- Published: 05 Mar 2018
Question:
Use of intranasal medications such as midazolam, ketamine, fentanyl, naloxone, dexmedetomidine in the emergency department and by EMS are increasing, especially in patients with difficult or no IV access, actively seizing patients, opioid overdoses, or in pediatric patients. How does the intranasal route work from a pharmacological standpoint? What is the typical dosage of midazolam for a pediatric patient? What is the typical time to sedation?
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Intranasal medications are delivered by an atomizer that delivers the medication on the surface of the nasal mucosa. For the medication to effectively cross the blood-brain barrier, it must possess several properties including physiologic pH, un-ionized state, high lipophilicity, and small molecular weight. To answer the first question, intranasal administration bypasses hepatic first-pass metabolism which permits rapid and predictable bioavailability. The typical dosage for midazolam for a pediatric patient is 0.1-0.2 mg/kg. Time to sedation is typically 10-12 minutes. The volume administered per nostril should not exceed 1 mL, with ideal dosing of 0.2-0.5 mL.
Reference:
Rech MA, Barbas B, Chaney W, Greenhalgh E, Turck C. When to Pick the Nose:
Out-of-Hospital and Emergency Department Intranasal Administration of
Medications. Ann Emerg Med. 2017 Aug;70(2):203-211.