6yo π¦ presents to your ED with multiple deep lacs after being attacked by the neighbor's π... He's screaming/crying in pain but wont let the RN get near him for an IV, looking at the π makes him π even harder.
How do you treat the pain?
(Josh)
1/...
How do you treat the pain?
(Josh)
1/...
Consider picking π!
How does intranasal drug delivery work?
β Capillary rich respiratory mucosa allows π to directly enter the π©Έ(systemic circulation)
β Olfactory mucosal absorption leads to rapid therapeutic levels in the CSF.
Source:[27397490]
2/
How does intranasal drug delivery work?
β Capillary rich respiratory mucosa allows π to directly enter the π©Έ(systemic circulation)
β Olfactory mucosal absorption leads to rapid therapeutic levels in the CSF.
Source:[27397490]
2/
A few nerdy PK pearls below:
π Quick onset of action
π Lipophilic drugs = better absorbed
π Unionized drugs π BBB more readily than ionized forms
π IN delivery bypasses GI & first past metabolism, BUT nasal mucosa contains lots of CYP450 enzymes!
PMID:[30449731]
3/
π Quick onset of action
π Lipophilic drugs = better absorbed
π Unionized drugs π BBB more readily than ionized forms
π IN delivery bypasses GI & first past metabolism, BUT nasal mucosa contains lots of CYP450 enzymes!
PMID:[30449731]
3/
Optimal for β‘οΈ Peds, no IV/IO access
Contraindicated in βοΈ Recent vasoconstrictor use (cocaine, oxymetazoline, etc), facial trauma or septal defect
Commonly used IN π in the ED β‘οΈ Fentanyl, midazolam, ketamine, naloxone, ketorolac, morphine, TXA
PMID:[28366351][29306421]
4/
Contraindicated in βοΈ Recent vasoconstrictor use (cocaine, oxymetazoline, etc), facial trauma or septal defect
Commonly used IN π in the ED β‘οΈ Fentanyl, midazolam, ketamine, naloxone, ketorolac, morphine, TXA
PMID:[28366351][29306421]
4/
π§βπΎ The PITCHFORK Studyπ©βπΎ
Double-blind RCT (n=80) in peds 3-13yo w/ mod-severe pain d/t limb injuries
β Fentanyl 1.5mcg/kg IN vs ketamine 1mg/kg IN
π Similar pain reduction on VAS @ 30min
π ADEs: Ketamine (~78%) vs fentanyl (~41%) β‘οΈ dizziness/taste/π΄π€
PMID:[25447557]
5/
Double-blind RCT (n=80) in peds 3-13yo w/ mod-severe pain d/t limb injuries
β Fentanyl 1.5mcg/kg IN vs ketamine 1mg/kg IN
π Similar pain reduction on VAS @ 30min
π ADEs: Ketamine (~78%) vs fentanyl (~41%) β‘οΈ dizziness/taste/π΄π€
PMID:[25447557]
5/
π₯The PRIME Trialπ₯ (2019)
Double-blind RCT (n=90) in children ages 8-17yo w/ acute extremity injuries
β Fentanyl 2mcg/kg IN vs ketamine 1mg/kg IN
π No difference in pain reduction on VAS @ 30min
π ADEs: Ketamine (77%) vs fentanyl (31%)
PMID:[30592476]
6/
Double-blind RCT (n=90) in children ages 8-17yo w/ acute extremity injuries
β Fentanyl 2mcg/kg IN vs ketamine 1mg/kg IN
π No difference in pain reduction on VAS @ 30min
π ADEs: Ketamine (77%) vs fentanyl (31%)
PMID:[30592476]
6/
Some tips I learned... the hard way π€¦ββοΈ
β π the kiddo's π½ for mucus or boogers. Suction is ur friend πͺ
β Use high conc. to avoid large volume β‘οΈ Peds (0.5mL per nostril)
β Positioning matters! Aim atomizer UP & OUT (point outward to the π)
Source: aliem.com/pet-pearls-intβ¦
β π the kiddo's π½ for mucus or boogers. Suction is ur friend πͺ
β Use high conc. to avoid large volume β‘οΈ Peds (0.5mL per nostril)
β Positioning matters! Aim atomizer UP & OUT (point outward to the π)
Source: aliem.com/pet-pearls-intβ¦
πBottom Lineπ
β If you pick π pick lipophilicπ
β Similar pain β¬οΈ fentanyl vs ketamine but β¬οΈ ADEs w/ Ketamine
β Pedsβ‘οΈ 0.5mL per nostril
β Aim atomizer UP & OUT point at π
Inspired by "In the Nose?!" CSHP'19 CE
by Kimberly Won PharmD BCCCP, Kevin Kaucher PharmD BCCCP
β If you pick π pick lipophilicπ
β Similar pain β¬οΈ fentanyl vs ketamine but β¬οΈ ADEs w/ Ketamine
β Pedsβ‘οΈ 0.5mL per nostril
β Aim atomizer UP & OUT point at π
Inspired by "In the Nose?!" CSHP'19 CE
by Kimberly Won PharmD BCCCP, Kevin Kaucher PharmD BCCCP
#TwitteRx do you have any tips or tricks for effective IN delivery??
Please share any experiences with IN meds you thought worked or did not work........ IN dexmedetomidine anyoneπ?
#NurseTwitter #FOAMed #MedTwitter #emergencymedicine
Please share any experiences with IN meds you thought worked or did not work........ IN dexmedetomidine anyoneπ?
#NurseTwitter #FOAMed #MedTwitter #emergencymedicine
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