Intranasal Analgesia

Intranasal

Being flexible and creative are important traits to have while working the ED.  It is also vital to always keep the end result in mind.  Pain control is always an important endpoint for us to constantly consider.  While most of us would say that we strive alleviate our patients’ pain, there is evidence that we are not great at it.

 

It’s Complicated

  • Why would we not alleviate pain optimally?  Well, like many things, it is more complicated than us just cruel and sadistic.
  • Certainly, there used to be a perception that pain in kids (especially neonates) was not as important since they wouldn’t remember it. – WRONG.
  • Additionally, there are times when our consultants have “requested” that we didn’t give pain medications (ex, Morphine for Appendicitis). – A MYTH.
  • Of course, we need to always remain optimally educated on the subject (THANKS FOR READING THE PEDEM MORSELS!).
  • But even with a highly educated and compassionate provider, delivering appropriate analgesics in a timely fashion is not easy:
    • You have to evaluate the patient, then write the orders.
    • Often these orders include Intravenous Analgesics (ex, IV Morphine).
    • This, in turn, requires an IV.
      • Now, in a busy ED, a nurse may not be able to promptly jump in that room an place the IV.
      • Placing an IV is also not always an easy task.
    • All of these steps and possible obstructions can easily lead to delayed analgesic administration.
    • Now, despite how compassionate you are… you appear to be cruel!

 

Intranasal Route – No Need for an IV

  • We all know that the blood supply to the nose is quite robust.
    • Anyone who has bonked their nose knows.
    • Our patients who snort heroine or cocaine also know.
  • The venous drainage from the nose conveniently ends up in the SVC, avoiding the liver (and 1st pass metabolism).
  • The anterior potion of the nose (the Vestibule) is the main site for drug absorption as it has a relatively large surface area and has a good blood supply.
  • Volumes of 0.3 mL are easily tolerated.
    • This requires concentrated solutions of the administered medications.
    • If you need to use larger volumes, you can divide the dose in half and use each nostril.
    • If the volume is still too large, you can administer in separate aliquots separated by 10-15 minutes… or use another strategy (nothing is perfect).

 

Intranasal Fentanyl to the Rescue

  • Fentanyl is a great example of a medication that works well when given via the intranasal route.
    • It has a low molecular weight.
    • It is lipophilic.
    • It has concentrated versions (50 microgr/mL – 150 microgr/mL).
  • Fentanyl (1-2 micrograms/kg) given via intranasal route has proven to be as efficacious as IV Morphine (0.1 mg/kg).
  • It has also been shown that intranasal fentanyl can be administered more rapidly than IV morphine to pediatric patients in the ED.

 

A Reasonable Approach (at least I think so)

  • Intranasal Fentanyl can be delivered before even an IV can be placed.
  • Even if you still need an IV (say for the grossly deformed forearm that you know will need procedural sedation), the intranasal fentanyl is still a faster way to get analgesics on board.
    • Yes, it might require some explanation that you are going to squirt pain meds up the kid’s nose and then still place an IV… but the focus is on delivering pain meds quickly.
    • This will likely also help the nursing team trying to get the IV, as now they have a more comfortable and cooperative patient.
    • It also helps speed up the process for getting your X-rays… now you are not waiting for the IV to give the pain meds so that you don’t feel like a sadist getting the xrays.
  • In the end, this also helps you… not feeling like a sadist is very helpful in avoiding compassion fatigue... and will help keep you happier as a physician!

 

 

 

 

References

Del Pizzo J1, Callahan JM. Intranasal medications in pediatric emergency medicine. Pediatr Emerg Care. 2014 Jul;30(7):496-501; quiz 502-4. PMID: 24987995. [PubMed] [Read by QxMD]

Dong L1, Donaldson A, Metzger R, Keenan H. Analgesic administration in the emergency department for children requiring hospitalization for long-bone fracture. Pediatr Emerg Care. 2012 Feb;28(2):109-14. PMID: 22270501. [PubMed] [Read by QxMD]

Holdgate A1, Cao A, Lo KM. The implementation of intranasal fentanyl for children in a mixed adult and pediatric emergency department reduces time to analgesic administration. Acad Emerg Med. 2010 Feb;17(2):214-7. PMID: 20070272. [PubMed] [Read by QxMD]

Borland M1, Jacobs I, King B, O’Brien D. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med. 2007 Mar;49(3):335-40. PMID: 17067720. [PubMed] [Read by QxMD]

Bauman BH1, McManus JG Jr. Pediatric pain management in the emergency department. Emerg Med Clin North Am. 2005 May;23(2):393-414, ix. PMID: 15829389. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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5 Responses

  1. Seth Brown says:

    Hi Sean,

    EXCELLENT morsel this week. I recently finished my PEM fellowship at Kosair Children’s Hospital (Louisville, KY) and really enjoy reading the morsels each week. Intranasal fentanyl is one of my favorites – especially with both bone forearm fractures prior to IV placement.

    I am working in Northeast TN as an attending at a smaller pediatric ER (Niswonger Children’s Hospital in Johnson City) and frequently perform educational outreach for critical access hospitals in rural areas. If these rural ERs don’t routinely stock atomizers for intranasal delivery, what are your thoughts regarding nasal delivery without an atomizer?

    Thanks again for distributing such an awesome weekly educational tidbit!

    Seth Brown

    • Sean Fox says:

      Seth,
      Thank you for your support!
      You can “Drip” the fentanyl (or other medication like Versed) into the nostril also… kind of tricky… need to position the patient to optimize the distribution to the vestibule. That does work though. I’d advocate for atomizer.

      Thank you,
      sean

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