Emergency Room Doctors Are Picking Noses — For Drug Delivery, That Is
In emergencies, administering drugs quickly and easily can be a matter of life and death. This has emergency departments turning to the nose as a delivery route because it's so accessible and doesn't require direct contact with a needle.
Using the nose as a passage for steroids like Flonase and vaccines like FluMist has been common practice for decades. In recent years, more Americans have also become aware of the emergency drug naloxone, which is used to reverse the effects of an opioid overdose, even when someone has stopped breathing.
The FDA approved naloxone in nasal spray form in late 2015. Police officers, emergency medical technicians and family members or friends can use a nasal spray version of naloxone to keep someone alive until they reach the hospital.
"It's almost like having an EpiPen," says Rana Biary, a toxicologist in the emergency department of New York University's Langone Medical Center. "Have it in case someone has a life-threatening overdose."
Developments in technology have made quickly delivering drugs through the nose easier than ever, increasing their popularity, says Megan Rech, an emergency medicine clinical pharmacist at Loyola University Medical Center in Maywood, Ill.
To administer medication nasally, caregivers attach a drug-filled syringe to a device called an atomizer and put it into the patient's nostril. By pushing down the syringe's plunger, they expel the drug as a vapor that crosses the patient's mucus membrane and starts to take effect.
"I've got nurses and residents to help out [in the hospital]," Biary says. "But if someone overdoses and is in the street somewhere, it might just be you."
In hospital emergency departments, naloxone is still usually administered with an IV or an injection. But even in a hospital setting, doctors are increasingly using nasal versions of other drugs such as the benzodiazepine midazolam and the synthetic opioid fentanyl to relieve patients' pain or sedate them.
The pros and cons of using such drugs are detailed in a review published last week in Annals of Emergency Medicine.
Rech, the lead author, notes that intranasal sprays typically deliver a maximum of only two milliliters of the drug at once, which is less than half of a teaspoon. That dosage tends to be just right for kids.
Midazolam is often used to calm patients down, says Jerri Rose, an assistant professor of pediatric emergency medicine at Case Western Reserve University School of Medicine. She says a nasal squirt of midazolam is great for when kids need stitches. "They don't need a really potent sedative, just something to calm them down and help with anxiety."
Intranasal midazolam can also relax patients having seizures. This is a welcome alternative to rectally administering another drug, diazepam, which is a common procedure for caregivers or family members outside of the hospital. Intranasal midazolam isn't currently available outside of hospitals.
The intranasal version of the synthetic opioid fentanyl is similarly well-suited for some children who end up in the emergency department. Rose says she most often uses intranasal fentanyl for children who come in with burns. "Burns happen really quickly and are so painful," she says. "It's very frightening for everyone, and the parents probably drove their child, who is in tears, frantically to the emergency department."
Being able to pop the child into a room and spray the inside of the nose with a painkiller instead of further traumatizing them with a needle, Rose says, is a game-changer.
Because the intranasal dose is relatively small, it can be difficult to give adult patients enough medication to fully relieve their pain or anxiety. But Rose and Rech note that intranasal painkillers can be used alongside IVs in both in adults and children. For example, a dose of fentanyl up the nose can make all the difference to someone with a broken bone or a serious lesion who is waiting for emergency room staff to organize the equipment and personnel to set up the IV.
Although both midazolam and fentanyl are potent medications — fentanyl is 50 to 100 times stronger than morphine — the review found hardly any negative side-effects associated with administering either drug through the nose. Midazolam gave patients a slight burning sensation, and fentanyl occasionally slowed their breathing.
"They're really nice options," Rose says. "For small children, it can be technically difficult to place an IV, and there's often a lot of fear related to the IV itself."
The review also considered the nasal options for administering the sedatives ketamine and dexmedetomidine, which are used less often in emergency rooms, according to Rose and Rech. Both drugs presented potential problems. It's hard to predict when ketamine will kick in when it's delivered up the nose, they found. In one study some patients felt sedated after five minutes, while for others it took 23 minutes.
As for nasal dexmedetomidine, it could be an attractive option for medical workers who need wiggly or traumatized kids to cooperate with procedures like CT scans.
"[Dexmedetomidine] takes a little time to kick in," Rech says, usually about 25 minutes. "So on the floor, you can administer it and physically take the patient over to [get a] CT. That could take 10 minutes to get down there, so by the time the patient is in the CT scanner, [the drug] is already working."
However, the review noted that in one study the drug slowed the heartbeat of one child who was sedated using it.
"I'd like to see some more study on [intranasal dexmedetomidine] before I feel like it would be become a routine part of my practice," Rose says.
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