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Offer intranasal drugs and reduce pain and risks
If you could find a way to ensure that medications were absorbed quicker with less pain and no risk of a needlestick injury, would you do this for your patients? Intranasal drug delivery offers all of these benefits, but the vast majority of EDs don’t use it, according to Timothy Wolfe, MD, associate professor of emergency medicine at University of Utah School of Medicine in Salt Lake City.
"This is a painless way to give medicine. It is such a simple thing, but many EDs just don’t think of it," says Deborah Critchett, RN, ED nurse at University of Utah Hospital and Clinics.
Use of intranasal medications will increase dramatically in EDs, especially in light of the nasal flu vaccine and soon-to-be-available nasal insulin, predicts Wolfe. "EDs will recognize how they can reduce patient discomfort, reduce needlestick risk, and speed up care, and will begin using it more and more," he says.
Increasing numbers of medications are becoming available intranasally, such as migraine medications, nasal opiates, and hormones, notes Wolfe. "Transmucosal delivery has a lot of advantages that the pharmaceutical industry can tout. It is much faster than oral delivery and is noninvasive," he adds.
Until recently, medications given intranasally often ran down the patient’s throat, but improved technology with inexpensive atomizers now deliver exact doses, Wolfe says.
Here are ways to use intranasal drug delivery in your ED:
Intranasal drug delivery is ideal for rapid onset of pain control when an intravenous (IV) line won’t be started, such as for wound repacking and orthopedic trauma, says Wolfe. "Oral drugs take 40 minutes to achieve reasonable pain control, and intramuscular medications take 20-30 minutes," he explains. "Also, they hurt to administer and present a needlestick risk."
The effect of intranasal fentanyl begins in about five to eight minutes and is titratable, adds Wolfe. "In adults, I give 25 mcg in each nostril, wait one to two minutes, and repeat," he says. "It is painless. It is much preferred over intramuscular injections and is as effective at pain control as IV titration — all without a needlestick."
Recently, Critchett administered fentanyl intra-nasally for the first time to alleviate a woman’s painful hip injury. "She was a hard IV stick because she had a lot of IVs in the past, so we decided to go ahead and gave it intranasally which I had never done before," she adds. "It worked very well, and she was comfortable within 30 minutes."
Recent research shows that intranasal fentanyl is an effective pain reliever for burn dressing changes, notes Wolfe.1
"In the ED, we do a lot of follow-up dressing changes and other painful procedures where a fast-acting, noninvasive, short half-life pain medication would be ideal," he says.
For minor pediatric procedures such as laceration repairs, Wolfe uses intranasal midazolam 0.5 mg/kg. "The downside is that midazolam burns when applied," he notes. "This can be overcome by pretreatment five minutes earlier with intranasal lidocaine." (See chart with procedural sedation using intranasal delivery of opiates and benzodiazepines.)
"This can be a messy procedure," says Wolfe. "Intranasal oxymetazoline plus lidocaine is an easy solution. Have the patient blow their nose, spray the meds up the nose, pinch for 10 minutes, and you are usually done. If not, they are numb, and you can cauterize them."
Makes this procedure a piece of cake’
Intranasal and oral 4% lidocaine plus oxymetazoline eliminates pain for nasogastric tube placement in most patients, says Wolfe. "This makes this painful procedure a piece of cake," he says. "It works great for fiberoptic procedures as well."
Spray the medication in both nostrils, recommends Critchett. "This way, in case it doesn’t go down one side, then the other one is numbed," she says. "Patients do seem more comfortable with the procedure."
Many emergency medical services agencies now use intranasal midazolam to sedate adults with psychiatric or drug-induced agitation, reports Wolfe. "Most use 5 mg per nostril and are anecdotally reporting good efficacy with no needlestick risk," he adds.
Intranasal naloxone awakens the vast majority of opiate overdoses without the risk of a needlestick from a heroin user, says Wolfe.
Intranasal midazolam works as well as IV diazepam and better than rectal diazepam to treat seizures in children, and it is effective in adults as well, according to Wolfe. "You can treat most seizures with intranasal therapy before you can even start an IV," he says.
1. Finn J, Wright J, et al. A randomized crossover trial of patient-controlled intranasal fentanyl and oral morphine for procedural wound care in adult patients with burns. Burns 2004; 30:262-268.
For more information about the use of intranasal drug delivery in the ED, contact: