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Tricks of the trade: Intranasal fentanyl for pediatric patients

 
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Pediatric patients often receive inadequate pain control in the setting of orthopedic injuries. Because the child experiences fear, anxiety, and pain with needles, practitioners often shy away from ordering IV or IM pain medications. Oral agents, while easier to administer, usually provide inadequate pain control.

Trick of the Trade

Intranasal (IN) fentanyl

Thanks to my friend Dr. Ron Dieckmann (Editor-in-Chief for PEMSoft, Chairman of Board for KidsCareEverywhere, and Pediatric Director for Valley Emergency Physicians) for his tip about intranasal fentanyl:

It is imperative that the drug be administered in a nebulized form using an atomizer device — one half the volume in each nostril. Attach a 1 cc syringe to the end of the atomizer to administer fentanyl intranasally.
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It is rapidly absorbed and provides excellent analgesia within minutes. It works just as well as IV morphine (1). If you just drop the liquid in the nose without using the atomizer, the child will swallow some of the drug, and onset and effect will be blunted significantly and titration is not possible.

The starting dose of 1.5 microgram/kg can be repeated in a dose of 0.5-1.5 microgram/kg IN in 5 minutes.  Be sure to use extreme caution in younger patients who are more susceptible to the respiratory depressant effects of all opiates; it has not been tested in children < 3 years of age at all, so I would not use in this age group. Put patients on a pulse oximeter. In the event that a child receives the drug and starts to desaturate, bag the patient, then just give naloxone 0.1 mg/kg/dose to a maximum of 2 mg intramuscularly, and the respiratory effects will be rapidly reversed.

Do you use intranasal fentanyl at your practice?

Reference
1. Borland M, Jacobs I, King B, O’Brien D. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med. 2007 Mar;49(3):335-40.

 

By |2016-11-11T19:00:24-08:00Oct 27, 2010|Pediatrics, Tricks of the Trade|
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Paucis Verbis card: Pediatric weight-based reference (5-34 kg)

Broselow

The foundation in any pediatric resuscitation is the length-based estimation of the patient’s lean body weight. Once determined, equipments and medications are sized and dosed, respectively, according to that weight. You can use electronic resources such as PEMSoft (Pediatric Emergency Medicine Software) or the more traditional paper-based Broselow tape.

If you have neither of these at your easy disposal, I thought I would create a multi-card reference which works best in electronic pdf form on your mobile device. Even if you DO have other available references, it’s still nice to have some redundant back-up sources just in case.

This data was collected by merging data from the Broselow tape and PEMSoft.

  • I created 30 individual cards for patients weighing between 5 kg and 34 kg.
  • I didn’t include whether endotracheal tubes should be cuffed or uncuffed. This is controversial currently. The traditional teaching is that patients younger than 8 years old should receive UNcuffed tubes.
  • D10W glucose should be given in patients younger than 1 year old. D25W glucose should be given for patients 1-2 years old. D50W glucose can be given to patients 2 years and older.
  • Please use these cards with caution. I’ve proof-read these cards multiple times, but there still may be some typos. Please let me know if you see any discrepancies.

PV Card: Pediatric Weight-Based Resuscitation Reference


Go to ALiEM (PV) Cards for more resources.

 

By |2021-10-17T09:30:51-07:00Oct 22, 2010|ALiEM Cards, Pediatrics|
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Paucis Verbis card: C3-C7 spinal fractures

Fig9E Fx FlexTear anatomy cervical spine fracture

This is the second Paucis Verbis card on cervical spine fractures. Part 1 covered C1 and C2 fractures. This card covers the lower cervical spine fractures. These two tables are part of my chapter on “Spine and Spinal Cord Injury” in the textbook Emergency Medicine by Dr. Jim Adams (Northwestern EM Chair).

PV Card: C3-C7 Fractures and Injuries


Go to ALiEM (PV) Cards for more resources.

By |2021-10-18T09:59:44-07:00Oct 8, 2010|ALiEM Cards, Orthopedic|
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Paucis Verbis card: C1-C2 injuries

Cervical spine C1-C2 fracture

I’m starting to work on co-authoring the next edition of my chapter on “Spine and Spinal Cord Injury” within the textbook “Emergency Medicine” by Dr. Jim Adams (Northwestern EM Chair). There are some useful tables that I created that I thought you might find helpful. This is the first installment covering C1-C2 fractures. The next PV card will cover the lower cervical fractures.

I always forget which are stable and unstable. For instance, the above extension teardrop fracture looks innocuous but is an unstable fracture because the anterior longitudinal ligament is ruptured.

PV Card: C1 and C2 Fractures and Injuries


Go to ALiEM (PV) Cards for more resources.

By |2021-10-18T10:02:37-07:00Oct 1, 2010|ALiEM Cards, Orthopedic|
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