One of the best innovations in EMS in recent years has been the introduction of intranasal medication through the use of an atomizer. We currently carry three drugs that we can use intranasally. These are Narcan, Fentanyl and Versed.
After several years of experience now with all of these drugs through the intranasal route, here are my impressions of the utility of each.
Narcan – I love intranasal Narcan. I use it often and almost always for heroin overdoses. It took a while for me to learn the patience required, but once I realized the patient would come around eventually (usually within 2-5 minutes, sometimes as long as 8-10), I stopped reaching for the IM Narcan and putting them into withdrawal with the IM Narcan added to the peaking IN Narcan. I have had conversation with many medics about this and each medic seems to have his preferred method. Some like IV which gives you the ability to slowly titrate. Some prefer IM for it fast action – the patient comes around sooner than the IV method because the IV method requires the time spend getting the IV. To each his own.
I like the simplicity of IN. The first responders are usually bagging the patient when I arrive or if I arrive first, my partner gets the ambu-bag out and begins. I screw the atomizer on our prefilled syringe, and give two brisk squirts, one in each nostril. I then like to apply the nasal capnography. It gives me a good gage on how the patient in ventilating. The readings are usually between 60 and 100. While the bagging continues, I watch the ETCO2 reading. Invariably, it will after a couple minutes, drop suddenly to the 35-45 range, and then we can safely stop bagging even though the patient may still be unresponsive. With a gentle prodding, the patient may soon open his eyes. I have yet to put anyone into withdrawal with IN Narcan alone. The patient’s may be angry, more with themselves than with me, and are usually fairly cooperative. There is no vomiting, diaphoresis, or ripping out of the IV. At least I haven’t experienced that yet with IN administration. Other the first few times when I wasn’t patient enough, none of my patients have required additional doses. I believe I read recently a study of first responders using the drug where 89% of the patients they encountered responded to the first dose.
I am a big believer in allowing first responders to carry IN Narcan. It’s simple to use and there is little risk of harming the patient. Sure, they could bag the patient until I get there, but bagging is rarely as effective as ventilating on your own. I could bag the patient all the way to the hospital myself, but I don’t have to because I carry Narcan. I don’t think it should be a paramedic only skill.
One final comment on IN versus IV. If the patient is overdosing on narcotic pills, particularly ones with extended release, then I want an IV where I can titrate the Narcan or even do a drip if there is a large dose involved. For basic heroin, IN remains my choice.
Fentanyl– I was a huge fan of IN Fentanyl when it first came out. I would squirt everyone, and then get an IV, and give additional doses IV if needed. I rarely do this now. I only give IN Fentanyl to children and to adults where I either can’t get or due to scene circumstances would have difficulty getting a quick IV.
Why the change? First, many people really dislike the sensation of intranasal drug delievery, finding it quite unpleasant. Two, it just doesn’t work as well as IV. I will give 100 IN and only a few people will get full relief from that. The relief most get is pretty minor. The bioavailability of the drug is less through this method, and sometimes no matter how briskly I squirt, I watch some of the drug drip back out of their nose.
If I can get the IV, I will do that, and then give them aliquots IV until the pain is under control. I still give it IN sometimes, but only if I think IV access will be delayed. And of course, IN is great for kids, who don’t want anything to do with needles.
Versed– I have used it IN a couple times for seizures with some success, but overall, I don’t see the need for it. If someone is in severe enough condition to require Versed – either because they are seizing or are violent, then the better and quicker route would be IM. I suppose I might have a very anxious patient or child who was unable to be calmed down and was refusing needles. If that were the case, then it would make sense to give them a squirt of Versed. I just haven’t had that situation yet.
I have heard of some people using IN Glucagon for hypoglycemia, but again if they are so low that they need Glucagon, then IM shouldn’t bother them. Whether or not IN Glucagon works as well as IM, I don’t know.
Call me crazy, but I would like to imagine a world where BLS could carry Fentanyl and Versed either IN or IM in prefilled auto-injectors. Either that or put a medic in every ambulance. I just don’t like to think of someone calling 911 and an ambulance arriving to save the day, but the crew not being able to take care of the patient’s severe pain or to stop their seizure.
Bottom line: Bravo to the innovators behind IN drug administration.
