Checklist for Fibrinolytic Therapy

CHEST PAIN CHECKLIST FOR STEMI FIBRINOLYTIC THERAPY

Step One: Has patient experienced chest discomfort for greater than 15 minutes and less than 12 hours?

YES          NO

Does ECG show STEMI or new or presumably new LBBB?

YES          NO           STOP

Step Two: Are there contraindications to fibrinolysis?

If ANY of the following is CHECKED YES, fibrinolysis MAY be contraindicated.

Systolic BP greater than 180 mm Hg                                                                                                        

YES         NO

Diastolic BP greater than 110 mm Hg                                                                                                      

YES         NO

Right vs. left arm systolic BP difference greater than 15 mm Hg                                                 

YES         NO

History of structural central nervous system disease                                                                       YES         NO

Significant closed head/facial trauma within the previous 3 months                                         

YES         NO

Recent (within 6 wks) major trauma, surgery (including laser eye surgery), GI/GU bleed               

YES         NO

Bleeding or clotting problem or on blood thinners                                                                            YES         NO

CPR greater than 10 minutes                                                                                                                     

YES         NO

Pregnant female    

                                                                                                                                                          YES         NO

Serious systemic disease (eg. advanced/terminal cancer, severe liver or kidney disease)              

YES         NO

Step Three: Is patient at high risk?

If ANY of the following is CHECKED YES, CONSIDER Transport/Transfer to PCI Facility

Heart rate greater than or equal to 100 bpm AND systolic BP less than 100 mm Hg                             YES         NO

Pulmonary edema (rales)                                                                                                                                             YES         NO

Signs of shock (cool, clammy)                                                                                                                    

YES         NO

Contraindications to fibrinolytic therapy                                                                                                YES         NO

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