergencies
1.Admit to:
2.Diagnosis: Hypertensive emergencies
3.Condition:
4.Vital Signs: q30min until BP controlled, then q4
5.Activity: Bed rest
6.Nursing: Intra-arterial BP monitoring, daily weig
inputs and outputs.
7.Diet: Clear liquids.
8.IV Fluids: D5W at TKO.
9.Special Medications:
-Nitroprusside sodium 0.25-10 mcg/kg/min IV (5
in 250 mL of D5W), titrate to desired BP
-Labetalol (Trandate, Normodyne) 20 mg IV bol
(0.25 mg/kg), then 20-80 mg boluses IV q10
15min, titrate to desired BP or continuous IV
sion of 1.0-2.0 mg/min, titrate to desired BP.
in patients with thoracic or aortic abdominal
aneurysm.
-Fenoldopam (Corlopam) 0.01mcg/kg/min IV inf
Adjust dose by 0.025-0.05 mcg/kg/min q15m
max 0.3 mcg/kg/min. [10 mg in 250 mL D5W
-Nicardipine (Cardene IV) 5 mg/hr IV infusion,
increase rate by 2.5 mg/hr every 15 min up t
mg/hr (25 mg in D5W 250 mL).
-Enalaprilat (Vasotec IV) 1.25- 5.0 mg IV q6h. D
use in presence of acute myocardial infarcti
bilateral renal stenosis.
-Esmolol (Brevibloc) 500 mcg/kg/min IV infusion
minute, then 50 mcg/kg/min; titrate by 50
mcg/kg/min increments to 300 mcg/kg/min (
in D5W 250 mL).
-Clonidine (Catapres), initial 0.1-0.2 mg PO follo
by 0.1 mg per hour until DBP <115 (max tot
dose of 0.8 mg).
-Phentolamine (pheochromocytoma), 5-10 mg I
repeated as needed up to 20 mg.
-Trimethaphan (Arfonad [dissecting aneurysm])
5.Activity: Bed rest.
6.Nursing: Fingerstick glucose.
7.Diet: Regular
8.IV Fluids: Normal saline at TKO.
9.Special medications:
High-Grade AV Block with Syncope:
-Atropine 1 mg IV x 2.
-Isoproterenol 0.5-1 mcg/min initially, then slowly
titrate to 10 mcg/min IV infusion (1 mg in 250 mL
NS).
-Transthoracic pacing.
Drug-Induced Syncope:
-Discontinue vasodilators, centrally acting hypotensive
agents, tranquilizers, antidepressants, and alcohol
use.
Vasovagal Syncope:
-Scopolamine 1.5 mg transdermal patch q3 days.
Postural Syncope:
-Midodrine (ProAmatine) 2.5 mg PO tid, then increase
to 5-10 mg PO tid [2.5, 5 mg]; contraindicated in
coronary artery disease.
-Fludrocortisone 0.1-1.0 mg PO qd.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Docusate sodium (Colace) 100-200 mg PO qhs.
11. Extras: CXR, ECG, 24h Holter monitor,
electrophysiologic study, tilt test, CT/MRI, EEG,
impedance cardiography, echocardiogram.
12. Labs: CBC, SMA 7&12, CPK, CK-MB, troponin T,
myoglobin, Mg, calcium, drug levels. UA, urine drug
screen.
6.Nursing: Fingerstick glucose.
7.Diet: Regular
8.IV Fluids: Normal saline at TKO.
9.Special medications:
High-Grade AV Block with Syncope:
-Atropine 1 mg IV x 2.
-Isoproterenol 0.5-1 mcg/min initially, then slowly
titrate to 10 mcg/min IV infusion (1 mg in 250 mL
NS).
-Transthoracic pacing.
Drug-Induced Syncope:
-Discontinue vasodilators, centrally acting hypotensive
agents, tranquilizers, antidepressants, and alcohol
use.
Vasovagal Syncope:
-Scopolamine 1.5 mg transdermal patch q3 days.
Postural Syncope:
-Midodrine (ProAmatine) 2.5 mg PO tid, then increase
to 5-10 mg PO tid [2.5, 5 mg]; contraindicated in
coronary artery disease.
-Fludrocortisone 0.1-1.0 mg PO qd.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Docusate sodium (Colace) 100-200 mg PO qhs.
11. Extras: CXR, ECG, 24h Holter monitor,
electrophysiologic study, tilt test, CT/MRI, EEG,
impedance cardiography, echocardiogram.
12. Labs: CBC, SMA 7&12, CPK, CK-MB, troponin T,
myoglobin, Mg, calcium, drug levels. UA, urine drug
screen.
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