Clinical Pearl 69
Background
·
Intranasal pain
control is as effective as intravenous (IV) pain control.
·
Ease of delivery /
Rapid delivery (If you do not have a preexisting IV catheter in place).
·
Painless
administration, no “shot” needed.
·
Can be titrated, may
repeat ½ to full dose every 10-15 minutes.
Indications for Pre Hospital Use
·
Pain control prior to
starting an IV.
·
Painful procedure.
·
Burns.
·
Orthopedic Trauma,
Suspected fracture.
Contraindications
·
Nasal Trauma, Septal
abnormalities or Obstruction (copious mucous, bleeding, anatomic obstruction or
foreign body)
Drugs and Dosing (NOT equivalent to IV
dosing)
·
Fentanyl 2 mcg/kg (Max dose 100mcg)
·
Most common concentration
is 50 mcg/mL, 5mcg = 0.1mL
·
Ex: 25kg child. 25 kg
x 2 mcg/kg = 50 mcg.
·
Draw up 1mL (50mcg) +
0.1mL (estimated dead space) = 1.1mL. Spray 1 spray in each nostril, alternating nostrils, for 4
sprays.
·
Ketamine 1mg/kg
(Max dose 10mg)
Tips
·
Minimize volume (large
volumes are lost in the pharynx or out of the nostril).
·
Maximize
concentration. Do NOT dilute.
·
Blood and mucus should
be suctioned if possible prior to administration.
·
Neck extended in
sitting position delivers medication higher onto the nasal turbinates to
enhance absorption and nose brain transport.
·
If you fail to use
adequate dosing then you will fail to achieve adequate effect.
·
There is often a “dead
space” within the delivery device, consider drawing up that extra volume into
the syringe to account for the dead space that will remain, approximately 0.1mL
of dead space. This may vary depending on type of device you are using.
·
0.2 to 0.3mL per
nostril is ideal, may push up to 1mL per nostril if needed but there will be
some drug loss.
·
Use BOTH nostrils for
volumes over 0.3mL. If you need more than 2mL total (3-4 sprays in each
nostril), consider titration with a second dose in 5 minutes.
Effect
·
It will take minutes
to absorb and begin achieving therapeutic effect in 3-5 minutes but peaking at
10-15 minutes.
·
Use of
vasoconstrictors might reduce drug absorption (cocaine, epinephrine,
oxymetazoline, phenyephrine).
Side Effects
·
Respiratory depression
is rare, except in sufentanil and high concentrated patented nasal formula of
fentanyl, 400mcg/spray. IN medications given in proper doses will rarely
achieve levels high enough to cause clinically important respiratory depression
due to the delay in rise of serum concentration.
·
Use of
vasoconstrictors might reduce drug absorption (cocaine, epinephrine,
oxymetazoline, phenyephrine).
·
Does not burn. IN
medications are tolerated well.
Reversal: Naloxone IN or IV for opioids.
Conclusion: Pediatric Pain... No IV... No Problem... Think Intranasal
(IN)
References
1.
Borland, A randomized
controlled trial comparing intranasal fentanyl to intravenous morphine for
managing acute pain in children in the emergency department, Ann Emerg Med,
2007.
2.
Goldman, Intranasal
drug delivery in children, Curr Drug Therapy, 2006.
3.
Graudins, A., R. Meek,
et al. The PICHFORK (Pain in Children Fentanyl or Ketamine) trial: a randomized
controlled trial comparing intranasal ketamine and fentanyl for the relief of
moderate to severe pain in children with limb injuries. Ann Emerg Med, 2015.
4.
Intranasal.net
5.
Reid, C., R. Hatton,
et al. Case report: prehospital use of intranasal ketamine for pediatric burn
injury. Emerg Med J, 2011.
6.
Rickard, A randomized
controlled trial of intranasal fentanyl vs. intravenous morphine for analgesia
in the prehospital setting, 2007.
7.
UpToDate, Lexicomp.
Fentanyl and Ketamine Drug Information.
8.
Wolfe, Intranasal
Medications in EMS, JEMS 2003.
9.
Wolfe and Braude,
Intranasal medication delivery for children: A brief review and update.
Pediatrics 2010.
10. Yeaman, F., E. Oakley, et al. Sub-dissociative dose
intranasal ketamine for limb injury pain in children in the emergency
department: A pilot study. Emerg Med Australas, 2013.
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