Originally published at Pediatric EM Morsels on September 5, 2014. Reposted with permission.

Follow Dr. Sean M. Fox on twitter @PedEMMorsels

Being flexible and creative are important traits to have while working the ED. It is also vital to always keep the end result in mind. Pain control is always an important endpoint for us to constantly consider. While most of us would say that we strive alleviate our patients’ pain, there is evidence that we are not great at it.

It’s Complicated

Why would we not alleviate pain optimally? Well, like many things, it is more complicated than us just cruel and sadistic.

Certainly, there used to be a perception that pain in kids (especially neonates) was not as important since they wouldn’t remember it. – WRONG .

. Additionally, there are times when our consultants have “requested” that we didn’t give pain medications (ex, Morphine for Appendicitis). – A MYTH .

. Of course, we need to always remain optimally educated on the subject (THANKS FOR READING THE PEDEM MORSELS!).

But even with a highly educated and compassionate provider, delivering appropriate analgesics in a timely fashion is not easy : You have to evaluate the patient, then write the orders. Often these orders include Intravenous Analgesics (ex, IV Morphine). This, in turn, requires an IV. Now, in a busy ED, a nurse may not be able to promptly jump in that room an place the IV. Placing an IV is also not always an easy task. All of these steps and possible obstructions can easily lead to delayed analgesic administration . Now, despite how compassionate you are… you appear to be cruel !

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Intranasal Route – No Need for an IV

We all know that the blood supply to the nose is quite robust. Anyone who has bonked their nose knows. Our patients who snort heroine or cocaine also know.

The venous drainage from the nose conveniently ends up in the SVC, avoiding the liver (and 1st pass metabolism).

(and 1st pass metabolism). The anterior potion of the nose (the Vestibule) is the main site for drug absorption as it has a relatively large surface area and has a good blood supply.

Volumes of 0.3 mL are easily tolerated . This requires concentrated solutions of the administered medications. If you need to use larger volumes, you can divide the dose in half and use each nostril. If the volume is still too large, you can administer in separate aliquots separated by 10-15 minutes… or use another strategy (nothing is perfect).

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Intranasal Fentanyl to the Rescue

Fentanyl is a great example of a medication that works well when given via the intranasal route. It has a low molecular weight. It is lipophilic. It has concentrated versions (50 microgr/mL – 150 microgr/mL).

Fentanyl (1-2 micrograms/kg) given via intranasal route has proven to be as efficacious as IV Morphine (0.1 mg/kg) .

. It has also been shown that intranasal fentanyl can be administered more rapidly than IV morphine to pediatric patients in the ED.

A Reasonable Approach (at least I think so)

Intranasal Fentanyl can be delivered before even an IV can be placed.

Even if you still need an IV (say for the grossly deformed forearm that you know will need procedural sedation), the intranasal fentanyl is still a faster way to get analgesics on board. Yes, it might require some explanation that you are going to squirt pain meds up the kid’s nose and then still place an IV… but the focus is on delivering pain meds quickly. This will likely also help the nursing team trying to get the IV, as now they have a more comfortable and cooperative patient. It also helps speed up the process for getting your X-rays… now you are not waiting for the IV to give the pain meds so that you don’t feel like a sadist getting the xrays.

(say for the grossly deformed forearm that you know will need procedural sedation), In the end, this also helps you… not feeling like a sadist is very helpful in avoiding compassion fatigue... and will help keep you happier as a physician!

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