What is Mona-Bash used for?

MONA-BASH: Medication Protocol for Acute Coronary Syndrome Management

MONA-BASH is a medical mnemonic used for the emergency management of acute coronary syndrome (ACS), representing a standardized approach to initial treatment that includes Morphine, Oxygen, Nitroglycerin, Aspirin, Beta-blockers, ACE inhibitors, Statins, and Heparin.

Components of MONA-BASH

Initial Management (MONA)

1. Morphine

   • Used for pain relief in ACS
   • Reduces anxiety and sympathetic drive
   • Caution: May mask symptoms and potentially increase mortality in some cases

2. Oxygen

   • Administered for hypoxemia (O₂ saturation <90%)
   • Not routinely recommended for non-hypoxemic patients
   • Goal: Maintain oxygen saturation ≥94%

3. Nitroglycerin

   • Provides coronary vasodilation
   • Reduces preload and afterload
   • Contraindicated in hypotension, right ventricular infarction, or recent phosphodiesterase inhibitor use

4. Aspirin

   • Immediate administration (162-325 mg chewed)
   • Inhibits platelet aggregation
   • Critical for mortality reduction

Additional Components (BASH)

1. Beta-blockers

   • Reduce myocardial oxygen demand
   • Decrease mortality and reinfarction rates
   • Contraindicated in cardiogenic shock, severe bradycardia, high-degree AV block

2. ACE inhibitors/ARBs

   • Started within 24 hours in stable patients
   • Particularly beneficial for anterior MI, heart failure, or reduced ejection fraction

3. Statins

   • High-intensity statin therapy regardless of baseline lipid levels
   • Pleiotropic effects beyond cholesterol lowering

4. Heparin/anticoagulation

   • Unfractionated or low molecular weight heparin
   • Prevents further thrombosis

Evolution of ACS Management

The original MONA approach has evolved over time as evidence has changed. For example, oxygen is now only recommended for hypoxemic patients 1, and morphine use has become more selective due to concerns about masking symptoms.

A more contemporary mnemonic is "THROMBINS2" which includes additional elements like thienopyridines (P2Y12 inhibitors) and early intervention 2.

Implementation in Clinical Practice

When a patient presents with suspected ACS:

1. Immediately administer aspirin
2. Assess oxygen saturation and provide supplemental oxygen only if needed
3. Give nitroglycerin for ongoing chest pain if not contraindicated
4. Consider morphine only for severe pain unresponsive to nitroglycerin
5. Initiate the remaining components (BASH) as soon as diagnosis is confirmed

Common Pitfalls to Avoid

• Administering oxygen to non-hypoxemic patients (may increase mortality)
• Using morphine routinely without considering its potential drawbacks
• Delaying aspirin administration (should be given immediately)
• Failing to consider contraindications for each medication
• Not progressing beyond initial management to definitive therapy (PCI when indicated)

The MONA-BASH protocol serves as a structured approach to ACS management, but clinical judgment remains essential for individualizing treatment based on specific patient factors and presentation.