A 12 year old fell off his bicycle and fractured his distal arm.
He is in significant pain.
EMS protocols call for IN administration of fentanyl (2 mcg/kg).
10 minutes later the child’s pain is improved but still substantial.
After a second dose of IN fentanyl he is comfortable.
Scenario 2: Frightened child
A 3-year old boy requires head CT scan (or a number of other procedures).
He does not have an IV in place and is terrified of needles.
He will not relax and clings to his parent.
You administer 0.5 mg/kg of IN midazolam and 10 minutes later he is dozing off and is easily separated from his parent and taken over for his testing.
Scenario 3: Seizing child
EMS is enroute with a 3 y.o. girl suffering a grand mal seizure for at least 15 minutes.
No IV can be established.
Rectal diazepam (Valium) is unsuccessful at controlling the seizure.
IV attempts in the ED are also unsuccessful.
However, on patient arrival a dose of nasal midazolam (Versed, Dormicum) is given and within 3 minutes of drug delivery the child stops seizing.
Scenario 4: Epistaxis
A 60 y.o male arrives at the ED with his third episode of epistaxis in 3 days.
He was cauterized and packed in another ED the day prior, but started bleeding 5 hours after the packing was removed.
You administer 1 ml of oxymetazoline (Afrin) into the nostril, and insert an oxymetazoline soaked cotton pledget.
15 minutes later his nasal mucosa is dry.
You discharge him with instructions to use oxymetazoline TID for 3 days, and to self treat in the future if possible.
Scenario 5: Heroin Overdose
EMS responds to an unconscious male. He has slow respirations, pinpoint pupils, cool dusky skin and obvious intravenous drug abuse needle track marks on both arms.
After an IV is established, naloxone (Narcan) is administered and the patient is successfully resuscitated.
Unfortunately, the paramedic suffers a contaminated needle stick while establishing the IV.
The patient admits to being infected with both HIV and hepatitis C. He remains alert for 2 hours in the ED with no further therapy (i.e.- no need for an IV) and is discharged.
Scenario 5: Heroin Overdose
The paramedic is given his first dose of HIV prophylactic medications. No treatment for hep C prophylaxis exists.
The next few months will be difficult: He faces the substantial side effects that accompany HIV medications and his personal life is in turmoil due to issues of safe sex with his wife and the mental anguish of waiting to see if he will contract HIV or hepatitis C.
A friend informs him that new evidence suggests that naloxone is effective at reversing heroin overdose if it is given intranasally – with no risk of a needle stick.
The problem! NEEDLESTICKS
Nasal drug delivery is attractive not because it is BETTER than injectable therapy……
BUT
…Because it is SAFER!
..No needle NO needle stick risk!
The problem! NEEDLESTICKS
The CDC estimates:
600,000 percutaneous injuries each year involving contaminated sharps in the U.S. A..
Technological developments can increase protection.
Nasal drug delivery is convenient and easy, but it may not always be effective.
Nasal drug delivery cannot completely replace the need for injections.
Being aware of the limitations and using the correct equipment and drug concentrations will assist you in predicting times when nasal drug delivery may not be effective.
Atomized spray of medications show much better absorption via the IN route
Bryant et al, Nucl Med Comm, 1999
Daley-Yates et al, Br J Clin Pharm 2001
Henry et al, Ped Dent 1998
“Intranasal Administration of Naloxone by Paramedics”
Prospective clinical trial
Preliminary study February, 2001
Barton et al, Prehosp Emer Care 2002
Final study completed
Barton et al, J Emerg Med 2005
Kelly et al, Med J Aust 2005 (a study in Australia)
Study design:
Required all patients to get an IV and IV naloxone (standard care) – however nasal naloxone was administered first and if the patient awoke prior to IV therapy they could stop.
IN Naloxone by Paramedics
Prehospital IN Naloxone
Results
43/52 (83%) = “IN Naloxone Responders.”
Median time to awaken from drug delivery = 3 min.
Median time from first contact = 8 min.
9/52 (17%) = “IN Non-responders.”
4 patients noted to have “epistaxis,” “trauma,” or “septal abnormality.”
Note – no one waited for them to respond, once IV started they got IV naloxone so some cases were given IV naloxone before the nasal drug could absorb.
Potentially higher if one waits a few minutes for its effect prior to giving IV naloxone.
Inexpensive device
Syringe driven atomizer
May decrease prehospital blood exposures
29% no IV in the field (woke up before one could be started.) Potential for at least 83% with no IV.
Other Naloxone Studies…
IV vs. SQ Naloxone:
Wanger et al, Acad Emer Med, 1998.
196 patients in Vancouver, BC.
IV naloxone (0.4mg) vs. SQ (0.8mg).
Response time = crew arrival to RR > 10.
Median response time IV = 9.3 min.
Median response time SQ = 9.6 min.
Conclusions = No significant difference.
Delay in SQ response offset by time for IV insertion.
*Median response time IN naloxone = 8.0 min.
Point: IN responses from time of arrival to RR > 10 are same as those for IV and SQ.
Prehospital IN Naloxone
Take away lessons for nasal naloxone:
Dose and volume – higher concentration preferred so use 1mg/ml IV solution.
Delivery – immediately on decision to treat inject naloxone into nose with atomizer, then begin standard care.
Successful awakening eliminates the need for any IV or further ALS care.
Awakening is gradual-patient doesn’t jump off the bed, but adequate respiratory efforts occur as fast or faster than IV naloxone due to no delays with IV start.
Not 100% effective so failures with IN naloxone need to be followed with IV naloxone.
What if intranasal naloxone does not work?
1st - Continue ABC’s to support breathing and circulation.
2nd – Administer Naloxone IM or IV.
3rd - Consider other causes for coma:
AEIOU-TIPPS
Is there anything you can do for these processes?
Protocol: Dosing for IN naloxone
Inspect nostrils for mucus, blood or other problems which might inhibit absorption.
(If these are present, consider other routes and be aware of increased risk of failure.)
Draw 2mg of 1mg/ml solution for delivery by atomizer device.
Give ½ of volume in each nostril.
Support ventilations for 3 to 4 minutes, if no response proceed to IV therapy and consider other causes for coma.
