Transcript 1 ml per nostril - Presence Health

Region 6 Protocol Update
2014 Pharmacology
Presence Regional EMS
Intranasal Drug Delivery – Clinical
Implications for Pre-hospital care
Educational Web site:
www.intranasal.net
Topics
Why use intranasal medications?
Intranasal drug delivery: General
concepts
Intranasal drugs indications with clinical
cases and personal insights:
• Pain Control
• Opiate overdose
Drug doses
Resources
Why is nasal drug delivery
important in prehospital care?
Efficacy, speed and ease of delivery
 No delivery delays (no IV)
 Can deliver to anyone with an exposed nose
 Rapid onset of action
 As effective and fast as IV drugs in most situations
Safety
 No needle stick risk
 Lower risk of respiratory depression (compared to IV)
Easier to proceed with additional care
 Start IV in children or agitated adult
 Calm the agitated patient
Understanding IN delivery: General
principles
First pass metabolism
Nose brain pathway
Bioavailability / Drug absorption
Safety vs IV drugs
First pass metabolism
Nasal Mucosa:
No first pass
metabolism
Gut
mucosa:
Subject to
first pass
metabolism
Nose brain pathway
Olfactory mucosa, nerve
 The olfactory mucosa
(smelling area in nose) is
in direct contact with the
brain and CSF.
 Medications absorbed
Brain
across the olfactory
CSF
mucosa directly enter the
CSF.
 Offers a rapid, direct
route for drug delivery to
the brain (skipping the
Highly vascular nasal mucosa
blood brain barrier).
Bioavailability/ Drug absorption
How much of the administered medication
actually ends up in the blood stream.
Examples:
IV medications are 100% bioavailable.
Most oral medications are about 5%-10%
bioavailable due to destruction in the gut and
liver.
Nasal medications vary depending on
molecule, pH, etc
Fentanyl 80+%
Naloxone 90+%
Optimizing Bioavailability of IN drugs
 Minimize volume - Maximize concentration
 0.2 to 0.3 ml per nostril ideal, 1 ml is maximum
 Most potent (highly concentrated) drug should be used
 Maximize total absorptive mucosal surface area
 Use BOTH nostrils (doubles your absorptive surface area)
 Use a delivery system that maximizes mucosal
coverage and minimizes run-off.
 Atomized particles across broad surface area
 Beware of abnormal nasal mucosal characteristics
 Mucous, blood and vasoconstrictors may reduce absorption
 Suction nose or consider alternate delivery route if present
Critical
Concept
Dropper vs Atomizer
Absorption
 Drops = runs down to pharynx
and swallowed
 Atomizer = sticks to broad
mucosal surface and absorbs
Usability / acceptance
 Drops = Minutes to give,
cooperative patient, head
position required
 Atomizer = seconds to deliver,
better accepted
Region 6 Protocols
Intranasal medications must be administered
through an atomizer
IN Administration
1.
Aspirate the proper volume of
medication required. Remember –
use a filtered needle for aspirating
from an ampule.
2.
Remove the needle from the syringe
and attach the MAD Nasal™ Device
to the syringe.
3.
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
toward the top of the ear.
4.
Briskly compress the syringe plunger
to deliver approximately half of the
medication into the nostril.
5.
Move the device over to the
opposite nostril and administer the
remaining medication.
What IN medications can we
use in prehospital care?
Region 6 Protocol – IN Medications
Scenario
Drug and Dose
Protocols
Pain Control:
Adult and
Pediatrics
Fentanyl: 1 mcg/kg
1 ml per nostril
Max dose 50 mcg;
May repeat x 1 after 5
minutes at 0.5 mcg/kg
Adult and Pediatrics:
• Amputation
• Burns
• Painful Swollen and
Deformed Extremity
Opiate
Overdose:
Adult and
Pediatrics
Naloxone: 1 mg/ml per
nostril (1 ml per nostril
maximum; 2 mg total
dose)
May repeat every 2-3
minutes to a maximum
dose of 4 mg
Adult and Pediatrics:
• Altered LOC
• Poisoning /
Overdose
Intranasal Medication Cases
Pain Control
Case: Pediatric Hand burn
A 5 year old burned her hand on the stove
Clinical Needs: Pain control, Transport for wound
care
Treatment: 2.0 mcg/kg of intranasal fentanyl (40
mcg – 0.8 ml of generic “IV” fentanyl)
Within 3-5 minutes her pain is improved
She is transported to a nearby medical facility
15 minutes later the patient easily tolerates cleansing of
the burn and dressing application.
