Medical Education

Intranasal Medications

CASE

A 7 year-old girl presents after falling off a jungle gym.  She has a visible deformity of the left humerus and wrist.  She won’t let the nurse get close enough for a blow-dart, let alone an IV, and your attending slaps the IO kit out of your hands as you desperately try to boost your procedure numbers.  She needs pain relief.  Now what?

BACKGROUND

Intranasal (IN) administration of medications enables rapid systemic delivery, avoids first-pass metabolism, and negates the pain associated with IV access.  Delivery is quick and can be accomplished with minimal training.[1]

The rate limiting factor for IN administration is the area of available nasal mucosa, i.e. your absorptive surface.  Typically, IN administration is limited to volumes less than 1 mL per nostril, perhaps less with the presence of intranasal blood or mucous, necessitating a higher concentration to achieve the desired effect.

The most effective method of IN administration is an atomizer (Figure 1).  Crushing medications or using a syringe as a dropper results in incomplete distribution across the nasal mucosa, imprecise delivery, and unpredictable bloods levels.  Atomizers achieve better delivery, less drug loss to the oropharynx, and greater clinical efficacy.[1]

Figure 1: LMA MAD NASAL atomizer attached to 3 mL syringe

Figure 1: LMA MAD NASAL atomizer attached to 3 mL syringe

IN administration carries a low risk of adverse effects and beyond the time saved via ease of IN administration, the cost is comparable to IV delivery, usually under $10.00 per dose.

INDICATIONS

There has been a push in recent years to develop IN formulations of marketed products, including drugs for migraine management, smoking cessation, and even hormone replacement therapy.[2]  The full breadth of indications for the current IN drug pipeline is beyond the scope of this post, in which we will focus on the indications for which IN medications are used in emergency or pre-hospital settings.

Pain.  Acute pain is a common problem in pediatric medicine, and multiple studies have proven IN administration of opioids to be as effective as the IV route without the need to establish access, and faster onset than IM delivery.  The ease of administration has also made it popular with first responders and practitioners in austere environments.  At Hasbro Children’s Hospital, we commonly use fentanyl.  Dose at 1.5 - 2.0 mcg/kg, allow 10-15 minutes for full effect, and consider co-administration of an oral medication or bridge to IV for longer-term analgesia.[1]

Anxiolysis.  There are numerous reasons children need to stay still during treatments, such as procedures, imaging, or dressing changes.  Midazolam is the most commonly used and well-studied IN anxiolytic, although other options include ketamine and dexmedotomidine.  Although IN midazolam is associated with a transient burning sensation (due to a preservative) in the nares during administration, studies have shown monotherapy provides satisfactory anxiolysis, with minimal risk of adverse events.  Dose at 0.3 - 0.5 mg/kg and allow 5-7 minutes for the medication to take effect.

Seizure.  Because the well-vascularized nasal mucosa is brain-adjacent, IN administration can quickly achieve therapeutic levels in CSF.  In cases without IV access, IN midazolam was found to have a more rapid onset of action than rectal diazepam for better seizure control, and decreased need for intubation and hospital admission.[1]

Overdose.  The opioid epidemic is a national emergency, and with the rise in deaths has come a push for first responders to use naloxone in cases of suspected overdose.  Kits come in 2 and 4 mg doses, and include an ampule of naloxone and an atomizer.

Figure 2: Naloxone IN kit

Figure 2: Naloxone IN kit

ADMINISTRATION TECHNIQUE

Approach from the side.  Even without needles, children will react to seeing a syringe with a lot of anxiety.  Approaching from the side will minimize this, allow you to get in a better position, and achieve better drug delivery.

Use both nostrils.  If you only use one nostril, you’re missing out on an entire half of the nasal mucosa!  Instead of spraying the entire volume into your favorite nares, spread the dose equally between right and left.

Direct the spray.  When you introduce the atomizer, point the tip laterally towards the tip of the ear.  This will afford you better coverage of the turbinates and mucosa.

