IN Fentanyl and no IV

18G

18G

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Had a call recently involving a 30 something female who injured her ankle from stepping off the back of a large moving truck. Ankle was pretty swollen with 7/10 pain. Injury was isolated.

I didn't see a need to start an IV and inflict more discomfort. I wanted to give IN fentanyl (IN not protocol for fentanyl but figured would try anyway) and was denied. This pt. just had to have an IV as insisted by MC.

There are numerous studies with evidence on IN fentanyl which show equal efficacy as compared to IV morphine. And the associated adverse reactions with IN fentanyl are very rare making it a very safe route and drug. Are there any systems that allow for IN fentanyl without first attempting an IV?

What are feelings on IN fentanyl without an IV in an isolated fracture?
 
We can do it here.

I ask if they've ever had Fentanyl before. If they have, and no problems, sure.
 
I like using IN Fentanyl, especially with kids. Several times I have used IN fentanyl on a kid with an isolated extremity injury. That being said (anecdotally) I have noticed that it seems to work half as well as an equivalent IV dosage. I personally think any protocols should leave the route of medication administration up to the provider (within reason), there is no reason to say that Fentanyl should be given IV over IN in all circumstances (but this is the inherent problem with ALL protocols).
 
sir.shocksalot said:
I like using IN Fentanyl, especially with kids. Several times I have used IN fentanyl on a kid with an isolated extremity injury. That being said (anecdotally) I have noticed that it seems to work half as well as an equivalent IV dosage. I personally think any protocols should leave the route of medication administration up to the provider (within reason), there is no reason to say that Fentanyl should be given IV over IN in all circumstances (but this is the inherent problem with ALL protocols).
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Thats a major problem with EMS in itself.
 
sir.shocksalot said:
I like using IN Fentanyl, especially with kids. Several times I have used IN fentanyl on a kid with an isolated extremity injury. That being said (anecdotally) I have noticed that it seems to work half as well as an equivalent IV dosage. I personally think any protocols should leave the route of medication administration up to the provider (within reason), there is no reason to say that Fentanyl should be given IV over IN in all circumstances (but this is the inherent problem with ALL protocols).
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are you using an atomizer with this or just squirting a jet of liquid from a syringe up their nose?
 
We carry the atomizers and are able to give fentanyl IN. I have given it that way, but personally I don't think it works as well as giving it IV. Because of that, I prefer to start a lock. If the patient is adamant about me not sticking them, then I go the IN route. However, a lot of them will opt for the IV after the first dose. I have been told it leaves a horrible taste in the back of your throat/mouth.
 
Veneficus said:
are you using an atomizer with this or just squirting a jet of liquid from a syringe up their nose?
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We use an atomizer, however I am sure the jet of liquid has been used by someone out there :rofl:

I will also second that I have some patients that would have rather gotten an IV than deal with the sensation of the atomizer, I have heard it is rather unpleasant. However most kids have a fear of needles that far supersede a fear of a gross squirt up the nose.
 
ive done IN fentanyl on multiple occasions and only seen it work once surprisingly
 
I think that maybe they wanted the IV as a control measure in case she was a cheap date and one dose knocked her on her butt.

Although, fentanyl is much more cardiostable than MS with much less respiratory depression--- especially with severe pain. People can get juiced up pretty good with severe pain and show minimal changes in vitals.

Sounds like the doc was just going for CYA.
 
I've given IN fentanyl on several occasions and I'm not a fan. At all. It has never worked the way I or the patient was looking for.

If she was truly in that much pain a little poke from an IV wont be a big deal. If they complain about being poked I start to doubt the need for pain management. That's just my opinion though.

As for your original question, we can give fent IN without an IV on standing orders but we are to attempt to establish IV access after the first dose. I love not having to call medical direction. It's really rare that we have to, except for termination of resuscitation efforts.
 
It's subjective and my opinion but if you are any good at starting IVs and you are really only using it for med admin a 22g is plenty big and they don't hurt that bad. Just a quick pinch and you're done. Like I said above, if they are worried about the IV start I start doubting their pain scale.
 
I've done the literature review for pediatric intranasal fentanyl when I pushed for its adoption locally and found there is no reason not to use it when indicated. There is some literature supporting its use in adults, however, it is not nearly as well studied as in children. We got it approved locally, but at pretty weak dosages.

Last year I pushed for intranasal fentanyl's adoption into the 2012 NC EMS protocols and it made it into the draft for both adults and children (albeit at lower dosages than I would have liked to have seen).

Hopefully you can use the literature review and point to NC's protocols to get it adopted in your area.
 
NVRob said:
I've given IN fentanyl on several occasions and I'm not a fan. At all. It has never worked the way I or the patient was looking for.
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How much were you giving? I've had great success with 1 mcg/kg in kids. I've not used it in enough adults to judge its adequacy in my own practice.
 
We use IN fentanyl in kids and adults. My entirely anecdotal and subjective experience is that it is excellent for children, rubbish for adults. I have no idea why that may be, that is just what I have observed.
 
I love IN fentanyl. There have been many times where it has been handy and a few time where its been almost essential, even in my short time on road.

I agree that it seems to work better in kids. I seem to remember reading something about age related damage to mucous membranes affecting its admin in oldies..perhaps in one of the IN fent studies..I don't remember where now, and I can't seem to find it.

I think a lot of the problems are dose related. I don't think you can just atomise your IV dose and expect it to work as well.

Relatively speaking we use a lot more for the loading dose (Adults: 200mcg <60yrs/>60kg, 100mcg >60yrs/<60kg. Kids: 2mcg/kg) and maintenance doses (50mcg or 1mcg/kg q5). I think the 50mcg maintenance doses are a little conservative, it would be nice to have a little wiggle room there, especially in the severe pain pt with delayed IV access.
 
We are just rolling out IN fentanyl here, with ICP's getting IV/IM hopefully to pass the drug down to our ACP level.

Our IN loading dose is 1.5 mcg / kg

repeated once at 1 mcg/kg at 10 minutes

total max dose 100 mcg
 
Maryland just got Fentanyl as a substitute for morphine due to the national shortage, however they haven't approved any other route other than IV.
 
I've given it IN a few times. I'm cautious in my dosing. I prefer the "safety net" of an IV, but it isn't always a possibility.

Thinking about IN Fentanyl for a Wilderness ALS operation I'm going to be a part of. Will keep everyone posted on what I do.
 
I've given fentanyl IN a few times, all were in elderly patients. I've really only had it work well in one instance, all of the other times I was disappointed with how effective it was.

That being said, we have the option of giving fentanyl IV, IN, IM, or IO. If I have a patient with an isolated fracture, I may give a dose of fentanyl IN, then start a line and give subsequent doses via IV, depending on the situation.
 
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