Iowa STEMI Transport Record PATIENT LABEL
ACC/AHA Recommended treatment of choice for STEMI: □ Anticipate FMC-to-Device in < 90 minutes Tx by: □ Air □ Ground □ Anticipate FMC-to-Device in < 120 minutes: Tx by: □ Air □ Ground □ Anticipate FMC-to-Device via transfer > 120 minutes: Tx by: □ Air □ Ground evaluate for Lytics (Door-to-Needle < 30 minutes)
TIME
(h:mm) EMS Agency/Unit #: ______Run # ______: Symptom onset:
: EMS Dispatch time:
: EMS Arrival on scene
EMS : EMS at patient side (FMC) : EMS Enroute to hospital : EMS ECG (send copy with patient) Goal: < 10 minutes of FMC
Patient arrival to ER Goal Door In/Door out < 30 mins
:
ED Obtain ECG (send copy with patient) Goal: < 10 minutes of arrival
: ACTIVATION/TRANSFER for STEMI
CALL FOR TRANSPORT 1st Goal ≤ 5 minutes of obvious STEMI EKG □ Cap all IV’s and remove all clothing : Service Called: ______□ Upon pt. transfer: Fax ECG, STEMI report form, ED
: □ Ground ______□ Air ______summary, labs, H&P and demographics
System System
Activation Call Receiving Center 2nd : PCI/Receiving Center called: ______
: Transport arrival : Transport departure/Door out Transferring ED Physician: ______Call back number: ( ) -______
Transfer
TIME MEDICATION DOSE Verified by : Aspirin chewed □ 324 mg PO
PRIMARY PCI PATHWAY : CHOOSE ONE □ Ticagrelor 180 mg PO Ticagrelor/Brilinta (preferred) or □ Clopidogrel 600 mg PO
Clopidogrel/Plavix □ Prasugrel (Effient) 60 mg PO Prasugrel (Effient): Precautions with Prasugrel: Do not use in patients with active bleeding, hx of TIA or stroke, age >75 years, body weight less than 60 kg or 132 lbs. : CHOOSE ONE □Heparin: ______units Heparin; 70 units/kg bolus IV; maximum dose 4000 □ Enoxaparin: 30 mg IV plus 1 mg/kg SC. units Max 100 mg (age <75) Enoxaparin (Lovenox) □ Enoxaparin: No bolus. 0.75 mg/kg SC. Max 75 mg (age>75) FIBRINOLYTIC PATHWAY
: Clopidogrel (when administering lytics) □ Clopidogrel 300 mg PO (age <75) □ Clopidogrel 75 mg PO (age>75) Heparin; 60 units/kg bolus IV; maximum dose 4000 □Heparin: ______units : Units. Heparin gtt: 12 Units/kg/hr. (max 1,000 units/hr.) &______gtt rate (dose) Optional to Heparin: Enoxaparin (Lovenox): □ Enoxaparin: 30 mg IV plus 1 mg/kg SC. Age < 75: 30mg IV plus 1 mg/kg SC (max 100mg) Max 100 mg (age <75) Age > 75: No bolus. 0.75 mg/kg SC (max 75mg) □ Enoxaparin: No bolus. 0.75 mg/kg SC. Max 75 mg (age>75)
Protocol Medications Protocol : Tenecteplase/TNKase Discuss with Cardiology for □ TNK______mg IV ½ dose for age >75
Physician/RN Signature: ______Date: ______
List and contact info for Primary PCI Hospitals:
Ames - Mary Greeley Medical Center 515-239-2251 Iowa City - University of Iowa Hospitals & Clinics 319-467-6666 Bettendorf - UnityPoint Trinity Regional Health System 563-742-3200 Marshalltown - Central Iowa Healthcare 641-754-5040 Cedar Rapids - UnityPoint St. Luke’s Hospital 888-369-7105 Mason City - Mercy Medical Center North 877-422-7162 Cedar Rapids - Mercy Medical Center 866-583-0896 Ottumwa - Ottumwa Regional Health Center 641-799-6827 Clinton - Mercy Medical Center 563-244-3641 Sioux City - Mercy Medical Center 712-560-6529 Council Bluffs - CHI Health Mercy Hospital 844-577-0577 Sioux City - UnityPoint St. Luke’s Hospital 712-635-2022 Council Bluffs - Methodist Jennie Edmundson 844-536-6431 Sioux Falls, SD - Avera Heart Hospital 605-977-7000 Davenport - Genesis Medical Center 563-421-7681 Sioux Falls, SD - Avera McKennan 605-322-2000 Des Moines - Mercy Medical Center 877-886-3729 Sioux Falls, SD - Sanford Health 800-601-5084 Des Moines - UnityPoint Iowa Lutheran 800-806-1787 Waterloo - Covenant Medical Center 319-272-4327 Des Moines - UnityPoint Iowa Methodist 800-806-1787 Waterloo - UnityPoint Allen Hospital 319-235-3697 Dubuque - Mercy Medical Center 563-589-9666 West Burlington - Great River Medical Center 319-768-4700 Dubuque - UnityPoint Finley Hospital 563-589-2560 West Des Moines - Mercy West Lakes 877-886-3729 Ft. Dodge - Trinity Regional Medical Center 515-574-6684 Iowa City - Mercy Hospital 319-688-7874
http://www.heart.org/missionlifelineIA IA Guideline Worksheet 6/20/2016