# Mona



## Sublime (Oct 29, 2012)

Just wondering how you guys use MONA, as paramedics around here that I've talked to have differing opinions on how to use this combination of medications. I found that the way I was originally taught to use MONA in medic school (by my old school firefighter teachers) is much different that what I practice now.

M - Do you give morphine if nitro relieved the chest pain? 

O - Do you give oxygen in chest pain / ACS if the 02 saturation is within normal ranges? What if the sat. is 98-100%? If not at what point will you give it?

N - If you have a patient who appears to be having an MI according to their ekg but does not complain of chest pain, will you still give nitro? If someone is complaining of chest pain but it is relieved after one or two nitro, do you still give another?

A - Not much to ask here.


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## Shishkabob (Oct 29, 2012)

Sublime said:


> M - Do you give morphine if nitro relieved the chest pain?


  Nope.  Then again, I also no longer have morphine due to the national shortage...

My thought process is pain causes catecholamine release causing vasoconstriction.  Let's stop constriction.  



> O - Do you give oxygen in chest pain / ACS if the 02 saturation is within normal ranges? What if the sat. is 98-100%? If not at what point will you give it?


  Yes, but via NC.  It IS possible to "over" saturate the blood with oxygen, so what little can pass the blockage helps.



> N - If you have a patient who appears to be having an MI according to their ekg but does not complain of chest pain, will you still give nitro? If someone is complaining of chest pain but it is relieved after one or two nitro, do you still give another?


  If they have no pain, no nitro.  It's a peripheral dilator, anyhow.  



> A - Not much to ask here.


 Aspirin is the only proven medication in MIs.


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## Ridryder911 (Oct 29, 2012)

Although MONA is still widely used as general guidelines; as usual there is NEVER black and white treatment regime. 

One needs to remember although Morphine Sulfate is a great analgesic, it has been reported and documented in certain and specific conditions to actually increase morbidity and mortality.. hence; the reason to learn and fully understand cardiac variables and treatments. 

As described many have removed oxygen as therapy unless indicated; ( if the main problem is a blocked coronary artery, supplemental oxygen will not increase oxygenation to that portion of myocardial tissue)

Nitrates alike Morphine is a great medication and again... can lead to very deadly consequences if not given appropriately and again in certain chest pain and AMI can lead to potential risks and dangers. Hence the reason XII lead ECG should be performed and interperted as soon as possible before administration of nitrates. 

Aspirin- the only true medication that probably makes the difference. It's cheap and effective. Ironically, studies have revealed no less than two and no more than four is quite effective... 

good luck, 

R/r 911


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## mycrofft (Oct 29, 2012)

two or four of which doseage, 81 or 325mg? Just being lazy. Good to read you, Rid.


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## Thricenotrice (Oct 29, 2012)

M - if pain is not alleviated by nitro yes
O - yes. Cannula most likely
N - of course
A - yes, 162 to start, 324 if I believe it's an MI

Also, I do in the order of ANOM


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## lightsandsirens5 (Oct 29, 2012)

RID! Glad to see you! 

Mycrofft, I believe that's 2-4 81Mg tablets he's taking about. I seem to remember reading a study on that somewheres.


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## medicsb (Oct 29, 2012)

Sublime said:


> M - Do you give morphine if nitro relieved the chest pain?



No.



> O - Do you give oxygen in chest pain / ACS if the 02 saturation is within normal ranges? What if the sat. is 98-100%? If not at what point will you give it?



I would generally give 2lpm via NC.  If they're 98-100, they probably don't need it.



> N - If you have a patient who appears to be having an MI according to their ekg but does not complain of chest pain, will you still give nitro? If someone is complaining of chest pain but it is relieved after one or two nitro, do you still give another?



Well, why was the 12 lead performed?  If it was run, then there was some suspicion.  In that case, I would consider trialing NTG.  I did have a couple patients where I ran a 12 lead and found signs of ischemia for which I gave NTG (though no chest pain, per se, was present).  In at least one case there was normalization of the ECG.  Once CP is relieved, no additional SL sprays/tabs will be given.  However, a maintenance NTG infusion or nitro paste may be given.



> A - Not much to ask here.


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## socalmedic (Oct 29, 2012)

Sublime said:


> M - Do you give morphine if nitro relieved the chest pain?



No, only on persistent chest pain after 2-3 NTG



Sublime said:


> O - Do you give oxygen in chest pain / ACS if the 02 saturation is within normal ranges? What if the sat. is 98-100%? If not at what point will you give it?



No, current AHA recommendations are O2 titrated to SpO2 of 96%



Sublime said:


> N - If you have a patient who appears to be having an MI according to their ekg but does not complain of chest pain, will you still give nitro? If someone is complaining of chest pain but it is relieved after one or two nitro, do you still give another?



tricky, but generally no. are there any other symptoms indicating chest discomfort. if not, why did you do a 12-lead in the first place?



Sublime said:


> A - Not much to ask here.



not much to answer here...


