From the Guidelines
A comprehensive medical decision-making template for emergency room physicians should include four key components: presenting problem, diagnostic data, risk assessment, and management plan. Begin by documenting the presenting problem with relevant history, severity, and duration of symptoms. Next, record all diagnostic data including vital signs, physical exam findings, laboratory results, and imaging studies. For risk assessment, evaluate the complexity of the case by considering comorbidities, potential complications, and differential diagnoses. Finally, detail your management plan with specific medications (including names, doses, routes, and frequencies), procedures performed, consultations requested, and disposition decisions (admit, discharge, transfer) 1.
Some key considerations in the management plan include:
- Administering aspirin (160 to 325 mg) as soon as possible after symptom onset to patients with suspected acute coronary syndrome (ACS) 1
- Using a 12-lead ECG to evaluate patients with suspected ACS, and performing it as soon as possible after arrival to the emergency department 1
- Considering cardiac catheterization and coronary angiography in patients with ACS, particularly those with ST-elevation myocardial infarction (STEMI) 1
- Using a structured approach to decision-making, including the use of protocols and checklists, to reduce errors and improve patient outcomes 1
This structured approach ensures thorough documentation while supporting clinical reasoning. The template helps demonstrate medical necessity for billing purposes and provides clear communication to other healthcare providers. Using this systematic framework reduces the risk of missing critical information during high-stress emergency situations and improves continuity of care as patients transition between providers or care settings.
Key aspects of the initial evaluation include:
- Identifying signs of immediate life-threatening instability
- Ensuring rapid transport to the most appropriate environment for the level of care needed
- Using a combination of cardiac biomarkers, short-term observation, diagnostic imaging, and provocative stress testing to evaluate patients with suspected ACS 1
- Considering the use of advanced testing, such as computed tomography (CT) angiography or cardiac magnetic resonance, to detect coronary ischemia and CAD in patients with nonischemic ECGs and negative biomarkers 1
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Medical Decision Making Template for ER
The following template can be used for medical decision making in the Emergency Room (ER) for patients with suspected acute coronary syndrome (ACS):
- Initial Assessment: Evaluate the patient's symptoms, medical history, and perform an electrocardiogram (ECG) to determine the presence of ACS 2
- Medication Administration:
- Aspirin: administer to all patients with suspected ACS unless contraindicated 2, 3
- Nitroglycerin: administer to patients with suspected ACS to relieve chest pain 2, 3
- Morphine: administer to patients with suspected ACS to relieve chest pain 2, 4
- Oxygen: administer to patients with suspected ACS to increase oxygen supply to the heart 2, 4
- Other medications: consider administering beta blockers, statins, and angiotensin-converting enzyme inhibitors to patients with ACS 2, 5
- Shared Decision Making: Involve patients in the decision-making process whenever possible, taking into account their values, preferences, and medical history 6
- Intervention: Consider percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for patients with ACS, depending on the severity of the condition and the presence of any contraindications 2
- Monitoring: Continuously monitor the patient's condition, including their ECG, blood pressure, and oxygen saturation, to quickly identify any changes or complications 2
Considerations for Prehospital Care
- Prehospital Administration of Aspirin and Nitroglycerin: Consider administering aspirin and nitroglycerin to patients with suspected ACS in the prehospital setting, as this may be associated with improved outcomes 3
- Communication with Emergency Medical Services (EMS): Ensure that EMS personnel are aware of the patient's condition and any medications that have been administered in the prehospital setting 3
Updates to Traditional Mnemonics
- MONA: This traditional mnemonic (morphine, oxygen, nitrates, and aspirin) is no longer recommended, as it does not reflect current best practices for ACS management 4, 5
- THROMBINS2: Consider using this updated mnemonic (thienopyridines, heparin/enoxaparin, renin-angiotensin system blockers, oxygen, morphine, beta blocker, intervention, nitroglycerin, statin/salicylate) to guide ACS management 5