Use the right concentration.  Using a higher concentration of medication allows you to use less volume, and since absorption is limited by volume when it comes to IN delivery, less drug will be lost.[3] 

SUMMARY 

IN administration of medications is a safe and effective way to manage a number of conditions in situations where other means of drug delivery are inefficient, ineffective, or not available.  As for the patient from our introductory case, she received 25 mcg of IN fentanyl with great improvement in her pain, got x-rays that confirmed a displaced fracture, and tolerated reduction of her wrist with procedural sedation.

Faculty Reviewer: Dr. Chris Merritt

references 

  1. Wolfe TR, Braude DA. Intranasal Medication Delivery for Children: A Brief Review and Update. Pediatrics. 2010; 126: 532-537.

  2. Fortuna A, Alves G, Serralheiro A, Sousa J, Falcao A. Intranasal delivery of systemic-acting drugs: small-molecules and biomacromolecules. Eur J Pharm Biopharm. 2014; 88(1): 8-27.

  3. Using the MAD Nasal Intranasal Mucosal Atomization Device. Teleflex Medical Europe Ltd. Ireland. www.lmaco.com/products. Accessed August 24, 2017.

 

Interview with Dr. Jessica Mason

Welcome to a special episode of the Brown Emergency Medicine Podcast. In this episode, we have the pleasure of hearing from Dr. Jessica Mason in an interview conducted by Brown EM resident Dr. Jessie Werner.

Dr. Mason speaks with us regarding her career as an Emergency Medicine physician and renowned educator. She describes how she got her start with podcasting with her series ‘Med Forum’ and how she expanded her reach to not only physicians with ‘EM:RAP’ and ‘Resident Call Room,’ but also to non-physicians with her series ‘This Won’t Hurt a Bit.’

Listen Now:

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Jessica Mason, MD

Assistant Clinical Professor, Department of Emergency Medicine, UCSF Fresno

Dr. Mason is an Assistant Clinical Professor at UCSF Fresno and is the fellowship director of the Emergency Medicine Medical Education fellowship. She is the Deputy Editor of EM:RAP and the Managing Editor of EM:RAP C3, EM:RAP HD, EM:RAP Live, and EM:RAP C3. She is also a co-host and writer for the podcast series ‘This Won’t Hurt a Bit.’

Special thanks to Dr. Jessica Mason for her mentorship in creating this podcast and for her ongoing dedication to medical education.


Catch our other interviews and other new series on our new Brown EM Podcast iTunes stream. Subscribe here!

AEM Education and Training 09: Looking Through the Prism - Caring for LGBTQI Patients in the ED

Welcome to the ninth episode of AEM Education and Training, a podcast collaboration between the Academic Emergency Medicine E&T Journal and Brown Emergency Medicine. Each quarter, we'll give you digital open access to AEM E&T Articles or Articles in Press, with an author interview podcast and links to curated supportive educational materials for EM learners and medical educators.

Find this podcast series on iTunes here.

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DISCUSSING (CLICK ON TITLE TO ACCESS):

Looking Through the Prism: Comprehensive Care of Sexual Minority and Gender‐nonconforming Patients in the Acute Care Setting. Angela F. Jarman MD, MPH; Alyson J. McGregor MD, MA; Joel L. Moll MD ; Tracy E. Madsen MD, ScM; Elizabeth A. Samuels MD, MPH; Mollie Chesis; Bruce M. Becker MD.

LISTEN NOW: AUTHOR INTERVIEW WITH angela jarman, MD, Mph

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Angela Jarman, MD, MPH

Assistant Professor, Department of Emergency Medicine

University of California, Davis

This interview discusses a commentary in AEM E&T which synthesizes a didactic session co‐led by the SAEM Sex and Gender in Emergency Medicine Interest Group and the Academy for Diversity and Inclusion, which was presented by the authors at the SAEM 2018 annual meeting in Indianapolis, Indiana.

The National Institutes of Health have recently recognized LGBTQ (lesbian, gay, bisexual, transgender, queer) as an official health disparity and designated the Sexual and Gender Minority Research Office in an effort to support evidence‐based medical care for this underserved patient population. As the front line of medical care for the underserved, emergency medicine (EM) physicians need to be equipped with the tools to care for these patients in a culturally competent and clinically appropriate manner. EM providers must develop an understanding of their patients’ social and medical context to provide both sensitive and effective care and to teach residents and other learners. A significant number of patients who seek treatment in the emergency department define themselves as LGBTQI—lesbian, gay, bisexual, transgender, queer, or intersex. This commentary combines both affective and objective information on the importance of semantics and language, appropriate communication, and confronting our own implicit biases in caring for this vulnerable population, creating a unique perspective and paradigm for the practice of EM and a blueprint for education. 

