›Time critical pathway
›Continuous monitoring
›Two large bore IV access when threatened limb
›NPO status
›Active warming of whole patient
›Immediate escalation actions
›If motor deficit present then emergent vascular surgery consult
›If hard signs of ischemia then heparin unless contraindicated
Anticoagulation and antiplatelet
›Unfractionated heparin protocol
›IV bolus 80 units per kg
›IV infusion 18 units per kg per hour
›Titration to aPTT per local protocol dependent
›Heparin contraindications
›Active major bleeding
›Suspected intracranial hemorrhage
›Known heparin induced thrombocytopenia
›Antiplatelet therapy
›Aspirin loading if not already on and no contraindication
›Local protocol dependent for dual antiplatelet therapy after intervention
Analgesia and symptom control
›Analgesia strategy
›Acetaminophen PO or IV per local protocol dependent
›Opioid IV titration for severe ischemic pain
›Antiemetic support
›Ondansetron PO or IV per local protocol dependent
›QT prolongation risk review when applicable
›Imaging sequence
›If threatened limb then CTA without delay
›If stable and CTA not immediately available then duplex arterial ultrasound
›Lab sequence
›CBC
›Electrolytes
›Creatinine
›Lactate
›CK
Revascularization coordination
›Specialist activation
›Vascular surgery emergent for threatened limb
›Interventional radiology coordination when endovascular planned
›Reperfusion preparedness
›Hyperkalemia monitoring plan
›Metabolic acidosis monitoring plan
›Compartment syndrome surveillance after reperfusion
›Reassessment cadence
›Neurovascular checks every 30 to 60 minutes in ED while awaiting intervention
›Pain trajectory trend
›Doppler signal trend