Acute Coronary Syndrome (ACS)

MONA (morphine-Oxygen-Nitrate- Aspirin)

Oxygen 4 L/min
Nitrate SL, max 3 tab, interval 5 minutes
Morphine 2-4 mg IV slow (dilute with 10 cc NaCl), can be
repeated every 5-30 min until the pain resolve, max dose?
Aspirin 160-325 mg (chewed)
IV line
Vital signs and Monitor

ST-segment elevation Normal or

ST-segment depression
or New LBBB Non Diagnostic EKG

If pain persists and BP High risk: High risk:

>100 mm Hg,
Nitroglycerin drip 10-20
ug/Min, can be increased
5-10 ug every 5-10 min,
max 200 ug/min.
Alternative: B-blocker IV,
Heparin IV.
Persistent symptoms Serial EKGs
Recurrent schema ST-segment monitoring
Diffuse or widespread Serum cardiac markers
ECG abnormalities Perfusion radionuclide
Depressed LV function imaging
CHF Stress echocardiography
Serum marker: positive
troponin or CK-MB +

<12 hours

Fibrinolitic therapy Heparin Aspirin

Streptokinase 1.5 Aspirin Other therapy as
million unit diluted in Glicoprotein IIb/IIIa appropriate
100 ml Normal Saline, Inhibitors Patient with positive
infused for 30-60 min B-blocker serum markers, ECG
Nitrate changes: manage as
high risk

Note:
Mayor Contraindication Fibrinolitic:
- Intra cranial tumor - Stroke hemorrhage
- Stroke non-hemorrhage within 1 year - Aorta dissecting
- Active abdominal bleeding (except menstrual hemorrhage)
Watch out during fibrinolitic therapy drip: allergy, post reperfusion arrhythmia,
bleeding, dropped BP
Fibrinolitic therapy is not effective/not recommended for ACS more then 12 hours
When using morphine, naloxon and resuscitator shall be on hand