Question, because I've been playing with IN Fentanyl quite a bit here lately and the AUS and NZ providers seem to be the experts on it.
Does the higher inital dose provide supperior relief via the IN route? Our guidelines call for the same dose (1-2mcg/kg) no matter the route, so I've usually been going with 75% or so of the first dose IN with the remainder of the 1st dose IV once I can get them in position which an IV start is convinent for everyone. Should I be hitting them with higher doses right off the bat?
The higher dose as I understand it is due to limited absorption. IN isn't equivalent to IV, which makes sense I spose. One of its bigger advantages is added pain relief for kids whom we cannot cannulate at the basic level here.
For reference the complete guideline is:
Adult (>14yrs): (>60kg AND age <60yrs); 200mcg, 4x 50mcg q5. (<60kg and/or age >60yrs); 100mcg, 2x 50mcg q5.
Paeds: 2mcg/kg, 2x 1mcg/kg q5.
With consideration to active asthma, the possible deleterious affects of combining it with amiodarone for our MICA chaps, elderly patients, pts with renal or hepatic impairment, COPD and combination with MAOIs.
The studies that validated IN fent used smaller doses (still above 2mcg/kg for adults) and it was regularly not enough. So I would say it would be better to consider bigger initial doses, within protocol and reason of course, etc. I feel our max doses are still on the conservative side for kids esp. But we shall see what I feel once I get out there using it regularly. It is encouraged that IN doses be followed up with prompt IV morphine with obvious consideration to combining the effects. MelbMICA will be far more useful to you in that regard.
It seems to work better in some pts than others. Anecdotaly, I've seen it work faster and with more reliable analgesia in younger pts. It seems to be a bit unpredictable in older people. A few other people have agreed with that observation, but its just based on opinion as far as I know, so take it or leave it. I've got the references to just about all the IN fent research ever done, so shoot me a PM if you want the list.
Like IN naloxone, there's a bit of an issue with concentration. You've got to have a high concentration drug prep otherwise you end up squirting litres of fluid up their nose. For the IN route, we carry 900mcg/3ml vials. What presentation of fent are you using?
its been a while since I dealt with flight teams on a regular basis. I used to see fixed wing PHI and SWME crews on a very regular basis since I ran the BLS night truck at my old service.
I usually smile when I see other NM providers on here since they don't tend to hang around. Although I'm another NM EMT that's most likely going to TX, so I shouldn't say anything 