Pain control – Literature support
Over a decade of prehospital and ER literature exists for
burn, orthopedic trauma and visceral pain in both adults
and children showing the following:
Faster drug delivery (no IV start needed) so faster onset
Equivalent to IV morphine
Superior to IM morphine
Care givers are more likely to treat pediatric severe pain
Highly satisfied patients and providers
Safe
The Doubters: Surely IN drugs can’t be
as good as an injection for pain control!
Nasal
Intravenous
ACTUALLY – They are equivalent or better (in these settings)
 Borland 2007 – IN fentanyl onset of action and quality of pain control
was identical to IV morphine in patients with broken legs and arms
 Borland 2008, Holdgate 2010, Crellin 2010 - time to delivery of IN
opiates was half that of IV and more patients get treated
 Kendal 2001 – IN opiate superior to IM opiate for pain control
 Conclusions
IN opiates are just as good as IV
IN opiates are delivered in half the waiting time as IV
IN opiate are preferred by patients, providers and parents over
injections
Intranasal Medication Cases
Opiate Overdose
Case: Heroin Overdose
The ambulance responds to an unconscious, barely breathing
patient with obvious intravenous drug needle marks on both
arms – consistent with heroin overdose
 After an IV is established, naloxone (Narcan) is administered
and the patient is successfully resuscitated.
 Unfortunately, the medic suffers a contaminated needle stick
while establishing the IV.
 The patient admits to being infected with both HIV and
hepatitis C. He remains alert for 2 hours with no further
therapy in the ED (i.e.- no need for an IV) and is discharged.
Case: Heroin Overdose
The medic now needs treatment - HIV prophylaxis
The next few months will be difficult for him:
Side effects that accompany HIV medications
Personal life is in turmoil due to issues of safe sex with
his spouse
Mental anguish of waiting to see if he develops HIV or
hepatitis C.
He wonders why his system is not using MAD nasal
to deliver naloxone on all these patients.
Opiate overdose – Literature support
Intranasal naloxone literature
 Barton 02, 05; Kelly 05; Robertson 09; Kerr 09; Merlin 2010;
Doe Simkins 09; Walley 12:
 IN naloxone is at least 80-90% effective at reversing opiate
overdose
 When compared directly it is equivalent in time of onset and in
efficacy to IV or IM therapy.
 IN naloxone results in less agitation upon arousal
 IN naloxone is lay person approved in many places. It is safe, has
saved many lives and reduces medical resource consumption
IN naloxone for opiate overdose
Why not? Is there a downside?
 High risk population for HIV, HCV, HBV
 Difficult IV to establish due to scarring of veins
 Elimination of needle eliminates needle stick risk
 They awaken more gently than with IV naloxone
 New epidemiology shows prescription drugs
(methadone, etc) are causing many deaths that
naloxone at home could reverse.
 Simple enough that lay public can administer and
not even call ambulance
Intranasal Medications Summary
Another tool for drug delivery to
supplement standard IV, IM, PO–
very useful when appropriate
Supported by extensive literature
Inexpensive
Speeds up care in many situations
Safe
Intramuscular Injections
Preferred sites:
Deltoid
Thigh
Hip
How much can the muscle hold?
Preferred site
General volume
Maximum volume
Deltoid
< 0.5 ml
1.0 ml
Thigh
< 1.0 ml
2.0 ml
Buttocks / Hip
< 2.5 ml
5.0 ml
Amiodarone
Ventricular Ectopy
Tachyarrhythmia – Stable
No longer need to mix with D5W
Dose: 150 mg IVP; may repeat q 5 – 10 minutes;
maximum dose 450 mg