My last shift started with a 3-year-old with a dog bite to the face, a 10-year-old with a forearm injury, and an anxious 16-year-old who needed a lumbar puncture. When working with children and young adults, we are constantly looking for ways to make the emergency department visit more tolerable for all involved. There are two things that have helped me come closer to that goal. The first is having child life specialists. The second is intranasal medication delivery.
Initially created for local nasal effects, intranasal medications have become a desired route for certain drugs when seeking a systemic effect. Some immunizations have found success using the intranasal method, and several other medications have followed suit, namely those used for sedation and analgesia. There are several benefits to using the intranasal route, including:
- High vascularization of the nasal mucosa
- Wide absorption area
- Avoidance of first-pass metabolism by the gastrointestinal or hepatic pathways
- Avoidance of IV placement
- High patient tolerance of the drug administration
- Quick onset of action1
The nasal fossa is divided into three parts: the vestibule, the cavity, and the turbinates (see Figure 1). The turbinates are classified into the inferior, middle, and superior. The main site for systemic drug entry is around the inferior turbinate due to its high surface area and vascularization.
There are several factors that may play into the effectiveness of intranasal drug delivery, including volume administered, particle diameter, spray administration, factors influencing the site of absorption (eg, other drugs such as phenylephrine), nasal blood flow, and mucociliary clearance and medical conditions that affect it, and these things should be taken into account when administering intranasal medications.2 The best absorbed medications have low molecular weights, are highly lipophilic, and have no net charge at physiologic pH.3
The most basic is the drip method, but this does require a compliant child to achieve success. Probably the most widely used device is the mucosal atomizer.
Intranasal delivery has been used for several different purposes including vaccinations; treatment of certain conditions such as rhinosinusitis, seizures, migraines, and diabetes insipidus; antipsychotic medications; and sedation and analgesia.4 For purposes of this article, we will focus on sedation and analgesia. Historically, two main classes of drugs have been used in intranasal administration: opioids and benzodiazepines (see Table 1 for dosing guidelines). More recently, other drugs, such as ketamine and dexmedetomidine, have also been studied.