CLINICALIntranasal Drug Delivery: An Alternative to Intravenous Administration in Selected Emergency Cases
Section snippets
Factors affecting nasal drug absorption
The percentage of medication that ends up in the bloodstream after administration is termed “bioavailability.” Intravenous medication is 100% bioavailable after administration. Oral medications are about 5% to 10% bioavailable because of gastrointestinal and hepatic destruction. Intranasal medication bioavailability varies from negligible to almost 100%.
If a drug molecule can cross the nasal mucosa, the primary factors influencing bioavailability are medication concentration and volume,
Intranasal medication delivery in the emergency department
A number of commonly used ED medications are effective when delivered intranasally. These medications include the synthetic opiates fentanyl and sufentanil for the treatment of acute pain; midazolam, for procedural sedation and for the treatment of seizures; naloxone, for opiate overdose; and topical anesthetics/vasoconstrictors for use prior to nasal intubation or nasogastric tube (NGT) placement or for the treatment of epistaxis (Table 2).
Pain control: intranasal opiates
Many patients who visit the emergency department fail to obtain adequate pain relief.4 One reason is the lack of a rapid, effective, painless method for pain control. Nasal opiates offer an effective, inexpensive solution. The synthetic opiates fentanyl and sufentanil are uniquely suited for transmucosal delivery because of their high lipid solubility and their high potency (100 to 1000 times more potent than morphine).2., 5., 6., 7. Sufentanil is probably the best opiate medication currently
Procedural sedation: intranasal opiates, benzodiazepines, and ketamine
Procedural sedation also can be achieved using intranasal medications.5., 7., 8. Midazolam is the most commonly studied medication for this indication, although data on fentanyl, ketamine, sufentanil, and combinations of these drugs are available.5 The data allow a few generalizations. First, intranasal medications are effective for mild to moderate sedation but not for deep sedation. Second, benzodiazepines and opiates produce varying levels of patient sedation, regardless of the route of
Seizure control: intranasal benzodiazepines
In situations where an intravenous line is not available, intranasally administered benzodiazepines offer a rapid, effective method to treat an acutely seizing patient. Fisgin et al9 found that intranasally administered midazolam was effective in 87% of patients with prolonged seizures, whereas rectally administered diazepam was only effective 60% of the time (P < 0.05). The authors concluded that intranasal midazolam is more effective, socially acceptable, and convenient than rectally
Nasopharyngeal procedures: nasal and oral 4% lidocaine
Nasogastric tube placement is a very painful procedure. Nevertheless, it is routinely performed with little or no analgesia.13 A number of prospective studies demonstrate that topical 4% lidocaine applied to both the nose and the throat results in dramatic reduction in pain compared with lidocaine jelly alone.13., 14. The addition of a topical vasoconstrictor also appears beneficial because of nasal mucosal shrinkage and the prevention of epistaxis. These data strongly suggest that topical
Epistaxis: nasal oxymetazoline and 4% lidocaine
Epistaxis is a common and messy problem, and its treatment can require substantial time and resources. Interestingly, otolaryngologists note that most epistaxis is easily controlled with intranasal oxymetazoline.16., 17. This method eliminates suction, cautery, and nasal packing, and the patient can continue topical oxymetazoline treatment at home. Triage nurses can start the treatment (in patients without significant cardiovascular disease), often resulting in bleeding cessation before the
Opiate overdose treatment: intranasal naloxone
Intravenous drug abusers requiring injectable naloxone place the emergency nurse at an especially high risk for bloodborne pathogen exposure.19 Because these patients rarely need an intravenous line for any reason beyond the administration of naloxone, it would be helpful to have a needleless method for administering the medication.20 Fortunately, naloxone is a small molecule that easily crosses the nasal mucosal membranes. Intranasal naloxone exhibits opiate antagonist effects almost as
Conclusion
Although the intranasal route is a rapid and convenient way to deliver medications in the emergency department, it will not replace the need for injections. However, awareness of its limitations combined with the correct equipment and medication concentrations will allow emergency nurses to bypass the need for intravenous lines in certain cases. This improves the safety of the work environment and eliminates the professional, personal, and family turmoil that may occur when a medical worker
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