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Intranasal Drug Delivery – Clinical Implications for acute trauma

Intranasal Drug Delivery – Clinical Implications for acute trauma. Intranasal Medication cases. Case: MVC pinned in car. A 35 year old male pinned in a car following an MVC. Bilateral upper arm fractures, femur fracture, likely other injuries. Screaming in pain.

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Intranasal Drug Delivery – Clinical Implications for acute trauma

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  1. Intranasal Drug Delivery – Clinical Implications for acute trauma

  2. Intranasal Medication cases

  3. Case: MVC pinned in car A 35 year old male pinned in a car following an MVC. Bilateral upper arm fractures, femur fracture, likely other injuries. Screaming in pain. Clinical Needs: Pain control, calming, rapid extraction, IV access (cannot do so now), transport. Treatment: 2.0 mcg/kg of intranasal fentanyl plus 5 mg IN midazolam In 7 minutes his pain is much better controlled and he is calmer Extraction requires 20 minutes, then full trauma assessment and care proceeds.

  4. Case: Excited Delirium A 27-year old male is apprehended by police and paramedics for extremely violent, out of control behavior following use of cocaine and meth. He is bleeding from severe lacerations to his arms suffered from punching and shattering a window He is at significant risk of further injuring himself and others. It is too dangerous (needle stick risk) to give him an injection. The paramedic administers 10 mg of IN midazolam and 7 minutes later he is calmer, an IV is established for further sedation, pain control and future antibiotics and he is transported safely to the hospital.

  5. Case: Pediatric Hand burn A 5 year old burned her hand with boiling water Clinical Needs: Pain control, debride, clean and dress the wound. 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 15 minutes later the patient easily tolerates cleansing of the burn and dressing application. She is discharged with an oral pain killer less than one hour after arrival.

  6. Literature to support these cases – pediatric long bone fractures Nasal Intravenous Borland, Ann Emerg Med 2007

  7. Literature to support this case – adults with long bone fractures, dislocations Steenblik, Am J Emerg Med 2012

  8. Trauma literature overview Over a decade of ambulance 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 Pain control – Literature support

  9. Safety of nasal opiates

  10. The Doubters: Surely IN drugs can’t be as good as an injection for pain control! 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 Nasal Intravenous

  11. IN opiates for Pain control – My insights • I use nasal opiates in my practice - daily. • Generic concentrations available in U.S. work fine and are • inexpensive ($1-4/vial) • Efficacy: Very effective – and it can be titrated. • Segway to IV therapy in the appropriate situation (fear, agitation) • Use a pulse oximeter with sufentanil: • Sufentanil is especially potent and must be treated with • respect. • Fentanyl seems fine and can safely be given with minimal • risk • Give an oral pain killer as well: It kicks in as IN drug wears off

  12. Drug doses

  13. Optimizing absorption of IN drugs Minimize volume - Maximize concentration 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 Critical Concept

  14. 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

  15. Questions? Educational Web site: www.intranasal.net

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