As we begin to talk about the last several routes of administration, it’s important to recap a couple of comments made earlier that apply to all medications and delivery methods. Before administering any medication, be sure to do three things:
Intranasal administration of medications uses a transmucosal approach like that seen with OTFC and ondansetron but uses the nasal mucosa as opposed to the oral mucosa.
There are a few things to do to prepare your casualty for an intranasal medication. First, confirm the nasal airway is clear of obstructions and no blood or clear fluid is coming from the nose. If one nasal passage is partially (or completely) obstructed, use the other side (and if both appear partially obstructed, use the side that seems to have less obstruction). And finally, have the casualty blow their nose before the first medication dose (only the first one), if possible.
The three most common delivery systems are:
In the TFC setting, the three medications that are potentially delivered intranasally include ketamine, naloxone, and fentanyl (with current recommendations that Combat Paramedic and provider level medics administer IN fentanyl). There is no difference between the IM and the IN dose for ketamine (50 mg) or naloxone (0.4 mg), but the ketamine does come in different concentrations; the higher concentration option (100 mg/ml) is recommended when using IN dosing route to minimize the volume administered intranasally. For Combat Paramedics, the fentanyl IN dose is higher than its IV dose (100 mcg, as opposed to 50 mcg).
It is essential that you familiarize yourself with the medication system your unit will stock for a mission, as there are subtle differences from one supplier to the other, and the time to familiarize yourself with the delivery mechanism is not when you are down-range.