# nasal atomizers anyone?



## joedittfurth (Dec 12, 2013)

anybody out there have any insight on nasal atomizers specifically with glucagon


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## NomadicMedic (Dec 12, 2013)

What type of insight are you looking for? Onset of action?


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## mycrofft (Dec 12, 2013)

Nasal neb can be affected by nasal congestion, mucus, dried sections, and broken mucosae (as in drug abuse, or prolonged dehumidified respirations, or dehydration).


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## TransportJockey (Dec 13, 2013)

What about them? We use them for Narcan, Fent, Versed, etc here at my service... but never heard of them used for glucagon


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## STXmedic (Dec 13, 2013)

Same as above. I know it can be used for glucagon, but have never tried it- nor have I seen it tried. The preparation we have is ready for IM upon mixing, and works well when given that route.


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## joedittfurth (Dec 13, 2013)

just wondering about effectiveness and difference vs iv drugs never gotten to use its as an emt basic silly paramedics always get in the way


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## Handsome Robb (Dec 14, 2013)

I don't personally like the MAD. It's not reliable, like has been said many things can negatively affect absorption.

Works great for kids.

With a perfect scenario the onset is supposedly similar to IV. We had a bunch of studies provided to us at work when they started pushing its use but I don't have them in front of me.


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## unleashedfury (Dec 14, 2013)

with any tool, they have their place. 

I.E. the seizing patient that you are going to have a hard time getting an IV on. wanna break that seizure. with Valium 

Cardiac arrest where narcotic toxicity is the suspected cause 

just because you got the NAD dosent mean it fits every patient.


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## Tigger (Dec 14, 2013)

unleashedfury said:


> with any tool, they have their place.
> 
> I.E. the seizing patient that you are going to have a hard time getting an IV on. wanna break that seizure. with Valium
> 
> ...



Why this one?


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## Handsome Robb (Dec 14, 2013)

unleashedfury said:


> with any tool, they have their place.
> 
> I.E. the seizing patient that you are going to have a hard time getting an IV on. wanna break that seizure. with Valium
> 
> ...



Intranasal is not a viable route of administration for patients in cardiac arrest. Like IM and SQ IN requires peripheral circulation for the drug which cardiac arrest patients severely lack.


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## Fire51 (Dec 14, 2013)

I have never gave meds through IN, but have seen it done before and it has not had good reactions except when I saw a medic give it to a kid. So my thoughts are the same as the others, that it has to much complications for the meds to get fully absorbed.


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## NomadicMedic (Dec 14, 2013)

If you've never given it, and only seen it one, how can you form an opinion?

I use IN Narcan exclusively now for Opiate ODs. I have had excellent results with it. I find that Versed is hit or miss, depending on the concentration I have in my box. Fentanyl IN works great for kids, but I find IV Fent better for adults.


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## Fire51 (Dec 14, 2013)

DEmedic said:


> If you've never given it, and only seen it one, how can you form an opinion?
> 
> I use IN Narcan exclusively now for Opiate ODs. I have had excellent results with it. I find that Versed is hit or miss, depending on the concentration I have in my box. Fentanyl IN works great for kids, but I find IV Fent better for adults.



I have seen it more then once before and have seen it only really work once, that's what I was saying and yes your right I will have to give it myself in situation to see for myself if I like it or not. Don't have a very strong opinion on it yet. From the medics I have talked to all of them have mixed opinions on it, some like it  some don't. So after I use it more I will have more of a opinion about it. The one I actually saw work well was Fent for a kid.


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## STXmedic (Dec 14, 2013)

I use it for fentanyl with kids. That's about it. I've had such varying responses on all other uses, that I typically just go IM when I can't go IV. While it may not be as fast as IN could potentially be, it's more consistent and reliable. 

For instance: excited delirium- The thought of no needle and a quick onset is awesome. However, my concentration of versed is only 1:1. 2mg of versed isn't going to do anything for an ED patient. Besides the fact that many of our ED patients are on cocaine, which they commonly like to snort... That whole vasoconstriction thing really hampers absorption through the mucosa. Nope. I'll stick with giving a full dose in the muscle and waiting an extra minute or two.


