CME REVIEW ARTICLE
Intranasal Medications in Pediatric Emergency Medicine Jeannine Del Pizzo, MD and James M. Callahan, MD Abstract: Intranasal medication administration in the emergency care of children has been reported for at least 20 years and is gaining popularity because of ease of administration, rapid onset of action, and relatively little pain to the patient. The ability to avoid a needle stick is often attractive to practitioners, in addition to children and their parents. In time-critical situations for which emergent administration of medication is needed, the intranasal route may be associated with more rapid medication administration. This article reviews the use of intranasal medications in the emergency care of children. Particular attention will be paid to anatomy and its impact on drug delivery, pharmacodynamics, medications currently administered by this route, delivery devices available, tips for use, and future directions. Key Words: intranasal, children, emergency, absorption, atomizer, nebulizer, midazolam, fentanyl, ketamine, lorazepam, nalaxone, sumitriptan (Pediatr Emer Care 2014;30: 496Y504)
route impractical. Obtaining intravenous access may be difficult and even when possible is associated with a painful needle stick and may be associated with a delay in medication administration. Because of these challenges, multiple alternative delivery systems and routes of delivery have been explored. Intranasal medication administration in the emergency care of children has been reported for at least 20 years1 and is gaining popularity because of ease of administration, rapid onset of action, and relatively little pain to the patient. The ability to avoid a needle stick is often attractive to practitioners, in addition to children and their parents. In time-critical situations for which emergent administration of medication is needed, the intranasal route may be associated with more rapid medication administration. This article reviews the use of intranasal medications in the emergency care of children. Particular attention will be paid to anatomy and its impact on drug delivery, pharmacodynamics, medications currently administered by this route, delivery devices available, tips for use, and future directions.
TARGET AUDIENCE This article is intended for all medical caregivers of children including nurses, nurse practitioners, physician’s assistants, pediatricians, pediatric emergency medicine physicians, critical care physicians, emergency physicians, family physicians and prehospital emergency providers.
LEARNING OBJECTIVES After completion of this article, the reader should be able to: 1. Administer intranasal medications to children in the emergency department. 2. Compare the various routes of medication administration.
D
elivering medications to children in emergency settings can be challenging. Traditionally, oral and intravenous routes have been the most often utilized methods of drug delivery. However, it is not always possible to use these routes in children in acute care settings. Children may be unable or unwilling to take medications orally. In addition, the delayed and unpredictable absorption of oral medications may make this
Attending Physician and Research Fellow (Del Pizzo), Division of Emergency Medicine, The Children’s Hospital of Philadelphia; Attending Physician and Vice Director (Callahan), Division of Emergency Medicine, Pediatric Residency Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and Professor (Callahan), Clinical Pediatrics Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. The authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interest in, any commercial organizations pertaining to this educational activity. The authors have disclosed that the U.S. Food and Drug Administration has not approved the use of intranasal ketamine and lorazepam for sedation; intranasal naloxone for reversal of opioid overdose; and the devices OptiNose and DirectHaler Nasal to deliver medications intranasally to children as discussed in this article. Please consult the products’ labeling for approved information. Reprints: Jeannine Del Pizzo, MD, Division of Emergency Medicine, Children’s Hospital of Philadelphia, Colket Translational Research Bldg, 9th Floor, 3501 Civic Center Blvd, Philadelphia, PA 19104 (e
Intranasal Medications in Pediatric Emergency Medicine Jeannine Del Pizzo, MD and James M. Callahan, MD Abstract: Intranasal medication administration in the emergency care of children has been reported for at least 20 years and is gaining popularity because of ease of administration, rapid onset of action, and relatively little pain to the patient. The ability to avoid a needle stick is often attractive to practitioners, in addition to children and their parents. In time-critical situations for which emergent administration of medication is needed, the intranasal route may be associated with more rapid medication administration. This article reviews the use of intranasal medications in the emergency care of children. Particular attention will be paid to anatomy and its impact on drug delivery, pharmacodynamics, medications currently administered by this route, delivery devices available, tips for use, and future directions. Key Words: intranasal, children, emergency, absorption, atomizer, nebulizer, midazolam, fentanyl, ketamine, lorazepam, nalaxone, sumitriptan (Pediatr Emer Care 2014;30: 496Y504)
route impractical. Obtaining intravenous access may be difficult and even when possible is associated with a painful needle stick and may be associated with a delay in medication administration. Because of these challenges, multiple alternative delivery systems and routes of delivery have been explored. Intranasal medication administration in the emergency care of children has been reported for at least 20 years1 and is gaining popularity because of ease of administration, rapid onset of action, and relatively little pain to the patient. The ability to avoid a needle stick is often attractive to practitioners, in addition to children and their parents. In time-critical situations for which emergent administration of medication is needed, the intranasal route may be associated with more rapid medication administration. This article reviews the use of intranasal medications in the emergency care of children. Particular attention will be paid to anatomy and its impact on drug delivery, pharmacodynamics, medications currently administered by this route, delivery devices available, tips for use, and future directions.
TARGET AUDIENCE This article is intended for all medical caregivers of children including nurses, nurse practitioners, physician’s assistants, pediatricians, pediatric emergency medicine physicians, critical care physicians, emergency physicians, family physicians and prehospital emergency providers.
LEARNING OBJECTIVES After completion of this article, the reader should be able to: 1. Administer intranasal medications to children in the emergency department. 2. Compare the various routes of medication administration.
D
elivering medications to children in emergency settings can be challenging. Traditionally, oral and intravenous routes have been the most often utilized methods of drug delivery. However, it is not always possible to use these routes in children in acute care settings. Children may be unable or unwilling to take medications orally. In addition, the delayed and unpredictable absorption of oral medications may make this
Attending Physician and Research Fellow (Del Pizzo), Division of Emergency Medicine, The Children’s Hospital of Philadelphia; Attending Physician and Vice Director (Callahan), Division of Emergency Medicine, Pediatric Residency Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and Professor (Callahan), Clinical Pediatrics Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. The authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interest in, any commercial organizations pertaining to this educational activity. The authors have disclosed that the U.S. Food and Drug Administration has not approved the use of intranasal ketamine and lorazepam for sedation; intranasal naloxone for reversal of opioid overdose; and the devices OptiNose and DirectHaler Nasal to deliver medications intranasally to children as discussed in this article. Please consult the products’ labeling for approved information. Reprints: Jeannine Del Pizzo, MD, Division of Emergency Medicine, Children’s Hospital of Philadelphia, Colket Translational Research Bldg, 9th Floor, 3501 Civic Center Blvd, Philadelphia, PA 19104 (e
