EMS Medication Administration - Intranasal (IN) Route

EMS Providers should be knowledgeable about intranasal (IN) medication administration to ensure patient safety and effective treatment. 

Here are some points they should know:

1. INDICATIONS AND CONTRAINDICATIONS

Indications:

• Rapid absorption needed and IV access is not practical or available.
  
• Common medications include naloxone (for opioid overdose), midazolam (for seizures), fentanyl (for pain management), and certain sedatives or anxiolytics.

Contraindications:

• Nasal trauma or significant nasal obstruction.
  
• Excessive nasal secretions or epistaxis (nosebleed).
  
• Allergy to the medication.
  
• Severe head trauma with potential nasal fractures.

2. MECHANISM OF ACTION

Rapid Absorption: 

• Medications administered intranasally are absorbed through the nasal mucosa directly into the bloodstream, 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 intranasal administration and prepare it according to protocol.

Device Preparation:

• Use a mucosal atomization device (MAD) for proper delivery.
• Ensure the device is properly assembled and the medication is correctly loaded.

Patient Preparation:

• Ensure the patient is in a semi-reclined or upright position to facilitate administration and absorption.
• Clear any visible nasal obstructions if possible.

4. ADMINISTRATION TECHNIQUES

Administering the Medication:

• Attach the MAD to the syringe containing the medication.
• Hold the patient’s head steady.
• Insert the MAD into one nostril and aim slightly upward and outward (towards the ear on the same side).
• Administer half of the medication dose rapidly and firmly, ensuring atomization.
• Repeat the process in the other nostril with the remaining dose to ensure maximal absorption.

Dosage Considerations:

• Split larger doses between both nostrils to increase mucosal surface area for absorption.
• Typical volumes per nostril should not exceed 1 mL to prevent runoff and ensure effective absorption.

5. PATIENT COMMUNICATION AND EDUCATION

Explain the Medication: 

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

Instructions: 

• Provide clear instructions and reassurance to keep the patient calm and cooperative during administration.

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.

Nasal Discomfort: 

• Reassure the patient about any transient burning or discomfort in the nasal passages.

8. SPECIAL CONSIDERATIONS

Pediatric and Geriatric Patients: 

• Adjust instructions and dosage appropriately; children may require smaller doses or more gentle handling.

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 intranasal administration, such as nasal obstructions or severe trauma.

9. TRAINING AND PROFICIENCY

Simulation Training: 

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

Continuing Education: 

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

Erich, J (2023) How Scared Kids Spurred The Development of Intranasal Medication Delivery. EMS 1 https://www.ems1.com/ems-products/medical-equipment/how-scared-kids-spurred-the-development-of-intranasal-medication-delivery Accessed July 2, 2024

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