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## Medic Tim (Dec 14, 2013)

unleashedfury said:


> with any tool, they have their place.
> 
> I.E. the seizing patient that you are going to have a hard time getting an IV on. wanna break that seizure. with Valium
> 
> ...



IM benzo is the preferred seizure med route...if there is no IV (rampart study)
and why the narcan during cardiac arrest? Your priority should be compressions and airway


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## Christopher (Dec 17, 2013)

joedittfurth said:


> anybody out there have any insight on nasal atomizers specifically with glucagon



You need to give ~2 mg if you're going to do IN glucagon, which is an expensive proposition.


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## NomadicMedic (Dec 17, 2013)

Really? Why is that? Our IN dose is 1mg.


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## Christopher (Dec 17, 2013)

DEmedic said:


> Really? Why is that? Our IN dose is 1mg.



If you're looking for _equivalence_ to IM glucagon you need to give 2 mg IN. Studies comparing 1 mg IN, 2 mg IN, and 1 mg IM show that 2 mg is the equivalent dose for the nasal route.

I could only find one of the three studies that included a graph, and it appears 1 mg may well be _clinically_ equivalent. But there have been no studies large enough to say whether the observed differences in 1 mg and 2 mg are actually clinically relevant.





(I added the blue for folks not used to mmol/L as a glucose measurement)


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## NomadicMedic (Dec 17, 2013)

Interesting. I'll share that with the guy in our Protocol Revision group. I'm sure they'll just say, "continue to give 1mg IM" however.


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## Christopher (Dec 17, 2013)

DEmedic said:


> Interesting. I'll share that with the guy in our Protocol Revision group. I'm sure they'll just say, "continue to give 1mg IM" however.



Like I said, clinical relevance is perhaps more appropriate for the provider. There are statistical differences in BGL curves between IV D10 and D50, but clinically there is little difference.

I think if you gave 1 mg IN while working on a line, you'd be fine in practice, but given the lower than equivalent dose you may find non-responders.


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## NomadicMedic (Dec 17, 2013)

I've not had opportunity to use Glucagon IN yet. In fact, in the last 3 years, I've used it only once. I believe it's overall use in my system is low. However, the safety of not having a sharp around a potentially seizing/combative patient is a good option and one we should look at more often.


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## Av8or007 (Jan 17, 2014)

With the glucagon, why not just give it IM?

Simple and effective.


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## NomadicMedic (Jan 17, 2014)

Av8or007 said:


> With the glucagon, why not just give it IM?
> 
> Simple and effective.




Look up.  





> the safety of not having a sharp around a potentially seizing/combative patient is a good option and one we should look at more often.


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## unleashedfury (Jan 17, 2014)

Tigger said:


> Why this one?





Robb said:


> Intranasal is not a viable route of administration for patients in cardiac arrest. Like IM and SQ IN requires peripheral circulation for the drug which cardiac arrest patients severely lack.





Medic Tim said:


> IM benzo is the preferred seizure med route...if there is no IV (rampart study)
> and why the narcan during cardiac arrest? Your priority should be compressions and airway



First off I really need to learn to keep up with my posts.. 

The theory behind it for our use was medic chase car with two BLS providers on location. Since ETT, and EPI are farther down the list on the ACLS guidelines So is initiating IV therapy. 

So In theory you would have 2 BLS provider at minimum(depending on location you might get fire or a 2nd BLS crew) performing BLS CPR with a AED attached. Upon arrival of ALS the AED pads can be transferred over to the LP monitor. If suspected Opiate Toxicity 2MG IN Narcan can be immediately administered as CPR is continued with a BLS airway and compressions. Works great in theory I have yet to see success we are a big Heroin use area. 

as far as onset of action, to IN medications I was told various things with no studies to prove it.


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## Tigger (Jan 17, 2014)

I don't think Naloxone via any route during cardiac arrest works at all, not even in theory.

If the patient is pulseless, it has nothing to do with any amount of opiods onboard but rather that they were not breathing for a prolonged period of time.


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