EMS World Expo Quick Take: BLS intranasal drug delivery – why not?
How to add intranasal drugs to the BLS scope of practice, and why it would be a valuable addition to the BLS toolbox
Intranasal medication delivery is a growing treatment modality in EMS as well as in the hands of the lay public, rapidly advancing with new therapeutic medication options emerging every few years.
Tim Wolfe, MD, adjunct associate professor of emergency medicine (ret.) at the University of Utah and clinical faculty at Jordan Valley Medical Center in Salt Lake City, Utah, delivered a Pulmodyne-sponsored session on BLS applications for intranasal drug delivery at the virtual EMS World Expo 2020 conference.
A former Utah paramedic school medical director, Summit County EMS director, and co-director of the division of emergency medicine at the University of Utah, Dr. Wolfe has invented two EMS devices, the EID esophageal detector device and the MAD Mucosal Atomization device, and currently consults for Pulmodyne.
Memorable quotes on intranasal drug delivery
Here are some of Dr. Wolfe’s quotes that stood out during his presentation:
- “I’ve heard this before; ‘you’re nuts doc … we’re never going to be allowed to use these drugs in our practice.’ I want you to take a step back and not believe that rhetoric.”
- “I certainly think that Afrin is a BLS level therapy,” Dr. Wolfe said. “I let my kids use it when they have a nosebleed. I send patients home with it all the time, I tell them to buy it in the grocery store.”
- “There are many studies that have directly compared nasal naloxone with IV and intramuscular naloxone and across the board they show similar efficacy with waking up – maybe not quite as fast in some studies, but similar efficacy and your goal as a BLS provider is to get them to wake up and start breathing and if it takes 5 minutes rather than 3 minutes, hey, they’re still breathing.”
4 takeaways on BLS intranasal drug delivery
Dr. Wolfe discussed how to deliver intranasal drugs and why they are a good option to add to the BLS toolbox, as well as several scenarios in which they could improve patient care. Here are 4 takeaways on adding intranasal drug delivery to the BLS scope of practice.
1. How intranasal drug delivery works
Dr. Wolfe provided a brief background of the principals behind intranasal drug delivery to explain how it works, and how it differs from other drug delivery models.
With oral administration, once ingested, the drug sits in the stomach and it takes 10, to 15, to 20 minutes to become solubilized, pulverized and ready for absorption. It is then absorbed by the portal circulation system, which means is is taken to the liver for detoxification. Only about 5-10% of the drug gets past the liver to be distributed throughout the body by the heart. This process takes about 20-40 minutes, obviously not suited to an emergent condition.
With intranasal drug delivery, once sprayed into the nasal cavity, the drug absorbs through the nasal mucosa, directly into the facial veins, to the jugular, vena cava, and the heart. It takes just 3-5 minutes to absorb and be distributed, and bypasses the liver, so the majority of the drug makes it into the blood stream. The olifactory mucosa is in direct contact with the brain – termed the nose-brain pathway – meaning absorbed medications enter the cerebrospinal fluid.
The amount of drug to enter the bloodstream varies depending on concentration, the health of the nasal mucosa and the delivery system, but is fairly high, Dr. Wolfe noted, encouraging providers to always choose the highest concentration available when administering intranasal drugs.
2. Tips for administering intranasal drugs
Dr. Wolfe offered the following tips for best effect when administering intranasal drugs:
- Minimize volume, maximize concentration. 0.2-0.3 mL per nostril is ideal; 1 mL is the maximum that should be administered
- Maximize total absorptive mucosal surface area. Use both nostrils
- Use a delivery system that maximizes mucosal coverage and minimizes run-off. Atomized particles cover a broad surface area
- Beware of abnormal nasal mucosal characteristics. Blood, mucous or vasoconstrictors may reduce absorption (suction or consider alternate delivery route if present)
- Aim correctly. Slightly up and out, towards ear
- Push briskly. If you push slowly, it will leak out of the nasal cavity
- Titrate the dose. If it doesn’t work, try another dose
3. Use cases for BLS intranasal drug delivery
Dr. Wolfe presented a few different use cases involving the use of intranasal medications for common clinical cases such as status epilepsy, severe pain, epistaxis and opiate overdose.
Case: Opiate overdose. Firefighters respond to an unconscious, barely breathing patient with obvious intravenous drug needle marks on both arms, consistent with heroin overdose. They administer BLS nasal naloxone, then support his respirations with BVM. The patient slowly awakens, begins breathing, remains mildly sedated. He is transported to the ED, observed for a few hours and then released. No intravenous or ALS level care is administered.
Dr. Wolfe noted intranasal naloxone is 80-90% effective at reversing opiate overdoses – even higher with BVM support and time. Weiner 2017 found intranasal naloxone 95% effective in 793 patients if BLS administered it, provided BVM support and waited.
- Case: Epistaxis. An elderly male has profuse bleeding from his left nostril after suffering facial trauma. Treatment includes atomized oxymetazoline (Afrin) and tranexamic acid (TXA) into the nostril, followed by manual pinching of the nose. On arrival to the hospital 15 minutes later, manual compression is released and his nasal mucosa is dry. The ED physician examines him, repairs his lip laceration and discharges him with a bottle of oxymetazoline and told to use it for 3 days to promote vasoconstriction and prevent rebleeding. No packing, expensive clotting factors or ENT consult are required.
- Case: Extreme pain. A 35-year-old female complains of severe pain in her left flank radiating to left lower abdomen. She is rocking back and forth in pain. She has a history of kidney stones and describes the pain as similar. She is treated with 70 mg (1 mg/kg) intranasal ketamine. In 10 minutes, her pain is a 5/10 and she is calmer. ALS arrives and administers another half dose of nasal ketamine. On arrival to hospital she is calm, pain is a 2/10 and further evaluation confirms kidney stone diagnosis.
- Case: Status epilepticus. A 5-year old girl has been suffering a seizure for 10-15 minutes. Rectal diazepam administered by parents was ineffective. Parents are frantic because child usually ends up intubated and in the ICU if the seizures can’t be stopped. Your rural EMS director has started a new treatment modality – you give a dose of nasal midazolam and within 3 minutes of drug delivery, the child stops seizing.
4. Research, medical direction
Dr. Wolfe asks the question, if these medications are safe for the lay public to use, why aren’t they a part of BLS practice?
He offered the following benefits of intranasal drug delivery:
- Rapidly effective (onset within 2-10 minutes)
- Safe: no high peak serum levels
- No special training required
- Eliminated risk of needlesticks
- No delay in starting IV
- Reduced cost
- Reduced opiate use
- Increased patient dignity
- Make drugs more quickly available in the rural setting
While there are certainly challenges to bringing intranasal drug delivery to the BLS scope of practice, like drug security and tracking, Dr. Wolfe thinks it’s a conversation worth starting. “Don’t be afraid to think outside the box,” he said. “If you find it compelling, talk to your EMS director and see if some of these things might be appropriate in your practice.”
He noted it will take those conversations with the medical director and participation in research to pave the way for BLS intranasal drug delivery – something that could prove invaluable as we anticipate millions of COVID-19 vaccines in our future, as intranasal delivery could open up vaccinator staffing.
“If you are in a situation where you have a good research group in your EMS system, maybe convince them to do topical TXA study at a paramedic level and once they show how effective and safe it is there, repeat the exact same study at a BLS level and voila, you will have changed how we treat patients in the field,” he said. “It won’t come overnight, it will take a lot of work, just like everything that’s important.”
Additional resources on prehospital intranasal drug delivery
Learn more about intranasal drug delivery with these resources: