Unique Plan Description: ED PE/DVT
Plan Selection Display: ED PE/DVT
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-01 15:32:40
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-09-05 09:20:34
Available at all facilities: Yes

ED PE/DVT
Laboratory
	Heparin Anti-Xa Heparin
		Stat, spec type = Blood
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
	CBC with Diff
		Stat, spec type = Blood
	Comprehensive Metabolic Panel
		Stat, spec type = Blood
	Pregnancy Test Urine
		Stat, spec type = Urine
	hs Troponin T - MH/WH/JE
		Stat, spec type = Blood
	hs Troponin I - FH
		Stat, spec type = Blood
	Beta-HCG Quantitative - Pregnancy
		Stat, spec type = Blood
	Blood Gases Arterial (ABG) - MH/WH/JE
		Stat, spec type = Blood
	Blood Gases Arterial (ABG) - FH
		T;N, Stat, spec type = Blood
	Urinalysis
		T;N, Stat, Stat, spec type = Urine
	UA (Culture if Positive)
		Stat, spec type = Urine
	D-Dimer - MH/WH/JE
		Stat, spec type = Blood
	ProBNP
		Stat, spec type = Blood
Diagnostic Tests
	ECG in ED
		Stat, Indication: Chest Pain
	Echo w Doppler resting
		T;N, Indication: Chest pain
	Venous Duplex Bil Upper or Lower
		Stat, Indication: Pain, Location Upper Bilateral
		Stat, Indication: Pain, Location Lower Bilateral
		Stat, Indication: Shortness of breath
	Venous Duplex Unilat Upper or Lower
		Stat, Indication: Pain, Location Left Upper
		Stat, Indication: Pain, Location Left Lower
		Stat, Indication: Pain, Location Right Upper
		Stat, Indication: Pain, Location Right Lower
		Stat, Indication: Shortness of breath
Radiology
	CTA Chest Pulmonary Arteries
		Stat, Pulmonary Emboli
	CTA Chest
		Stat, Dissection of Aorta
	Chest 1 View
		Stat, Dyspnea
IV Solutions

	Sodium Chloride 0.9%
		1,000 mL, IV, STAT, 999 ml/hr
		1,000 mL, IV, STAT, 500 ml/hr
Medications
	rivaroxaban
		15 mg, Tab, By Mouth, Once, STAT
			Comment: take with food
		If patient going home use Starter pack order (JE)(NOTE)*
	Xarelto Starter Pack
		15 mg, Kit, By Mouth, Once, STAT
			Comment: take with food, Send remainder of pack home with patient
	apixaban
		10 mg, Tab, By Mouth, Once, STAT
	Lovenox
		1 mg/kg, Syringe, SUBCUTANEOUS, Once, STAT
		1.5 mg/kg, Syringe, SUBCUTANEOUS, Once, STAT
		Arixtra-use in place of heparin/enoxaparin if history of HIT(NOTE)*
	Arixtra
		5 mg, Injection, SUBCUTANEOUS, Once, STAT
			Comment: weight <50 kg
		7.5 mg, Injection, SUBCUTANEOUS, Once, STAT
			Comment: weight 50-100 kg
		7.5 mg, Injection, SUBCUTANEOUS, Once, STAT
			Comment: weight 50-100 kg
		7.5 mg, Injection, SUBCUTANEOUS, Once, STAT
			Comment: weight >100 kg
Patient Care
	ED Cardiac Telemetry Monitoring
		T;N
	Continuous Pulse Oximetry by Nurse
		T;N, Once
	Glucose POC - RN
		T;N
	Oxygen Therapy, Nurse to Administer
		T;N, Via Nasal Cannula, Continuous
	Foley Catheter
		Insert, Once
	Straight Catheter
		Insert, Once
	Notify MD
		T;N, for surgical patients, contact surgeon for approval to start heparin protocol
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal limit of 22-37 seconds)
		T;N, if critical PTT >135
	Avoid IM Injections if possible while on anticoagulants
		
Consults/Follow-up
	Consult Cardiologist
		Reason for Referral: PE/DVT
	Consult Hospitalist
		Reason for Referral: PE/DVT
	Consult Pulmonologist
		Reason for Referral: PE/DVT
	Consult Interventional Radiologist
		Reason for Referral: PE/DVT
	Consult Vascular Surgeon
		Reason for Referral: PE/DVT

ED Peripheral Lock Insert with Flush
Medications
	sodium chloride 0.9% flush injectable soln
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush, 4 hr
Patient Care
	Peripheral Lock-Insert
		T;N, Once

