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 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 DeliriumA 27-year old male is apprehended by police and

paramedics for extremely violent, out of control behavior following use of cocaine and meth. He is bleeding from severe lacerations to his arms suffered

from punching and shattering a window 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) 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

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: 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

Pain control – Literature support

Safety of nasal opiates

The Doubters: Surely IN drugs can’t be as good as an injection

for pain control!ACTUALLY – They are equivalent or better (in these settings)

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

Nasal

Intravenous

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 dosesScenario Drug and Dose Important Reminders

Pain Control Fentanyl: 2 mcg/kgSufentanil 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

Minimize volume - Maximize concentration Most potent (highly concentrated) drug should be used

Maximize total absorptive mucosal surface area Use BOTH nostrils (doubles your absorptive surface area)

Use a delivery system that maximizes mucosal coverage and minimizes run-off.

Atomized particles across broad surface area

Critical Concept

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