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## Aprz (Oct 30, 2012)

socalmedic said:


> No, current AHA recommendations are O2 titrated to SpO2 of 96%


I think it's 94-99%.

Since we are talking about MONA, I was wondering about aspirin and patients with allergic-like (I'm not sure what it's called) reactions to it e.g. aspirin, nasal polyps, etc. If the patient has a _known_ history of sensitivity to aspirin like that, should aspirin still be administered?


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## socalmedic (Oct 30, 2012)

Aprz said:


> I think it's 94-99%.
> 
> Since we are talking about MONA, I was wondering about aspirin and patients with allergic-like (I'm not sure what it's called) reactions to it e.g. aspirin, nasal polyps, etc. If the patient has a _known_ history of sensitivity to aspirin like that, should aspirin still be administered?



I believe it is recommended to withhold ASA so that plavix can be administered. an you are correct, 94% is the cut off.


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## EMSrush (Oct 30, 2012)

Sublime said:


> M - Do you give morphine if nitro relieved the chest pain?
> *Generally not; depends on Pt condition. How's the BP? Is the Pt anxious?*
> 
> O - Do you give oxygen in chest pain / ACS if the 02 saturation is within normal ranges? What if the sat. is 98-100%? If not at what point will you give it?
> ...



I'd be curious to hear your answers to your own questions.


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## Handsome Robb (Oct 30, 2012)

Sublime said:


> Just wondering how you guys use MONA, as paramedics around here that I've talked to have differing opinions on how to use this combination of medications. I found that the way I was originally taught to use MONA in medic school (by my old school firefighter teachers) is much different that what I practice now.
> 
> M - Do you give morphine if nitro relieved the chest pain?
> 
> ...




Morphine - Never given it in the presence of chest pain, in theory I'd only jump to MS if they were a STEMI patient with pain refractory to NTG or an inferior MI and hypotension contraindicated NTG. 

Oxygen - by protocol we are required to, usually by nasal cannula, I brought my one and only STEMI in on 2 lpm with an SpO2 of 98% and didn't hear any argument against my treatment

Nitro - Probably not. Potentially to see if there are any changes in the ECG pre/post NTG but that's a situation I haven't been put in before. Like others have said, if they are complaining of discomfort that lead me to have a high enough index of suspicion to do a 12-lead seeing if the NTG has any effect on that discomfort would be appropriate in my opinion. 

Aspirin - Not much to answer. I will say I get ASA onboard early on if I'm thinking cardiac. Read: as the 12-lead is being placed or just after it's captured. 

FWIW I take 324 mg of ASA and a spray bottle of NTG in my pocket into all chest pain calls. I'm not a huge fan of giving NTG before having a line but I still carry it in my pocket into these calls. Easier for me to jump in the back real quick and grab ASA and NTG out of the caddy while my partner is pulling the gurney rather than digging through my bags for it.


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## Sublime (Oct 30, 2012)

EMSrush said:


> I'd be curious to hear your answers to your own questions.



M - I will not give morphine if nitro has relieved the pain. There is no evidence to show that morphine is a beneficial drug in the outcome of ACS patients. Some will even tell you morphine increases mortality in these patients.
http://www.theheart.org/article/516527.do

With that being said, if the nitro is not controlling the pain to an acceptable amount for the patient, I will give it. If the patient is truly having an MI, I believe the possible negatives of giving morphine are outweighed by the negatives of additional catecholamines / stress from the pain. But that is just opinion.

O - My protocols don't say I have to give oxygen in a patient having an MI, so unless they're showing signs of hypoxia I am not going to give it. If they're hanging around 96% I will put them on 2L via nasal cannula. 

Here's a little piece of a JEMS article (I know its JEMS, but its a great article) that explains one reason hyperoxia is believed to be harmful.



> Hyperoxia also causes free-radical damage. Free radicals are oxygen atoms with a charge due to an unequal number of protons and electrons. These radicals are known to cause intracellular damage and cell destruction (much like pouring hydrogen peroxide into an open would). It’s known that ischemic tissues are particularly sensitive to free-radical damage. This may be a major factor in the pathogenesis of hyperoxia.



And here is a link to the whole JEMS article and another page about potential harm of supplemental oxygen.
http://www.theheart.org/article/1125119.do
http://www.jems.com/behind-the-mask

N - This first question I asked is tricky and very situational, I know. Sometimes diabetics and elderly patients (women especially) can present abnormally. I had a diabetic lady complaining of right shoulder blade pain who turned out to be an MI not too long ago.

For those asking why a 12-lead was done without a complaint of chest discomfort... I have a habit of doing a 12-lead for a wide variety of complaints including dizziness, weakness, syncope, and even some abdominal pains. This became habit working in the ER where the doc's ordered 12-leads on just about everything. 

So if they're having any sort of discomfort, it is not a right sided MI, and their blood pressure allows, I will trial nitro. If they are absolutely pain free I do not give nitro.

A - If I suspect ACS they're getting 324 mg aspirin. Like I said not much to discuss here as this is pretty straight forward.


