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ACEP Now: Vol 34 – No 10 – October 2015(Click for larger image)
Table 1. Dr. Sorrentino’s Cheat Sheet for Intranasal Drug Dosing
Medications to Use
Midazolam is a useful drug in pediatrics for situations where you need anxiolysis and amnesia. It can be given in a variety of ways, and intranasal use has been widely studied. Doses ranging from 0.2 mg/kg to 0.5 mg/kg have been evaluated. Overall, it has been shown to have a rapid onset of action and achieve adequate sedation, and it is associated with high parent satisfaction. One consistently found drawback is that intranasal was more irritating than other routes of administration.3 One study evaluated using intranasal lidocaine as a premedication and found that its use helped prevent the burning that is often associated with the use of intranasal midazolam.5 Further prospective studies have been done, and preliminary data (ahead of publication) show similar results. Intranasal midazolam is a great choice when you need something to take the edge off but analgesia is not your main focus. I find that it works best in situations where my analgesia is managed by other means, typically topical anesthetics and/or regional blocks. Its mild amnestic properties are also helpful when it comes to potential follow-up.
Fentanyl is the ideal intranasal medication, highly lipophilic and low molecular weight. It has been shown to be more effective than intravenous morphine for pain reduction in long bone fractures.3 It is very well tolerated overall and produces adequate analgesia. It has recently been compared with intranasal ketamine and found to be equally analgesic but have fewer side effects (mainly dizziness), although they were mild overall.6 This is a great choice when you need analgesia quickly and you don’t know if you’ll need an IV or if they need to be NPO. I use this routinely before getting imaging in my orthopedic patients.
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Table 2. When to Consider Using Intranasal Analgesia and Sedation
Other agents for sedation and analgesia have also been assessed. Intranasal ketamine has been evaluated in the emergency department as well as in the pre-hospital setting. Doses ranging from 0.5 mg/kg to 9 mg/kg have been used with adequate sedation.3 Further studies need to be done to establish the ideal dose in the pediatric patient. Intranasal dexmedetomidine was evaluated in an observational study and showed good sedation and image quality when it was used for sedation for computed tomography scans in children.7
Delivery
Delivering intranasal medications can be done in a few different ways. The most basic is
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