Intranasal sedation - Revision history

Rossdonaldson1: /* See Also */

2022-03-29T20:24:37Z

Mholtz at 08:11, 24 December 2016

2016-12-24T08:11:34Z

← Older revision		Revision as of 08:11, 24 December 2016
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	==General Instructions==		==General Instructions==
			===Indications===
			*Need for pain control when IV or PO routes are unavailable or inappropriate
			*Alternative to IM route

	===Materials===		===Materials===
	*~~Two syringes: 1ml~~ or ~~3ml~~		*Syringes (1mL or 3mL)
	*~~Needle to draw up the medication~~		*Blunt fill needle
	*Atomizer		*Atomizer
	*~~Vial of medication~~		*Medication

	===Procedure===		===Procedure===
	*~~Aspirate~~ the ~~proper~~ volume/dose of medication ~~per~~ the ~~weight based dosing protocol~~		*Load the appropriate volume/dose of medication into the syringe
	*~~Twist off/remove the syringe from the~~ needle~~/needleless~~ device		*Remove needle and attach atomizer device to syringe
	*Attach the atomizer tip via Luer lock mechanism – it twists into place
	*Using your free hand to hold the crown of the head stable, place the tip of the atomizer snugly against the nostril aiming slightly up and outward (towards the top of the ipsilateral ear)		*Using your free hand to hold the crown of the head stable, place the tip of the atomizer snugly against the nostril aiming slightly up and outward (towards the top of the ipsilateral ear)
	*Briskly ~~compress~~ the syringe plunger to deliver the medication into the nostril		*Briskly depress the syringe plunger to deliver the medication into the nostril
	*~~Place second device over to the~~ opposite nostril ~~and briskly administer the remaining half of the medication into that nostril~~		*May repeat on opposite nostril if dose volume is too large for one nostril
	*Consider using a pulse oximeter for 45-60 minutes following medication delivery due to the rare but possible risk of respiratory depression from an opiate

	~~===Indications===~~
	*Anytime pain control is needed but oral medication is too ~~slow OR IV access not obtainable~~
	*Burn dressing changes
	*Re-packing wounds such as abscesses
	*Any time you consider an IM shot for ~~pain control (IN works as well or better with faster onset and no pain on delivery)~~
	*Titration of opioids is often needed and very easy and effective – repeat does every 15 minutes until desired effect is obtained.
	*Research data now demonstrates IN opioids are as effective as IV, just faster due to no delays in obtaining an IV:

	==Delivery Method==		==Delivery Method==
	*~~1/3~~ to ~~½ ml~~ per nostril is ideal but ~~you~~ can ~~push~~ up to 1ml per nostril ~~though~~ some ~~will~~ run off. If you need more than 2ml total, consider titration with second dose in 5 minutes		*⅓ to ½ml per nostril is ideal, but can deliver up to 1ml per nostril (expect some fluid to run off). If you need more than 2ml total, consider titration with second dose in 5 minutes
	*Consider administering an oral pain medication at the same time as the nasal medication or after about 15 minutes. ~~This way as~~ the effect of the nasal drug wanes, ~~the effect of~~ the oral medication ~~begins to have an~~ effect		*Consider administering an oral pain medication at the same time as the nasal medication or after about 15 minutes. As the effect of the nasal drug wanes, the oral medication takes effect
	*The single biggest reason for failure of intranasal opioids is ~~the clinician gives an in-appropriate dose~~ (~~i.e. they underdose with an IV dose which tends to be too low~~)		*The single biggest reason for failure of intranasal opioids is inappropriate dosing (usually underdosing)
	*Medications get absorbed in the nasal mucosa so inhalation is not needed and my cause deposit in the nasal pharynx		*Medications get absorbed in the nasal mucosa so inhalation is not needed and my cause deposit in the nasal pharynx
	*Be aware of the “dead space” in your delivery atomizer and add that extra volume to your dose
	**You should draw up the additional appropriate dead space of the delivery device you choose. In this table the 0.1ml represents a typical dead space in a 1ml syringe connected to a syringe driven atomizer.
	*If the volume exceeds 1ml you might want to consider delivering as two separate doses 5 minutes apart
	**Volumes in this range should definitely be divided in half and administered 5 minutes apart to reduce runoff

