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Common Medications Administered Via Intranasal Route

Medications that may be administered intranasally include but are not limited to fentanyl, ketamine, midazolam, and naloxone. Use the injectable formulation of medication for preparation.

Fill the syringe with the ordered dose and volume of medication. Add an additional 0.1 mL of drug volume to the syringe to account for dead space in the atomizer. Connect Mucosal Atomization Device (MAD) using the luer-lok system. With the head gently tilted back and supported, place the atomizer snugly against the nostril of the patient and briskly compress half of the drug volume into each nostril.

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 Intranasal Medications and You

Learn the strengths and limits of intranasal fentanyl, midazolam, ketamine, and dexmedetomidine.

 Intranasal Medications in the Pediatric ER

This method is used to rapidly provide anxiolysis, sedation, amnesia, and/or analgesia in the pediatric population and can play an important role in a safe and successful intervention. Let’s review four common intranasal medications used in the ER: fentanyl, versed, ketamine, and dexmedetomidine.

 Up the Nose-Intranasal Medication Administration

For naloxone, fentanyl and midazolam or lorazepam in seizures the effect onset is 3-4 minutes but it keeps absorbing for 15. So relax, manage the airway if needed, they will wake up and breath in a few minutes which is all you really want (opiate OD) or stop seizing in a few minutes. This usually is in the time frame it takes to establish an IV anyhow – so just give the nasal drug, support their airway and don’t stress out. As long as you can oxygenate them – don’t get in a hurry with a needle.

 When Minutes Count: Intranasal Medications

Importantly, IN midazolam is a safe and equally effective option in children with seizures compared with IV or rectal benzodiazepines. Intranasal midazolam at 0.2 mg/kg can be used quickly and easily inside and outside (with the release of prescription intranasal benzodiazepines) a hospital setting for rapid acute seizure cessation.

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HINT: How to use a nasal atomizer to safely deliver intranasal medication

Draw up the required dose into a single Luer-Lock syringe. Draw up an extra 0.1 ml of medication to account for the medication that will remain in the neck of the MAD (known as the "dead space") after administering the dose.

Intranasal Drug Administration — An Attractive Delivery Route for Some Drugs

Intranasal drug administration has a long tradition and was and is still used for medical as well as recreational purposes. The most common use is for treatment of local symptoms e.g. nasal congestion in the course of a common rhinitis or inflammation linked to allergic rhinitis. The medications intended for local activity are well established and can be found across the globe in every pharmacy and drug store.

Intranasal drug delivery in pediatric emergency departments: brief review and future outlook

Currently, IN medications have various indications in PEDs, including for sedation, analgesia, anxiolysis, anti-inflammation, abortive therapy for migraine, and initial treatment for status epilepticus.

Intranasal Medications

Anxiolysis. There are numerous reasons children need to stay still during treatments, such as procedures, imaging, or dressing changes. Midazolam is the most commonly used and well-studied IN anxiolytic, although other options include ketamine and dexmedotomidine. Although IN midazolam is associated with a transient burning sensation (due to a preservative) in the nares during administration, studies have shown monotherapy provides satisfactory anxiolysis, with minimal risk of adverse events. Dose at 0.3 - 0.5 mg/kg and allow 5-7 minutes for the medication to take effect. Seizure. Because the well-vascularized nasal mucosa is brain-adjacent, IN administration can quickly achieve therapeutic levels in CSF. In cases without IV access, IN midazolam was found to have a more rapid onset of action than rectal diazepam for better seizure control, and decreased need for intubation and hospital admission.

Not Just a Single Squirt: Understanding Nasal Drug Delivery

Direct the atomized spray toward the top of the ear on the same side: Aiming upward and slightly lateral (toward the top of the ear) causes the medication to be directed away from the nasal septum (poorly vascularized) and towards the rich vascular mucosa of the turbinates and olfactory mucosa. This leads to better surface area coverage of the vascular mucosa and less runoff down along the septum into the throat.

Pain Profiles: Review of Intranasally Administered Medications for Use in the Emergency Department

Administration of IN analgesics while being triaged and worked up could result in an effective bridge prior to initiation of an individualized treatment regimen. This is but one example of IN utilization I envision incorporating into my own pain management practice and I appreciate the overview this article provided to do so.

Review of Intranasally Administered Medications for Use in the Emergency Department

IN medication delivery offers my two most favored characteristics of an analgesic regimen – ‘quick and painless’. I see great utility of this within an emergency setting, beyond just the well-discussed pediatric population. In my experience, sickle cell crisis patients often suffer through long ED wait times, hematology or pain management consults, and multiple IV access attempts, often requiring ultrasound guidance.

The benefits and drawbacks of intranasally-delivered medications

The nasal cavity is the only accessible surface on your body that has direct access to the central nervous system. But there are a few important considerations for using this administration route for brain-targeted medications.

When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications

The intranasal route for medication administration is increasingly popular in the emergency department and out-of-hospital setting because such administration is simple and fast, and can be used for patients without intravenous access and in situations in which obtaining an intravenous line is difficult or time intensive (eg, for patients who are seizing or combative). Several small studies (mostly pediatric) have shown midazolam to be effective for procedural sedation, anxiolysis, and seizures. Intranasal fentanyl demonstrates both safety and efficacy for the management of acute pain.

When to Use Intranasal Medications in Children

Midazolam is a useful drug in pediatrics for situations where you need anxiolysis and amnesia. It can be given in a variety of ways, and intranasal use has been widely studied. Doses ranging from 0.2 mg/kg to 0.5 mg/kg have been evaluated. Overall, it has been shown to have a rapid onset of action and achieve adequate sedation, and it is associated with high parent satisfaction.

Resources

4 Tips for Intranasal Medication Administration

Need a fracture reduced or a large laceration repaired in an uncooperative child? Then intranasal administration might not be the best option. Although there’s the theory of improved PK into the CNS, administering the required volume into a patient’s nose isn’t ideal, practically speaking.

Versed (Midazolam)

How to give intranasal midazolam...