Common Medications Administered Via Intranasal Route

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Rachel Rafeq
Emergency medicine pharmacist and toxicology enthusiast. Trained in medication safety and I apply that to everything. I love photography and world schooling my kids.

Pre-Brief

Intranasal medication administration can be a non-invasive way to administer medications resulting in a quick onset of action.  It’s a great option when you don’t have a line in place, or have anxious kiddo in the trauma bay. The pharmacokinetics of medications administered intranasally are optimized when administered via an intranasal mucosal atomization device (MAD), which fits on a standard luer-lock fitting syringe. It aerosolizes the medication, results in decreased particle size, and increases the surface area to which the medication is exposed.

Advantages

  • Needleless route of administration
  • Fast onset of action
  • Preferable pharmacokinetics over the intramuscular route 

Disadvantages

  • Volume limit
  • Not recommended in patients with recent use of intranasal vasoconstrictors (pseudoephedrine, cocaine, phenylephrine, oxymetazoline)
  • Preferable pharmacokinetics with intravenous or intraosseous route rather than intranasal
  • Additional adverse events specific to the intranasal route of administration (see below)

Contraindications

  • Copious blood or mucous in the nasal passage
  • Abnormal neurologic examination or developmental delay
  • Facial trauma
  • Medical conditions that affect ciliary function (i.e. cystic fibrosis)

Considerations

  • Use the most concentrated product available in an effort to minimize total volume being administered in each nostril
  • The total dose should be split between both nostrils to double the surface area of exposed drug
  • Maximum volume of one (1) mL per nostril per atomization (0.2-0.3 mL per nostril is ideal) because volumes greater than 1 mL are more likely to saturate the mucosal surface and then drip medication runoff into the proximal pharynx.

Administration

  • Use the injectable formulation of medication for preparation
  •  Fill the syringe with the ordered dose and volume of medication
  • Add an additional 0.1 mL of drug volume to the syringe to account for dead space in the atomizer
  • Connect Mucosal Atomization Device (MAD) using the luer-lok system
  • With the head gently tilted back and supported, place the atomizer snugly against the nostril of the patient and briskly compress half of the drug volume into each nostril 

The DeBrief

  • Intranasal route of administration serves as an excellent alternative to IV or IM administration for certain medications as it is non-invasive, does not require a needle, and results in a quick onset of action
  • Medications that may be administered intranasally include but are not limited to fentanyl, ketamine, midazolam, and naloxone.

References

  1. Bailey AM, Baum RA, Horn K, et al. Review of Intranasally Administered Medications for Use in the Emergency Department. J Emerg Med. 2017;53(1):38-48. doi:10.1016/j.jemermed.2017.01.020
  2. Rech MA, Barbas B, Chaney W, Greenhalgh E, Turck C. When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications. Ann Emerg Med. 2017;70(2):203-211. doi:10.1016/j.annemergmed.2017.02.015
  3. Corrigan M, Wilson SS, Hampton J. Safety and efficacy of intranasally administered medications in the emergency department and prehospital settings. Am J Health Syst Pharm. 2015;72(18):1544-1554. doi:10.2146/ajhp140630 

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