	==Intranasal Medications==		==Intranasal Medications==
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	==References==		==References==
	<references/>		<references/>

	[[Category:Pediatrics]]		[[Category:Pediatrics]]
	[[Category:Procedures]]		[[Category:Procedures]]
	[[Category:EMS]]		[[Category:EMS]]

Lmainis: uncapitalized "wary" - unnecessary as it was the second word

2016-10-23T18:55:03Z

uncapitalized "wary" - unnecessary as it was the second word

← Older revision		Revision as of 18:55, 23 October 2016
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	===Intranasal [[Fentanyl]]===		===Intranasal [[Fentanyl]]===
	*[[Fentanyl]]: 1-2 mcg/kg (comes in 50 ug/ml) (best for children)<ref> Saunders M, Adelgais K, Nelson D. Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med. 2010 Nov;17(11):1155-61. doi: 10.1111/j.1553-2712.2010.00905.x. </ref>		*[[Fentanyl]]: 1-2 mcg/kg (comes in 50 ug/ml) (best for children)<ref> Saunders M, Adelgais K, Nelson D. Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med. 2010 Nov;17(11):1155-61. doi: 10.1111/j.1553-2712.2010.00905.x. </ref>
	*Be ~~Wary~~ of respiratory depression		*Be wary of respiratory depression
	**Monitor patients with pulse oximetry and close observation		**Monitor patients with pulse oximetry and close observation
	*Titration to pain is often necessary		*Titration to pain is often necessary

Rossdonaldson1: Text replacement - "opiates" to "opioids"

2016-07-31T10:46:57Z

Text replacement - "opiates" to "opioids"

← Older revision		Revision as of 10:46, 31 July 2016
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	*Re-packing wounds such as abscesses		*Re-packing wounds such as abscesses
	*Any time you consider an IM shot for pain control (IN works as well or better with faster onset and no pain on delivery)		*Any time you consider an IM shot for pain control (IN works as well or better with faster onset and no pain on delivery)
	*Titration of ~~opiates~~ is often needed and very easy and effective – repeat does every 15 minutes until desired effect is obtained.		*Titration of opioids is often needed and very easy and effective – repeat does every 15 minutes until desired effect is obtained.
	*Research data now demonstrates IN ~~opiates~~ are as effective as IV, just faster due to no delays in obtaining an IV:		*Research data now demonstrates IN opioids are as effective as IV, just faster due to no delays in obtaining an IV:

	==Delivery Method==		==Delivery Method==
	*1/3 to ½ ml per nostril is ideal but you can push up to 1ml per nostril though some will run off. If you need more than 2ml total, consider titration with second dose in 5 minutes		*1/3 to ½ ml per nostril is ideal but you can push up to 1ml per nostril though some will run off. If you need more than 2ml total, consider titration with second dose in 5 minutes
	*Consider administering an oral pain medication at the same time as the nasal medication or after about 15 minutes. This way as the effect of the nasal drug wanes, the effect of the oral medication begins to have an effect		*Consider administering an oral pain medication at the same time as the nasal medication or after about 15 minutes. This way as the effect of the nasal drug wanes, the effect of the oral medication begins to have an effect
	*The single biggest reason for failure of intranasal ~~opiates~~ is the clinician gives an in-appropriate dose (i.e. they underdose with an IV dose which tends to be too low)		*The single biggest reason for failure of intranasal opioids is the clinician gives an in-appropriate dose (i.e. they underdose with an IV dose which tends to be too low)
	*Medications get absorbed in the nasal mucosa so inhalation is not needed and my cause deposit in the nasal pharynx		*Medications get absorbed in the nasal mucosa so inhalation is not needed and my cause deposit in the nasal pharynx
	*Be aware of the “dead space” in your delivery atomizer and add that extra volume to your dose		*Be aware of the “dead space” in your delivery atomizer and add that extra volume to your dose

