Download Nasal Drug Delivery in EMS

Intranasal Drug Delivery – Clinical
Implications for acute trauma
Intranasal Medication cases
Case: MVC
pinned in car
A 35 year old male pinned in a car following an MVC.
Bilateral upper arm fractures, femur fracture, likely
other injuries. Screaming in pain.
 Clinical Needs: Pain control, calming, rapid
extraction, IV access (cannot do so now), transport.
 Treatment: 2.0 mcg/kg of intranasal fentanyl plus 5
mg IN midazolam
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In 7 minutes his pain is much better controlled and he is
calmer
Extraction requires 20 minutes, then full trauma
assessment and care proceeds.
Case: Excited Delirium
A 27-year old male is apprehended by police and
paramedics for extremely violent, out of control
behavior following use of cocaine and meth.
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He is bleeding from severe lacerations to his arms suffered
from punching and shattering a window
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He is at significant risk of further injuring himself and others.
It is too dangerous (needle stick risk) to give him an injection.
The paramedic administers 10 mg of IN midazolam and 7
minutes later he is calmer, an IV is established for further
sedation, pain control and future antibiotics and he is
transported safely to the hospital.
Case: Pediatric
Hand burn
A 5 year old burned her hand with boiling water
 Clinical Needs: Pain control, debride, clean and
dress the wound.
 Treatment: 2.0 mcg/kg of intranasal fentanyl (40
mcg – 0.8 ml of generic “IV” fentanyl)
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Within 3-5 minutes her pain is improved
15 minutes later the patient easily tolerates cleansing of
the burn and dressing application.
She is discharged with an oral pain
killer less than one hour after arrival.
Literature to support these cases – pediatric
long bone fractures
Nasal
Intravenous
Borland, Ann Emerg Med 2007
Literature to support this case – adults with
long bone fractures, dislocations
Steenblik, Am J Emerg Med 2012
Pain control –
Literature support
Trauma literature overview
 Over a decade of ambulance and ER literature exists for
burn, orthopedic trauma and visceral pain in both adults
and children showing the following:
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Faster drug delivery (no IV start needed) so faster onset
Equivalent to IV morphine
Superior to IM morphine
Care givers are more likely to treat pediatric severe pain
Highly satisfied patients and providers
Safe
Safety of nasal opiates
The Doubters: Surely IN drugs
can’t be as good as an injection
for pain control!
Nasal
Intravenous
ACTUALLY – They are equivalent or better (in these settings)
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Borland 2007 – IN fentanyl onset of action and quality of pain control
was identical to IV morphine in patients with broken legs and arms
Borland 2008, Holdgate 2010, Crellin 2010 - time to delivery of IN
opiates was half that of IV and more patients get treated
Kendal 2001 – IN opiate superior to IM opiate for pain control
Conclusions
 IN opiates are just as good as IV
 IN opiates are delivered in half the waiting time as IV
 IN opiate are preferred by patients, providers and parents over
injections
IN opiates for Pain control – My
insights
• I use nasal opiates in my practice - daily.
• Generic concentrations available in U.S. work fine and are
inexpensive ($1-4/vial)
• Efficacy: Very effective – and it can be titrated.
• Segway to IV therapy in the appropriate situation (fear, agitation)
• Use a pulse oximeter with sufentanil:
• Sufentanil is especially potent and must be treated with
respect.
• Fentanyl seems fine and can safely be given with minimal
risk
• Give an oral pain killer as well: It kicks in as IN drug wears off
Drug doses
Scenario
Drug and Dose
Important Reminders
Pain Control
Fentanyl: 2 mcg/kg
Sufentanil 0.5 mcg/kg
• Titration is possible
• Half up each nostril
Sedation
Midazolam: 0.4 -0.5
mg/kg
(combination w/ pain)
• Use concentrated formula
Optimizing absorption of IN
drugs
Critical
 Minimize volume - Maximize concentrationConcept
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Most potent (highly concentrated) drug should be used
 Maximize total absorptive mucosal surface area
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Use BOTH nostrils (doubles your absorptive surface area)
 Use a delivery system that maximizes mucosal
coverage and minimizes run-off.
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Atomized particles across broad surface area
Dropper vs Atomizer
Absorption
 Drops = runs down to
pharynx and swallowed
 Atomizer = sticks to broad
mucosal surface and absorbs
Usability / acceptance
 Drops = Minutes to give,
cooperative patient, head
position required
 Atomizer = seconds to
deliver, better accepted
Questions?
Educational Web site:
 www.intranasal.net