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## Handsome Robb (Oct 30, 2012)

I'm wondering what people's thoughts are on aspirin in patients who state they are "allergic" or hypersensitive to it. Such as a mild allergy, obviously not going to mess around with someone who has a hx of anaphylactic reactions to NSAIDs. 

During my FTO time I withheld aspirin in a chest pain patient who stated they were allergic to NSAIDs "they make my stomach upset" and my FTO wanted me to spend more time weighing the risk vs reward and to push the patient towards allowing me to administer the aspirin anyways. An upset stomach is hardly an allergic reaction but how much time are you going to spend discussing it with patients such as this one?


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## lightsandsirens5 (Oct 30, 2012)

Sublime said:


> M - I will not give morphine if nitro has relieved the pain. There is no evidence to show that morphine is a beneficial drug in the outcome of ACS patients. Some will even tell you morphine increases mortality in these patients.
> http://www.theheart.org/article/516527.do
> 
> With that being said, if the nitro is not controlling the pain to an acceptable amount for the patient, I will give it. If the patient is truly having an MI, I believe the possible negatives of giving morphine are outweighed by the negatives of additional catecholamines / stress from the pain. But that is just opinion.



That's why we should start looking at FONA. Just my uneducated $0.02.


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## AnthonyM83 (Oct 30, 2012)

M Only to relieve active pain.

O NO!!! If sats are good, I don't want to INCREASE mortality by giving oxygen or be NEGLIGENT by going AGAINST AHAs recommendation based on pretty good data.

N In theory, it's working to relieve workload of heart, so should be given even if pain free. But since it hasn't been shown to decrease long-term mortality, I stop when pain-free.

A For any type of presumed ACS (symptomatic or just on ECG)


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## Brandon O (Oct 30, 2012)

Linuss said:


> My thought process is pain causes catecholamine release causing vasoconstriction.  Let's stop constriction.



Coronary vasoconstriction?


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## DrankTheKoolaid (Oct 30, 2012)

Brandon Oto said:


> Coronary vasoconstriction?



Even worse then morphine with coronary vasoconstriction is vasopressin,  go figure


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## Brandon O (Oct 30, 2012)

Corky said:


> Even worse then morphine with coronary vasoconstriction is vasopressin,  go figure



Well, my point was that the catcholamine effect on coronary vasculature is usually felt to be dilatory, not constrictive. (Obviously there is also stimulatory chronotropic and inotropic effects, so I'm not saying the net effect is necessarily to narrow the supply/demand deficit, but still.)


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## blindsideflank (Oct 31, 2012)

Too much Asa inhibits prostacyclin which is a natural dilator found in (and released by) the epithelial cells of your vessels.

02 is bad when used wrong- 02 toxicity, reperfusion injury, changes in pH

Morphine has been proven to cause harm in some studies, because of crappy health carenstaff that think the problem is fixed because the pain is gone, I don't think the morphine causes any physiological damage when used appropriately

Nitro-... I've got nothing to say I guess


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## medicsb (Oct 31, 2012)

blindsideflank said:


> Too much Asa inhibits prostacyclin which is a natural dilator found in (and released by) the epithelial cells of your vessels.


If I recall, it does this at the doses we use, but it is not sn issue because the endothelial cells can regenerate cyclooxygenase whereas platelets cannot.



> Morphine has been proven to cause harm in some studies, because of crappy health carenstaff that think the problem is fixed because the pain is gone, I don't think the morphine causes any physiological damage when used appropriately


No one had proven anything about morphine.  Only correlation has been shown.


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## highglyder (Nov 3, 2012)

MS is at our discretion, but only once all six NTG doses have been given.

Oxygen is a contentious issue.  In Ontario, our guiding document (Ministy of Health Basic Life Support Standards 2007, which applies to all levels of paramedics) dictates that anyone having chest pain MUST have high concentration O2 at 10-15LPM.  This cookbook approach is the bane of our existence.  Many of us will give it via N/C, even though we could get in major trouble with the Ministry if it were discovered.  But, as the saying goes, your pen is your only witness. :unsure:

NTG is delivered only after a 12-lead ECG is acquired (if the service has the capability) in order to rule out RVI.  Administration stops after 6 does, a 1/3 drop in SBP, or if the pain disappears.  Any recurrence is treated as a new episode, however only the ASA is not repeated.

ASA is always given if we believe it to be cardiac ischemia.


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## highglyder (Nov 3, 2012)

Almost forgot....the administration of medication is covered by directives issued by our Base Hospitals.  As they are directives, and no longer protocols, one can deviate as long as the rational is clinically sound.


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## lightsandsirens5 (Nov 3, 2012)

highglyder said:


> Almost forgot....the administration of medication is covered by directives issued by our Base Hospitals.  As they are directives, and no longer protocols, one can deviate as long as the rational is clinically sound.



Cool!


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## VFlutter (Nov 3, 2012)

Aprz said:


> patients with allergic-like (I'm not sure what it's called) reactions



anaphylactoid?


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