EMS Medication Administration - Sublingual (SL) Route

EMS Providers must be knowledgeable about sublingual (SL) medication administration to ensure patient safety and effective treatment. 

Here are some key points they should know:

1. Indications and Contraindications

Indications:

• Need for rapid absorption and onset of action.
• Common medications include nitroglycerin (for chest pain) and certain antiemetics or anxiolytics.
• Patients who can follow instructions and keep the medication under their tongue without swallowing.

Contraindications:

• Altered mental status or decreased level of consciousness.
• Difficulty following instructions or maintaining medication placement under the tongue.
• Severe mouth or tongue injuries.
• Allergies to the medication.

2. Mechanism of Action

Rapid Absorption: 

• Medications administered sublingually are absorbed directly into the bloodstream through the rich vascular supply under the tongue, bypassing the gastrointestinal tract and first-pass metabolism in the liver.

3. Preparation and Technique

Medication Preparation:

• Verify the “Six Rights” of medication administration: right patient, right medication, right dose, right route, right time and right documentation.
• Ensure the medication is appropriate for sublingual administration.

Patient Preparation:

• Ensure the patient is in a seated or semi-reclined position to facilitate easy administration and reduce the risk of aspiration.
• Instruct the patient to lift their tongue or open their mouth as needed.

Administration:

• Place the medication under the patient’s tongue.
• Instruct the patient to close their mouth and avoid chewing, swallowing, or moving the medication around.
• Ensure the patient understands to let the medication dissolve completely.

4. Patient Communication and Education

Explain the Medication: 

• Inform the patient about the purpose of the medication, how it will help, and any potential side effects.

Instructions: 

• Provide clear instructions on what to do with the medication (e.g., not to swallow or chew it) and how long it might take to dissolve.

5. Monitoring and Follow-Up

Observe for Effects: 

• Monitor the patient for the expected therapeutic effects and any adverse reactions.

Reassessment: 

• Regularly reassess the patient's condition to determine the effectiveness of the medication and any need for additional intervention.

6. Complications and Management

Ineffective Absorption: 

• Ensure the medication remains in place under the tongue to prevent reduced effectiveness.

Adverse Reactions: 

• Be prepared to manage potential adverse reactions, including allergic reactions or side effects specific to the medication being administered.

Local Irritation: 

• Monitor for signs of local irritation or discomfort under the tongue.

7. Special Considerations

Pediatric and Geriatric Patients: 

• Adjust instructions and consider additional challenges in administering sublingual medications to these populations.

Medication Properties: 

• Understand the specific characteristics of the sublingual medication being administered, including onset and duration of action.

Patient Condition: 

• Be aware of any conditions that might affect sublingual administration, such as dry mouth or oral lesions.

8. Training and Proficiency

Simulation Training: 

• Regular practice using simulation models to maintain proficiency in sublingual medication administration techniques.

Continuing Education: 

• Stay updated on best practices, new medications, and techniques for sublingual administration.

9. Legal and Ethical Considerations

Scope of Practice: 

• Adhere to the legal scope of practice for their certification level and local regulations.

Informed Consent: 

• Obtain informed consent from the patient or guardian whenever possible.

Documentation: 

• Accurate documentation of medication name, dose, route, time of administration, and any observed effects or adverse reactions.

Conclusion

Effective sublingual medication administration requires EMS Providers to combine theoretical knowledge with practical skills. 

Continuous training, adherence to protocols, and understanding the indications, techniques, and potential complications are essential for safe and effective patient care. 

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell