Intranasal Administration in the ED

April 20, 2017

When is it appropriate to pick a patient’s nose in the emergency department? When medications need to be administered easily, quickly, and non-invasively, according to Megan Rech, PharmD, MS, BCPS, BCCCP, emergency medicine clinical pharmacist at Loyola University Medical Center in Maywood, Ill.

She’s of course referring to the intranasal route for medication delivery, which is becoming increasingly popular in emergent care. Providers attach an atomizer device to a syringe and place the device in the patient’s nostril. When the syringe’s plunger is pushed, the atomizer sends a fine mist of the medication inside the nose. The delivery method requires no needles, is less painful than IV starts, and limits the spread of infectious diseases. Plus, the intranasal route sends medications into the bloodstream faster than intravenous delivery in pediatric patients, the elderly, and the obese.

Dr Rech recently discussed the article she authored about the benefits and drawbacks of using the intranasal route to administer midazolam, fentanyl, naloxone, ketamine, and dexmedetomidine.

What led you to write the article and how did you choose which medications to include?

The idea developed when I was creating a protocol for appropriate use of the intranasal route at my hospital and realized there wasn’t a great reference that summarized when the route should be used and how medication should be dosed. I included those medications because they’re the ones most commonly administered intranasally in the emergency department, where providers aren’t always able to secure intravenous access in patients, especially in IV drug abusers who have blown out veins or in pediatric patients with difficult-to-see veins. The intranasal route is well suited for challenging cases and lets providers quickly administer medications to central circulation without having to wait to start an IV line. The route is sometimes used to control the pain of minor injuries in children or to administer medications to calm anxious patients. It eliminates all of the pain and anxiety associated with establishing IV access, which is especially helpful in pediatric patients.

Which drugs provide the most benefit when they’re administered intranasally?

Midazolam has pharmacokinetic properties suited to the intranasal route and has nice bioavailability. It’s appropriate for use in patients who are seizing or pediatric patients who are very anxious. However, it’s not suitable for sedating adults, because, due to its volume, 10 milligrams is the most you can administer intranasally at one time. Fentanyl has great pharmacokinetic properties for delivery through the intranasal route. However, it also has limitations similar to midazolam. The volume given at one time is limited to 100 micrograms, which works well in children, but adults might have to be re-dosed. Administering naloxone, the opioid overdose rescue drug, intranasally is valuable when you can’t establish IV access in a clothed patient or you’re worried about transmission of infectious diseases by using a needle on an IV drug abuser. However, naloxone’s bioavailability is poor, so higher doses are required.

Are any of the drugs not ideally suited for intranasal delivery?

We use ketamine for many reasons in the emergency department, including the use of small doses to manage pain and anxiolysis. Volume constraints prevent its intranasal use for procedural sedation, even in pediatric patients. Dexmedetomidine comes in a fairly concentrated dose, but its onset for sedation is up to 25 minutes in pediatric patients and up to 45 minutes in adults, meaning it’s not overly helpful in emergent situations. The drug might be more effective in planned or controlled environments for sedation.

Administering medications intranasally is easier than starting an IV. How much of a benefit does that provide in practice?

The intranasal route helps providers administer medications quickly and effectively when therapy is needed immediately in patients in whom IV access might prove challenging. That definitely helps when attempting to administer drugs to combative patients in whom securing IV access would be difficult. The intranasal route is also easier in patients who are having a seizure, because you have to stabilize only the head to administer drugs. If patients are unconscious or unresponsive, we might use the intraosseous route, but that’s a very painful method. The intranasal route is a better option, because it’s a lot easier and faster to perform and it’s relatively painless. Patients might experience a bad taste in the back of their throat, but the method is generally well-tolerated.

Is the intranasal route appropriate for all patients?

I just gave a lecture on the intranasal delivery method at a national conference and asked how many of the 500 attendees had administered medications intranasally and most of the audience members raised their hands. That said, intranasal administration is a niche area, partly because it costs slightly more than administering IV medications: An atomizer kit costs approximately $6, compared with an IV setup that costs $1.20. But the cost differential isn’t enough to deter use of the intranasal route when it’s needed. If the patient isn’t writhing in pain or seizing or doesn’t require naloxone for immediate reversal of opioid ingestion, however, we try to wait to gain IV access.

—Dan Cook