Shove it up your nose

A 35 year old man arrives at your emergency room, he’s a construction worker and he’s put a large spike right through his forearm with a nail gun. Ouch! He’s freaking out, screaming and writhing around. ‘Stay still!’ the nurse is yelling, ‘I can’t help you until I get this IV in!’ The ambulance crew is trying to hold him flat, the patient is screaming, crying and can’t stop moving.

I hate this kind of messy situation, I like my emerg to be a well oiled machine and this situation is like the sound of metal shavings in the gears. What can you do? Obviously this patient needs analgesia, but in the current situation establishing IV access is proving difficult.

Intranasal fentanyl is the trick shot that can get you out of this situation. Estimate the patients weight, draw up 0.5mcg/kg of fentanyl into a 3ml syringe. If you have an atomizer device use it, if not just make sure the patients head is tilted back. Walk over to the patient and say “Sir I am going to give you some pain medication, do you have any allergies?’ then, shove it up his nose.

Ah, silence my favourite sound. Intranasal fentanyl is directly absorbed, bypasses first pass metabolism and rapidly accesses the brain to provide analgesia. It burns a little in the nose, but in the patient with severe pain they never seem to notice. A minute after giving the med you can take a history, do your examination and establish your IV in a cooperative, if slightly altered patient.