Logo

Log In Sign Up |  An official publication of: American College of Emergency Physicians
Navigation
  • Home
  • Multimedia
    • Podcasts
    • Videos
  • Clinical
    • Airway Managment
    • Case Reports
    • Critical Care
    • Guidelines
    • Imaging & Ultrasound
    • Pain & Palliative Care
    • Pediatrics
    • Resuscitation
    • Trauma & Injury
  • Resource Centers
    • mTBI Resource Center
  • Career
    • Practice Management
      • Benchmarking
      • Reimbursement & Coding
      • Care Team
      • Legal
      • Operations
      • Quality & Safety
    • Awards
    • Certification
    • Compensation
    • Early Career
    • Education
    • Leadership
    • Profiles
    • Retirement
    • Work-Life Balance
  • Columns
    • ACEP4U
    • Airway
    • Benchmarking
    • Brief19
    • By the Numbers
    • Coding Wizard
    • EM Cases
    • End of the Rainbow
    • Equity Equation
    • FACEPs in the Crowd
    • Forensic Facts
    • From the College
    • Images in EM
    • Kids Korner
    • Medicolegal Mind
    • Opinion
      • Break Room
      • New Spin
      • Pro-Con
    • Pearls From EM Literature
    • Policy Rx
    • Practice Changers
    • Problem Solvers
    • Residency Spotlight
    • Resident Voice
    • Skeptics’ Guide to Emergency Medicine
    • Sound Advice
    • Special OPs
    • Toxicology Q&A
    • WorldTravelERs
  • Resources
    • ACEP.org
    • ACEP Knowledge Quiz
    • Issue Archives
    • CME Now
    • Annual Scientific Assembly
      • ACEP14
      • ACEP15
      • ACEP16
      • ACEP17
      • ACEP18
      • ACEP19
    • Annals of Emergency Medicine
    • JACEP Open
    • Emergency Medicine Foundation
  • About
    • Our Mission
    • Medical Editor in Chief
    • Editorial Advisory Board
    • Awards
    • Authors
    • Article Submission
    • Contact Us
    • Advertise
    • Subscribe
    • Privacy Policy
    • Copyright Information

Fentanyl Versus Ketamine for Intranasal Pain Relief

By Ken Milne, MD | on March 12, 2019 | 0 Comment
Skeptics' Guide to EM
  • Tweet
  • Click to email a link to a friend (Opens in new window) Email
Print-Friendly Version

The Case

An 8-year-old boy presents to the emergency department with a painful wrist injury after falling at the playground. His parents gave him an appropriate dose of ibuprofen before arriving at the emergency department. His pain is a 7/10, and the triage nurse asks you for some additional medication for his pain while he is waiting for his X-ray.

You Might Also Like
  • ACEP Policy on Low-Dose Ketamine
  • Low-Dose Ketamine Emerges as Effective Opioid Alternative
  • When to Use Intranasal Medications in Children
Explore This Issue
ACEP Now: Vol 38 – No 03 – March 2019

Background

Children represent a group of patients who aren’t likely to receive adequate analgesia.1,2 This phenomenon is known as oligoanalgesia, or poor pain management through the underuse of analgesics. Despite three decades of research in this area, recent evidence confirms that ED pain management in children is still suboptimal.

A retrospective cohort study of children presenting to the emergency department with an isolated long-bone fracture showed almost one-third received inadequate medication, and 59 percent received no pain medications during the critical first hour of assessment.3 Other studies have demonstrated that only 35 percent of children presenting to a pediatric emergency department with fractures or severe sprains receive any analgesics.4,5 Two potential options for providing faster-acting, effective, and easy-to-administer pain medications to children are intranasal (IN) fentanyl and ketamine.

IN fentanyl is an excellent alternative to oral or IV opioids when rapid pain management is desired or IV placement is not otherwise necessary. Fentanyl at doses of 1.5–2 mcg/kg (maximum 100 mcg) provides effective and rapid analgesia comparable to that of IV morphine.

Ketamine is a noncompetitive N-methyl-D-aspartate (NMDA) and glutamate receptor antagonist that provides analgesia by virtue of decreasing central sensitization “wind-up” phenomenon (“a progressive increase in the number of action potentials elicited per stimulus that occurs in dorsal horn neurons”6) and pain memory. Sub-dissociative ketamine has been used in the adult population as an effective opioid-sparing alternative that is associated with higher rates of minor but generally well-tolerated adverse effects.

The sub-dissociative ketamine dose for children is 0.5–1 mg/kg. It can provide rapid pain management for children who lack vascular access with the added benefit of lasting longer (60 minutes) compared to IN fentanyl (30 minutes).

Clinical Question

In children with acute extremity injuries, is IN ketamine noninferior to IN fentanyl for pain management?

Reference

  1. Frey TM, Florin TA, Caruso M, et al. Effect of intranasal ketamine vs fentanyl on pain reduction for extremity injuries in children: the PRIME randomized clinical trial. JAMA Pediatr. 2019;173(2):140-146.
  • Population: Children ages 8 to 17 years presenting to the emergency department with moderate to severe pain due to traumatic limb injuries (visual analogue scale >35 mm).
    • Exclusions: Significant head, chest, abdomen, or spine injury; Glasgow Coma Scale <15 or inability to report a visual analogue scale score; nasal trauma or aberrant nasal anatomy; active epistaxis; ketamine or fentanyl allergy; history of psychosis; opioid administration prior to arrival; non-English speaking; in police custody; and postmenarchal girls without a negative pregnancy test.
  • Intervention: IN ketamine 1.5 mg/kg (max 100 mg)
  • Comparison: IN fentanyl 2 mcg/kg (max 100 mcg)
  • Outcomes:
    • Primary Outcome: Pain reduction after 30 minutes.
    • Secondary Outcomes: Sedation level, capnometry values, adverse events, the need for rescue analgesia, and change in vital signs.

Authors’ Conclusions

“Ketamine provides effective analgesia that is noninferior to fentanyl, although participants who received ketamine had an increase in adverse events that were minor and transient. Intranasal ketamine may be an appropriate alternative to intranasal fentanyl for pain associated with acute extremity injuries. Ketamine should be considered for pediatric pain management in the emergency setting, especially when opioids are associated with increased risk.”

Pages: 1 2 3 | Single Page

Topics: FentanylKetaminePain and Palliative CarePain Management

Related

  • June 2025 News from the College

    June 5, 2025 - 1 Comment
  • CHANTER Syndrome—Fentanyl and Cocaine Use Meets Neurotoxic Edema

    May 8, 2025 - 0 Comment
  • Evidence Mounts Backing Rescue Ketamine for Prehospital Status Epilepticus

    April 30, 2025 - 0 Comment

Current Issue

ACEP Now: July 2025

Download PDF

Read More

About the Author

Ken Milne, MD

Ken Milne, MD, is chief of emergency medicine and chief of staff at South Huron Hospital, Ontario, Canada. He is on the Best Evidence in Emergency Medicine faculty and is creator of the knowledge translation project the Skeptics Guide to Emergency Medicine.

View this author's posts »

No Responses to “Fentanyl Versus Ketamine for Intranasal Pain Relief”

Leave a Reply Cancel Reply

Your email address will not be published. Required fields are marked *


*
*

Wiley
  • Home
  • About Us
  • Contact Us
  • Privacy
  • Terms of Use
  • Advertise
  • Cookie Preferences
Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies. ISSN 2333-2603