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6yo 
presents to your ED with multiple deep lacs after being attacked by the neighbor's 
... He's screaming/crying in pain but wont let the RN get near him for an IV, looking at the 
makes him 
even harder.
How do you treat the pain?
(Josh)
1/...
presents to your ED with multiple deep lacs after being attacked by the neighbor's ... He's screaming/crying in pain but wont let the RN get near him for an IV, looking at the makes him even harder. How do you treat the pain?
(Josh)
1/...
Consider picking 
!
How does intranasal drug delivery work?
Capillary rich respiratory mucosa allows 
to directly enter the 
(systemic circulation)
Olfactory mucosal absorption leads to rapid therapeutic levels in the CSF.
Source:[27397490]
2/
![Consider picking !How does intranasal drug delivery work? Capillary rich respiratory mucosa allows to directly enter the (systemic circulation) Olfactory mucosal absorption leads to rapid therapeutic levels in the CSF. Source:[27397490]2/](https://pbs.twimg.com/media/EisUUw4WAAUDYBi.png "Consider picking !How does intranasal drug delivery work? Capillary rich respiratory mucosa allows to directly enter the (systemic circulation) Olfactory mucosal absorption leads to rapid therapeutic levels in the CSF. Source:[27397490]2/")
!How does intranasal drug delivery work?
Capillary rich respiratory mucosa allows to directly enter the (systemic circulation) Olfactory mucosal absorption leads to rapid therapeutic levels in the CSF. Source:[27397490]
2/
A few nerdy PK pearls below:
Quick onset of action
Lipophilic drugs = better absorbed
Unionized drugs 
BBB more readily than ionized forms
IN delivery bypasses GI & first past metabolism, BUT nasal mucosa contains lots of CYP450 enzymes!
PMID:[30449731]
3/
Quick onset of action Lipophilic drugs = better absorbed Unionized drugs BBB more readily than ionized forms IN delivery bypasses GI & first past metabolism, BUT nasal mucosa contains lots of CYP450 enzymes!PMID:[30449731]
3/
Optimal for 
Peds, no IV/IO access
Contraindicated in
Recent vasoconstrictor use (cocaine, oxymetazoline, etc), facial trauma or septal defect
Commonly used IN in the ED Fentanyl, midazolam, ketamine, naloxone, ketorolac, morphine, TXA
PMID:[28366351][29306421]
4/
Peds, no IV/IO accessContraindicated in
Recent vasoconstrictor use (cocaine, oxymetazoline, etc), facial trauma or septal defectCommonly used IN
in the ED Fentanyl, midazolam, ketamine, naloxone, ketorolac, morphine, TXAPMID:[28366351][29306421]
4/
The PITCHFORK Study
Double-blind RCT (n=80) in peds 3-13yo w/ mod-severe pain d/t limb injuries
Fentanyl 1.5mcg/kg IN vs ketamine 1mg/kg IN Similar pain reduction on VAS @ 30min ADEs: Ketamine (~78%) vs fentanyl (~41%) dizziness/taste/
PMID:[25447557]
5/
The PRIME Trial (2019)Double-blind RCT (n=90) in children ages 8-17yo w/ acute extremity injuries
Fentanyl 2mcg/kg IN vs ketamine 1mg/kg IN No difference in pain reduction on VAS @ 30min ADEs: Ketamine (77%) vs fentanyl (31%)PMID:[30592476]
6/
Some tips I learned... the hard way 
the kiddo's 
for mucus or boogers. Suction is ur friend 
Use high conc. to avoid large volume Peds (0.5mL per nostril)
Positioning matters! Aim atomizer UP & OUT (point outward to the 
)
Source: http://www.aliem.com/pet-pearls-intranasal-medications
the kiddo's for mucus or boogers. Suction is ur friend Use high conc. to avoid large volume Peds (0.5mL per nostril) Positioning matters! Aim atomizer UP & OUT (point outward to the )Source: http://www.aliem.com/pet-pearls-intranasal-medications
Bottom Line If you pick pick lipophilic Similar pain 
fentanyl vs ketamine but 
ADEs w/ Ketamine Peds 0.5mL per nostril Aim atomizer UP & OUT point at Inspired by "In the Nose?!" CSHP'19 CE
by Kimberly Won PharmD BCCCP, Kevin Kaucher PharmD BCCCP
#TwitteRx do you have any tips or tricks for effective IN delivery??
Please share any experiences with IN meds you thought worked or did not work........ IN dexmedetomidine anyone?
#NurseTwitter #FOAMed #MedTwitter #emergencymedicine
Please share any experiences with IN meds you thought worked or did not work........ IN dexmedetomidine anyone
? #NurseTwitter #FOAMed #MedTwitter #emergencymedicine
