- Two syringes: 1ml or 3ml
- Needle to draw up the medication
- Vial of medication
- Aspirate the proper volume/dose of medication per the weight based dosing protocol
- Twist off/remove the syringe from the needle/needleless device
- Attach the atomizer tip via Luer lock mechanism – it twists into place
- Using your free hand to hold the crown of the head stable, place the tip of the atomizer snugly against the nostril aiming slightly up and outward (towards the top of the ipsilateral ear)
- Briskly compress the syringe plunger to deliver the medication into the nostril
- Place second device over to the opposite nostril and briskly administer the remaining half of the medication into that nostril
- Consider using a pulse oximeter for 45-60 minutes following medication delivery due to the rare but possible risk of respiratory depression from an opiate
- Anytime pain control is needed but oral medication is too slow OR IV access not obtainable
- Burn dressing changes
- Re-packing wounds such as abscesses
- Any time you consider an IM shot for pain control (IN works as well or better with faster onset and no pain on delivery)
- Titration of opioids is often needed and very easy and effective – repeat does every 15 minutes until desired effect is obtained.
- Research data now demonstrates IN opioids are as effective as IV, just faster due to no delays in obtaining an IV:
- 1/3 to ½ ml per nostril is ideal but you can push up to 1ml per nostril though some will run off. If you need more than 2ml total, consider titration with second dose in 5 minutes
- Consider administering an oral pain medication at the same time as the nasal medication or after about 15 minutes. This way as the effect of the nasal drug wanes, the effect of the oral medication begins to have an effect
- The single biggest reason for failure of intranasal opioids is the clinician gives an in-appropriate dose (i.e. they underdose with an IV dose which tends to be too low)
- Medications get absorbed in the nasal mucosa so inhalation is not needed and my cause deposit in the nasal pharynx
- Be aware of the “dead space” in your delivery atomizer and add that extra volume to your dose
- You should draw up the additional appropriate dead space of the delivery device you choose. In this table the 0.1ml represents a typical dead space in a 1ml syringe connected to a syringe driven atomizer.
- If the volume exceeds 1ml you might want to consider delivering as two separate doses 5 minutes apart
- Volumes in this range should definitely be divided in half and administered 5 minutes apart to reduce runoff
- Fentanyl: 1-2 mcg/kg (comes in 50 ug/ml) (best for children)
- Be Wary of respiratory depression
- Monitor patients with pulse oximetry and close observation
- Titration to pain is often necessary
- Repeat dosing (1/2 to full dose) every 15 minutes until desired effect is achieved
- Be aware of dead space in delivery device
- Failure to account for the device dead space may lead to under-dosing of these highly concentrated drugs.
- Midazolam 0.3 to 0.5mg/kg (maximum = 10mg)  
- Use the lower dose for minor, non-painful procedures such as radiographic imaging
- Use the higher dose for better sedation prior to procedures such as laceration repair
- Results in mild somnolence with resultant reduction in anxiety and probably amnesia
- Be aware that midazolam causes some nasal burning benzyl alcohol preservative) for 30-45 seconds when administered.
- In small children; lidocaine 2% or 4%: 0.2ml per nostril 5 minutes prior to the midazolam to stop the burning
- Use only concentrated midazolam (5mg/ml) formulation
- Ketamine 3 to 9mg/kg (no routine recommendation yet)
- Ketamine may result in deeper sedation and is dose dependent, utilize the initial dose at 6mg/kg and repeated doses at 3mg/kg until desired sedation is achieved.
- Be aware that ketamine causes a bitter taste (lyophilized) when administered
- Behavioral changes (nightmares, enuresis nocturna, and irritability) in children less than five (unable to understand reasons for experience)
- Use only concentrated ketamine (100mg/ml) formulation
- Ideal volume is 0.3 to 0.5 ml per nostril, maximum is 1ml per nostril, and more will just run out nose. If you need more – titrate to effect
- Ketamine 1mg/kg may be used for pain control (not procedural sedation) 
- Good adjunct to opioids or as an opioid-sparing agent
- Dexmedetomidine 1-2 μg/kg
- Provides procedural analgesia and anxiolysis
- Currently unavailable in most EDs
- Pediatric Emergency Playbook Podcast: Intranasal Medications and You
- Saunders M, Adelgais K, Nelson D. Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med. 2010 Nov;17(11):1155-61. doi: 10.1111/j.1553-2712.2010.00905.x.
- Chiaretti A, Barone G, Rigante D, Ruggiero A, Pierri F, Barbi E, Barone G, Riccardi R. Intranasal lidocaine and midazolam for procedural sedation in children. Arch Dis Child. 2011 Feb;96(2):160-3. doi: 10.1136/adc.2010.188433. Epub 2010 Oct 27.
- Shavit I, Feraru L, Miron D, Weiser G. Midazolam for urethral catheterisation in female infants with suspected urinary tract infection: a case-control study. Emerg Med J. 2014 Apr;31(4):278-80. doi: 10.1136/emermed-2012-202088. Epub 2013 Feb 22.
- Graudins A, Meek R, Egerton-Warburton D, Oakley E, Seith R. The PICHFORK (Pain in Children Fentanyl or Ketamine) trial: a randomized controlled trial comparing intranasal ketamine and fentanyl for the relief of moderate to severe pain in children with limb injuries. Ann Emerg Med. 2015 Mar;65(3):248-254.e1. doi: 10.1016/j.annemergmed.2014.09.024. Epub 2014 Nov 18.