14 Prescription Writing
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elevation, severe hypertension, cerebrovascular disease, recent surgery
(within 2 weeks), cardiopulmonary resuscitation.
A. Alteplase (tPA, recombinant 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. 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 fibrinogen level now and q6h for 24h until level >100 mg/dL.
3. No IM or arterial punctures, watch IV for bleeding.
Angiotensin Converting Enzyme Inhibitors:
-Captopril (Capoten) initial dose 6.25 mg PO; after 2 hours, increase to 12.5
mg; after 6-8 hours, increase to 25 mg, then increase to 50 mg bid on day
2 OR
-Lisinopril (Zestril, Prinivil) 5 mg PO x 1 dose, then 10 mg qd, then 10-20 mg
bid.
-Enalapril (Vasotec) 2.5 mg PO x 1, then 5 mg qd. Increase dose to max dose
of 10-20 mg bid.
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.
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
mmHg OR
-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes, followed by 50-100 mg
PO qd OR
-Esmolol hydrochloride (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).
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.
-Dimenhydrinate (Dramamine) 25-50 mg IV over 2-5 min q4-6h or 50 mg PO
q4-6h prn nausea.
-Ranitidine (Zantac) 150 mg PO bid or 50 mg IV q8h.
12. Extras: ECG stat and in 12h and in AM, portable CXR. Cardiology consult.
