Contemplating life.

Intranasal Medication Administration

The intranasal route of medications seems to be growing in application. This article by Kane (@antidoped) from LITFL brought my attention to a whole new array of intranasal (IN) applications. I was aware of trialling IN Naloxone (e.g. here, and a list of trials here); and the service I work in uses Intranasal Fentanyl for pain relief.

IN Fentanyl has produced satisfactory results in most cases to my liking. The main positive aspect to mention is the quick, easy and pain free application (extremely beneficial for already anxious patients, those with needle phobias, and paediatric patients). The down side list is a little longer though: Many people in pain cry, or in some other way get a snotty and blocked up nose – deeming this route ineffective. I have had some people reporting up to 7/10 pain, and still refusing a squirt of liquid up their nose (questionable reasons, I won’t go in to more details). Application is not always straight forward, some people excessively (against all carefully formulated instructions and advice) breathe in or out during administration, reducing the effective dose. Sometimes seemingly half the dose still runs out of patients noses, or runs down their throat and is swallowed. Discrepancies between given and absorbed doses are bound to happen.

The obvious that IN application brings with it is that it negates the need of IV access, or an IM needle, thus reducing the potential for needle stick injuries. Great for dodgy situations e.g. administering naloxone to a potentially HIV and Hepatitis ridden junkie, or getting some anticonvulsant in to someone actively seizing. Hypoglycaemia, a favourite patient to stay at home (under appropriate circumstances of course), too.

But it shouldn’t be the only option. As stated above, not all patients (especially in the out of hospital environment) have patent nasal passageways, and anyway…if you’re administering powerful medications to patients, you would want a line up just in case.

Or would you? That is a topic for an entirely new post. At the end of the day I recommend looking at the use of intranasal administration of certain medications. If you already are using this route, why not see if you can expand the range of meds given? There are many benefits, most of which relate to the first two rules of a paramedic: #1:crew safety, and #2:patient comfort and wellbeing. Read up the whole story on, and I would be pleased to read any experiences you may have with IN medications in the comments section below. And if you do get your hands on an atomizer, I suggest to squirt some normal saline up your own nose, in order to know what you are putting your patient through.


PM says:

Well, I agree totally on this post beside the “placing the line” part.
I worked a lot with both intranasal Midazolam (which is the main use for intranasal applications in my service) and intranasal fentanyl, the statistic software just gave me 74 midazolam intranasal applications and 21 fentanyl application.
My colleagues I had a few complications with intranasal applications (3 patients went into apnoea which ended in a “cannot ventilate and difficult airway” situation once, 4 patients showed dyspnea during transport) so we changed our personal guidelines so every intranasal patient will get an i.V. as soon as possible after the intranasal application…
Note that especially in patient with an extended amount of nasal mucus there is a “depot function” describe by a lot of users which seems like it tends to release a lot of pharmaceutical ingredient at random and at once.

flobach says:

Hi PM,
What do you use IN Midazolam for – seizure I guess?
Did not know about the ‘depot function’, but it makes sense! Do you have any literature on this?

PM says:

yes, seizures is the main use, but it might be used as a ultima-ratio in very agitated/aggressive patients when you don’t want to use haldol.

Regarding the depot thing:
I just searched more than an hour but I can’t find the paper where I read it as it was just a “side observation” of some users.
To be exact I’m not that sure if we are talking of a real depot within the mucus or something else…There might be a “lake of midazolam” within the patients noose where the mucus prevents the drugs from entering the membrane which is “flushed” away when you move the patient or something like that… But this is just guessing…. I discussed this topic on a congress in november with some experts and they experienced the same problem sometimes… But it seems like there has been no definitive study or research done on this topic.
So everything is more or less just a “user’s observation” which of course should be seen with some caution.

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