Everyone in the world seems to be outdoors enjoying the sunshine and unseasonably mild temperatures. Everyone, that is, except you and your colleagues who are staffing the emergency department. You glare at the florescent lights and wait for the onslaught of bumps, bruises, lacerations, and orthopedic injuries to be expected when children tear around outside.
Your next patient is an 11-year-old boy who was playing ball when he tripped in the grass and landed on his outstretched right arm. He is right handed. He complains of pain and swelling in the right wrist, but reports no other injuries. He last ate about two hours before presentation. The rest of his history is unremarkable. His exam reveals swelling and tenderness of the distal radius and ulna. Everything proximal and distal to this is in good working order. He is neurovascularly intact but has somewhat diminished grip strength due to pain and he does not want to move the wrist through much of a range of motion. You explain to the child and his mother that the forearm is likely fractured, you make him NPO and explain about the X-rays you are planning to send him for. Then the conversation turns to pain control. Your patient is quite upfront in voicing his opinion of needles. He asks for something by mouth, so you give him some oxycodone and write for the films. Then you move on while awaiting developments.
The films show a displaced and angulated fracture of the distal radius, along with a nondisplaced distal ulnar fracture. Orthopedics comes down to have a look. They feel that the child is mature enough to handle reduction with pain control and a hematoma block. They don’t feel that sedation is necessary. But what do you want to give him for pain? He has been very brave, but he clearly doesn’t want a needle stick. Do you want to offer something oral? It is likely to be slow to kick in, and Orthopedics is here right now.
How about intranasal? In the old days, it was dripped up the nose in a syringe, mostly going into the pharynx where it was then swallowed. Not too effective. But now your hospital has these cool atomizing devices. They create a fine mist that saturates the nasal mucosa and allows for rapid absorption. When taken this way, pain meds are easily absorbed directly into the bloodstream and quickly pass the blood brain barrier, avoiding breakdown from both the liver and the GI tract. You offer this to your patient. He is a little doubtful at first but is readily persuaded that this will be more comfortable than a needle-stick. The Orthopedist is game to try this so he can move on to his next case. So you check up his nose to make sure that there is no mucous or blood in your path, then dose him with 1.5 micrograms per kilogram of intranasal fentanyl via atomizer, divided so that half the dose goes into each nostril.
It works like a charm. After one dose of intranasal fentanyl the fracture is blocked and reduced. Post-reduction films look good and the child goes home with a prescription for oral pain medication, sling, splint-care instructions and follow-up with Orthopedics. You provided pain management without an IV and your patient and consultant are happy with you. The only remaining question is this: what other drugs can you give this way?
So how do we treat pain in the ED? You can give medications by mouth but they are slow in onset, difficult to titrate and a problem if your patient is vomiting. Needle-sticks work great but kids don’t like getting stuck, the staff sometimes stick themselves with contaminated needles, and getting IV access can take a lot of time and effort in some children. IM works slower and absorption can be variable. Besides, there is still the needle anxiety problem. Rectal is not well-accepted by older kids.
Intranasal delivery allows medications to be absorbed very rapidly in a painless way. Staff need a little training, but nothing approaching the skill level required to start IVs in children. The literature show good results for the management of pain, anxiety, and seizures, and somewhat variable results for sedation. So what drugs can you give this way, and how do you give them?
There is literature on efficacy and dosing guidelines for:
- Pain management – fentanyl, sufentanil
- Anxiolysis/sedation – midazolam, sufentanil, fentanyl, ketamine, dexmedetomidine
- Seizures – midazolam
- Opiate overdose- naloxone
Getting Started with Intranasals in Your Department
Want to start using intranasal medicines in your ED? Start by getting your nursing staff on board. Ask them if they have a Clinical Practice Committee. If they don’t, they should start one because this is where these types of ideas get circulated and changes in practice can happen.
Plead your case with some of the provided references and web sites like intranasal.net. Get the support from your pharmacy, nurse management, and your nursing educator. Educational materials on administration are often provided on the devices web sites which can be downloaded and made into a poster board. There should be no need to have a new nursing policy written to allow for the administration of drugs by this route. This is because physicians are allowed to use their own judgment as to the route of administration of a drug even if that route is not described on the manufacturer’s labeling. Although, nursing staff must be educated as to the proper administration method. There is often adequate information on the manufacturer’s web site, or a representative for the device can also provide an inservice for the staff at the request of the educator.
This delivery method has plenty of upsides with little in the way of downsides when you finally get rolling. I hope this helps to ease some of the worries and gets many of you thinking of the nose as more than a just a place where little kids hide their crayons.
- Clear the nose of mucous or blood. Suction if you have to.
- You double your absorptive surface if you put half the dose up each nostril.
- Use the most concentrated form of the drug you have. You cannot put more than 1 mL of volume in a nostril or it loses efficacy. If you have to, wait a few minutes and dose again to get the full volume in.
- Aim slightly upward and toward the patients ear on the same side as the nostril. This is the direction to where most of the nasal mucosa are located. Remember to have someone hold the patients head to avoid accidently administering the drug to the whole room, including yourself.
- Depress the syringe briskly to create a fine mist from the device.
- Watch your Patient- Anything that can go wrong with these medicines can obviously happen when giving them intranasally. Consider taking all precautions you would normally take if administering these medications intravenously.
- Midazolam burns a bit – warn your patient
- Sufentanil causes deep sedation – if you are going to use this you will want a pulse ox and monitor
The web is a good source to get started with dosing guidelines. A good place to start is www.intranasal.net.
Amy Levine, MD, is an associate professor of pediatric emergency medicine at UNC Chapel Hill.
Tim Valeriote has been a Registered Nurse at the University of North Carolina in the Emergency Department for 10 years.