Neil.m.young at 15:53, 26 July 2016

2016-07-26T15:53:13Z

← Older revision		Revision as of 15:53, 26 July 2016
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	==Delivery Method==		==Delivery Method==
	*1/3 to ½ ml per nostril is ideal but you can push up to 1ml per nostril though some will run off. If you need more than ~~2 ml~~ total, consider titration with second dose in 5 minutes		*1/3 to ½ ml per nostril is ideal but you can push up to 1ml per nostril though some will run off. If you need more than 2ml total, consider titration with second dose in 5 minutes
	*Consider administering an oral pain medication at the same time as the nasal medication or after about 15 minutes. This way as the effect of the nasal drug wanes, the effect of the oral medication begins to have an effect		*Consider administering an oral pain medication at the same time as the nasal medication or after about 15 minutes. This way as the effect of the nasal drug wanes, the effect of the oral medication begins to have an effect
	*The single biggest reason for failure of intranasal opiates is the clinician gives an in-appropriate dose (i.e. they underdose with an IV dose which tends to be too low)		*The single biggest reason for failure of intranasal opiates is the clinician gives an in-appropriate dose (i.e. they underdose with an IV dose which tends to be too low)

Neil.m.young at 15:50, 26 July 2016

2016-07-26T15:50:50Z

← Older revision		Revision as of 15:50, 26 July 2016
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	**Behavioral changes (nightmares, enuresis nocturna, and irritability) in children less than five (unable to understand reasons for experience)		**Behavioral changes (nightmares, enuresis nocturna, and irritability) in children less than five (unable to understand reasons for experience)
	**Use only concentrated ketamine (100mg/ml) formulation		**Use only concentrated ketamine (100mg/ml) formulation
	**Ideal volume is 0.3 to 0.5 ml per nostril, maximum is ~~1 ml~~ per nostril, and more will just run out nose. If you need more – titrate to effect		**Ideal volume is 0.3 to 0.5 ml per nostril, maximum is 1ml per nostril, and more will just run out nose. If you need more – titrate to effect
	*[[Ketamine]] 1mg/kg may be used for pain control (not procedural sedation) <ref> Graudins A, Meek R, Egerton-Warburton D, Oakley E, Seith R. The PICHFORK (Pain in Children Fentanyl or Ketamine) trial: a randomized controlled trial comparing intranasal ketamine and fentanyl for the relief of moderate to severe pain in children with limb injuries. Ann Emerg Med. 2015 Mar;65(3):248-254.e1. doi: 10.1016/j.annemergmed.2014.09.024. Epub 2014 Nov 18. </ref>		*[[Ketamine]] 1mg/kg may be used for pain control (not procedural sedation) <ref> Graudins A, Meek R, Egerton-Warburton D, Oakley E, Seith R. The PICHFORK (Pain in Children Fentanyl or Ketamine) trial: a randomized controlled trial comparing intranasal ketamine and fentanyl for the relief of moderate to severe pain in children with limb injuries. Ann Emerg Med. 2015 Mar;65(3):248-254.e1. doi: 10.1016/j.annemergmed.2014.09.024. Epub 2014 Nov 18. </ref>
	**Good adjunct to opioids or as an opioid-sparing agent		**Good adjunct to opioids or as an opioid-sparing agent

Neil.m.young at 15:50, 26 July 2016

2016-07-26T15:50:28Z

← Older revision		Revision as of 15:50, 26 July 2016
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	**Results in mild somnolence with resultant reduction in anxiety and probably amnesia		**Results in mild somnolence with resultant reduction in anxiety and probably amnesia
	**Be aware that midazolam causes some nasal burning benzyl alcohol preservative) for 30-45 seconds when administered.		**Be aware that midazolam causes some nasal burning benzyl alcohol preservative) for 30-45 seconds when administered.
	**In small children; lidocaine 2% or 4%: 0.~~2 ml~~ per nostril 5 minutes prior to the midazolam to stop the burning		**In small children; lidocaine 2% or 4%: 0.2ml per nostril 5 minutes prior to the midazolam to stop the burning
	**Use only concentrated midazolam (5mg/ml) formulation		**Use only concentrated midazolam (5mg/ml) formulation

