- Need for pain control when IV or PO routes are unavailable or inappropriate
- Alternative to IM route
- Syringes (1mL or 3mL)
- Blunt fill needle
- Load the appropriate volume/dose of medication into the syringe
- Remove needle and attach atomizer device to syringe
- 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 depress the syringe plunger to deliver the medication into the nostril
- May repeat on opposite nostril if dose volume is too large for one nostril
- ⅓ to ½ml per nostril is ideal, but can deliver up to 1ml per nostril (expect some fluid to 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. As the effect of the nasal drug wanes, the oral medication takes effect
- The single biggest reason for failure of intranasal opioids is inappropriate dosing (usually underdosing)
- Medications get absorbed in the nasal mucosa so inhalation is not needed and my cause deposit in the nasal pharynx
- 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.