The authors have provided this handout for further information:

https://drive.google.com/file/d/1WDyk0HcCCP3DKmgGRdom53s8LKZB5Znz/view?usp=sharing

Excerpt:

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ADDITIONAL REFERENCES:

“Don’t be a jerk” EM Pulse Podcast, Episode 9. https://ucdavisem.com/2018/07/17/dont-be-a-jerk/

http://www.transstudent.org/gender/

NIH ORWH sex/gender. Available at https://orwh.od.nih.gov/research/sex-gender.

Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual and Transgender Health Issues and Research Gaps and Opportunities. The health of lesbian, gay, bisexual, and transgender people. National Academies Press (US), Washington, DC; 2011

Clayton JA, Tannenbaum C. Reporting Sex, Gender, or Both in Clinical Research? JAMA 2016; 316(18):1863-1864

Madsen TE, Bourjeily G, Hasnain M, Jenkins MJ, Morrison MF, Sandberg K, Tong IL, Trott J. Sex- and Gender-Based Medicine: The Need for Precise Terminology. Gender and the Genome;1(3):122-28.

Schuster MA, Reisner SL, Onorato SE. Beyond bathrooms — meeting the health needs of transgender people. NEJM 2016;375:101–103.

Soc Sci Med. 2014 Feb;103:33-41. doi: 10.1016/j.socscimed.2013.06.005. Epub 2013 Jun 18.

Structural stigma and all-cause mortality in sexual minority populations. Soc Sci Med. 2014 Feb;103:33-41. doi: 10.1016/j.socscimed.2013.06.005. Epub 2013 Jun 18.

The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding Editors: Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities.

Bauer GR, Scheim AI, Deutsch MB, et al. Reported Emergency Department Avoidance, Use, and Experiences of Transgender Persons in Ontario, Canada: Results From a Respondent-Driven Sampling Survey. Annals of Emergency Medicine. 2014;63(6):713-720.

Brown JF, Fu J. Emergency department avoidance by transgender persons: another broken thread in the "safety net" of emergency medicine care. Annals of Emergency Medicine. 2014;63(6):721-722.

Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. Available at www.transhealth.ucsf.edu/guidelines .

Chisolm-Straker M, Jardine L, Bennouna C, Morency-Brassard N, Coy L, Egemba MO, Shearer PL (2017) Transgender and gender nonconforming in emergency departments: a qualitative report of patient experiences, Transgender Health 2:1, 8-16, DOI: 10.1089/trgh.2016.0026.

Deutsch MB, Jamison Green, Keatley J, Mayer G, Hastings J, Hall AM. Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health. J Am Med Inform Assoc. 2013;20:700-703

IOM. Collecting sexual orientation and gender identity data in electronic health records: Workshop summary. Washington, DC: Institute of Medicine;2013.

James SE, Herman JL, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality;2016.

Jalali S, Sauer LM. Improving Care for Lesbian, Gay, Bisexual, and Transgender Patients in the Emergency Department. Annals of Emergency Medicine. 2015;66(4):417-423.

Lambda legal. Creating equal access to quality health care for transgender patients: transgender-affirming hospital policies. May 2016. Http://assets.Hrc.Org//files/assets/resources/transaffirming-hospitalpolicies-2016.Pdf?_Ga=2.179968679.225917522.1494296888-1373396650.1480810731

Samuels EA, Tape C, Garber N, Bowman S, Choo EK. “Sometimes you feel like the freak show”: A Qualitative Assessment of Emergency Care Experiences Among Trans and Gender Non-Conforming Patients. Ann Emerg Med 2017: doi:10.1016/j.annemergmed.2017.05.002.

World Professional Association for Transgender Health, Standards of Care for the Health of Transexual, Transgender, and Gender Nonconforming People 5 (7th ed.), http://www.wpath.org/uploaded_ les/140/ les/Stan- dards%20of%20Care,%20V7%20Full%20Book.pdf