Neil.m.young at 15:50, 26 July 2016

2016-07-26T15:50:02Z

← Older revision		Revision as of 15:50, 26 July 2016
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	==Delivery Method==		==Delivery Method==
	*1/3 to ½ ml per nostril is ideal but you can push up to ~~1 ml~~ per nostril though some will run off. If you need more than 2 ml total, consider titration with second dose in 5 minutes		*1/3 to ½ ml per nostril is ideal but you can push up to 1ml per nostril though some will run off. If you need more than 2 ml total, consider titration with second dose in 5 minutes
	*Consider administering an oral pain medication at the same time as the nasal medication or after about 15 minutes. This way as the effect of the nasal drug wanes, the effect of the oral medication begins to have an effect		*Consider administering an oral pain medication at the same time as the nasal medication or after about 15 minutes. This way as the effect of the nasal drug wanes, the effect of the oral medication begins to have an effect
	*The single biggest reason for failure of intranasal opiates is the clinician gives an in-appropriate dose (i.e. they underdose with an IV dose which tends to be too low)		*The single biggest reason for failure of intranasal opiates is the clinician gives an in-appropriate dose (i.e. they underdose with an IV dose which tends to be too low)
	*Medications get absorbed in the nasal mucosa so inhalation is not needed and my cause deposit in the nasal pharynx		*Medications get absorbed in the nasal mucosa so inhalation is not needed and my cause deposit in the nasal pharynx
	*Be aware of the “dead space” in your delivery atomizer and add that extra volume to your dose		*Be aware of the “dead space” in your delivery atomizer and add that extra volume to your dose
	**You should draw up the additional appropriate dead space of the delivery device you choose. In this table the 0.~~1 ml~~ represents a typical dead space in a ~~1 ml~~ syringe connected to a syringe driven atomizer.		**You should draw up the additional appropriate dead space of the delivery device you choose. In this table the 0.1ml represents a typical dead space in a 1ml syringe connected to a syringe driven atomizer.
	*If the volume exceeds ~~1 ml~~ you might want to consider delivering as two separate doses 5 minutes apart		*If the volume exceeds 1ml you might want to consider delivering as two separate doses 5 minutes apart
	**Volumes in this range should definitely be divided in half and administered 5 minutes apart to reduce runoff		**Volumes in this range should definitely be divided in half and administered 5 minutes apart to reduce runoff

Neil.m.young: continuity and prevent word wrap issues

2016-07-26T15:49:17Z

continuity and prevent word wrap issues

← Older revision		Revision as of 15:49, 26 July 2016
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	==General Instructions==		==General Instructions==
	===Materials===		===Materials===
	*Two syringes: ~~1 ml~~ or ~~3 ml~~		*Two syringes: 1ml or 3ml
	*Needle to draw up the medication		*Needle to draw up the medication
	*Atomizer		*Atomizer
	*Vial of medication		*Vial of medication

	===Procedure===		===Procedure===

Neil.m.young: Text replacement - "9 mg" to "9mg"

2016-07-23T16:50:46Z

Text replacement - "9 mg" to "9mg"

← Older revision		Revision as of 16:50, 23 July 2016
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	===Intranasal [[Ketamine]]===		===Intranasal [[Ketamine]]===
	*[[Ketamine]] 3 to ~~9 mg~~/kg (no routine recommendation yet)		*[[Ketamine]] 3 to 9mg/kg (no routine recommendation yet)
	**[[Ketamine]] may result in deeper sedation and is dose dependent, utilize the initial dose at 6mg/kg and repeated doses at 3mg/kg until desired sedation is achieved.		**[[Ketamine]] may result in deeper sedation and is dose dependent, utilize the initial dose at 6mg/kg and repeated doses at 3mg/kg until desired sedation is achieved.
	**Be aware that ketamine causes a bitter taste (lyophilized) when administered		**Be aware that ketamine causes a bitter taste (lyophilized) when administered

← Older revision		Revision as of 20:24, 29 March 2022
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	==See Also==		==See Also==
	*[[Sedation (~~Main~~)]]		*[[Sedation (main)]]
	*[[Procedural ~~Sedation~~ (~~Peds~~)]]		*[[Procedural sedation (peds)]]

	==External Links==		==External Links==