ED PE/DVT High Dose (antiXa)
Laboratory
STAT Lab
	Heparin Anti-Xa Heparin
		T;N+360, Routine, Once, spec type = Blood
		Stat, spec type = Blood
	INR - MH/WH/JE
		Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Stat, spec type = Diagnostic Blood
	CBC with Diff
		Stat, spec type = Blood
Diagnostic Tests
Radiology
	CTA Chest Pulmonary Arteries
		Stat, Pulmonary Emboli
IV Solutions

	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV, STAT, 1 Dose(s)/Time(s)
			Comment: conc: 100 units/mL. Titrate according to High Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.1)Anti-factor Xa UFH <less than 0.2 units/mL,bolus 70 units/kg & increase rate by 4 units/kg/hr.2)Anti-factor Xa UFH =0.2-0.29 units/mL,bolus 35 units/kg & increase rate by 2 units/kg/hr.3)Anti-factor Xa UFH =0.3-0.7 units/mL,(therapeutic range) Do not give bolus & do not change rate.4)Anti-factor Xa UFH =0.71-0.95 units/mL,do not bolus. Decrease rate by 2 units/kg/hr.5)Anti-factor Xa UFH =0.96 units/mL or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Document all rate changes on the Titrated Medication Flowsheet while in EDUpper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber
		25,000 units, EVERY BAG, 18 unit/kg/hr
Medications
	HEParin 1000 units/mL injectable soln
		35 units/kg, Injection, IV Push, Once, T;N+360
			Comment: Anti-factor Xa UFH level between 0.2-0.29 units/ml. Patient on high dose heparin protocol. Pharmacy to calculate dose. While in ED.  (MAXIMUM bolus = 3800 units)
		70 units/kg, Injection, IV Push, Once, T;N+360
			Comment: Anti-factor Xa UFH level < 0.2 units/ml Patient on high dose heparin protocol. Pharmacy to calculate dose. While in ED.  (MAXIMUM bolus = 7700 units)
		70 units/kg, Injection, IV Push, Once, STAT
			Comment: Patient on high dose heparin protocol. Pharmacy to calculate dose. While in ED.  (MAXIMUM bolus = 7700 units)
Patient Care
	Notify MD
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal limit of 22-37 seconds).
Consults/Follow-up
	Consult Hospitalist
		Reason for Referral: PE/DVT

ED PE/DVT Heparin High Dose PTT (MH WH)
Laboratory
STAT Lab
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T;N+360, Routine, spec type = Blood
	CBC with Diff
		Stat, spec type = Blood
Diagnostic Tests
Radiology
	CTA Chest Pulmonary Arteries
		Stat, Pulmonary Emboli
IV Solutions

	HEParin 25,000 units/premixed diluent 250 mL
		25,000 units, EVERY BAG, 18 unit/kg/hr
		250 mL, IV, STAT, 1 Dose(s)/Time(s)
			Comment: conc: 100 units/mL. Titrate according to High Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg1) PTT < 52 seconds, bolus 70 units/kg & increase rate by 4 units/kg/hr.2) PTT = 52-64 seconds, bolus 35 units/kg & increase rate by 2 units/kg/hr.3) PTT = 65-110 seconds, (therapeutic range) Do not give bolus & do not change rate.4) PTT = 111-135 seconds, do not bolus. Decrease rate by 2 units/kg/hr.5) PTT = 136 seconds or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr. Document all rate changes on the Titrated Medication Flowsheet while in ED. Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber
Medications
	HEParin 1000 units/mL injectable soln
		35 units/kg, Injection, IV Push, Once, T;N+360
			Comment: PTT = 52-64 seconds. Patient on high dose heparin protocol. Pharmacy to calculate dose. While in ED.  (MAXIMUM bolus = 3800 units)
		70 units/kg, Injection, IV Push, Once, T;N+360
			Comment: PTT < 52 seconds Patient on high dose heparin protocol. Pharmacy to calculate dose. While in ED.  (MAXIMUM bolus = 7700 units)
		70 units/kg, Injection, IV Push, Once, STAT
			Comment: Patient on high dose heparin protocol. Pharmacy to calculate dose. While in ED.  (MAXIMUM bolus = 7700 units)
Patient Care
	Notify MD
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal limit of 22-37 seconds).
Consults/Follow-up
	Consult Hospitalist
		Reason for Referral: PE/DVT

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase