EMS Medication Administration - Buccal Route

EMS Providers need to be knowledgeable about buccal medication administration to ensure effective and safe patient care. 

Here are some key points they should know:

1. Indications and Contraindications

Indications:

• Need for rapid absorption and onset of action.
• Medications commonly administered via buccal route include glucose gel (for hypoglycemia), midazolam (for seizures), and certain analgesics or antiemetics.
• Patients who can follow instructions and keep the medication in the buccal cavity without swallowing.

Contraindications:

• Altered mental status or decreased level of consciousness.
• Inability to follow instructions or maintain medication placement in the buccal cavity.
• Severe oral infections or injuries.
• Allergy to the medication.

2. Mechanism of Action

• Rapid Absorption: Medications administered buccally are absorbed directly into the bloodstream through the mucous membranes in the cheek, 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 buccal administration and prepare it according to protocol.

Patient Preparation:

• Ensure the patient is in a seated or semi-reclined position to facilitate administration and reduce the risk of choking or aspiration.
• Clear the buccal area if necessary to ensure the medication can be placed correctly.

4. Administration Techniques

Administering the Medication:

• Instruct the patient to open their mouth and gently pull back their cheek.
• Place the medication between the patient’s gum and cheek.
• Instruct the patient to hold the medication in place and not to chew or swallow it.
• Ensure the medication remains in place until it is fully dissolved or absorbed.

5. 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 how to keep the medication in the buccal cavity without swallowing or chewing it.

6. 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.

7. Complications and Management

Ineffective Absorption: 

• Ensure proper technique to maximize absorption; consider a second dose if no response and protocol allows.

Adverse Reactions: 

• Be prepared to manage potential adverse reactions, including allergic reactions or local irritation.

Oral Discomfort: 

Reassure the patient about any transient discomfort in the buccal area.

8. Special Considerations

Pediatric and Geriatric Patients: 

• Adjust instructions and dosage appropriately; children may require more gentle handling, and the elderly may have difficulty keeping the medication in place.

Environmental Factors: 

• Consider the environment, such as the need for privacy or managing in a moving vehicle.

Patient Condition: 

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

9. Training and Proficiency

Simulation Training: 

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

Continuing Education: 

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

10. 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 buccal 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