Intranasal Fentanyl

February 1 was the first day we would use intranasal Fentanyl. My first shift on, I made certain I had an atomizer in my pocket. In the guidance for intranasal Fentanyl, it says “useful for patients who lack IV access or in whom IV access is not desired”. But we put nothing in the guideline that says you can’t give it to anyone. I was eager to try it out. Years ago when we first got bougies, I used bougies on all my intubations for several months, just so I could learn how to handle it, so I would be ready when it was truly needed.

My first patient was a man with intractable pain post surgery. He had no contraindications to narcotic pain management. No allergies and a stable blood pressure. He was a large man laying in bed grimacing. I asked him if I could give him some pain relief and he said yes. I drew up 50 mcgs of Fentanyl in a 1 cc syringe. I had him block one nostril. I stuck the atomizer in the other nare and told him to inhale as I briskly squirted the Fentanyl in. Then I repeated this with the second 50 mcg in the other nostril. Within a couple minutes, we were taking him downstairs in the elevator and he was chatting away with us without a care in the world. In the ambulance, I put in an IV, and eventually gave him a second dose IV. His pain was a one by the time we hit the ED.

The next day I used intranasal Fentanyl on an old woman with a hip fracture. Instead of spreading out my IV kit on the floor and strapping a tourniquet on her arm, I shot 25 mcgs up each nostril. Again, she was feeling dandy by our ED arrival.

I have been studying about Fentanyl for a presentation on the drug I am giving and here are some facts I have come upon.

IN Fentanyl should work within 3 minutes. It has a bioavailability of between 71% and 89% meaning for every 100 mcgs of Fentanyl you give them up their nose, they absorb 71 to 89 mcgs. It should last for the same length of time as IV Fentanyl. The say never give more than 1 ml at a time up a nostril and ideally only 0.5 ml. Another medic I know gave 25 mcgs up one nostril, then 50 mcgs up another and 25 mcgs back in the first, and then asked the patient which they preferred. The patient said the 25 or 0.5 ml was much more pleasant for them.

I repeated this experiment on myself using just normal saline (alas). 1 ml in one nostril and 0.5 ml up the other. My verdict. The half was much better.

So on my next patient my plan will be to give 25/ 25/ 25 and 25. Or in other words, 0.5 ml/0.5 ml/0.5 ml and 0.5 ml.

Our protocols allow for 1.5 mcg/kg with a max of 100 mcgs, followed by a repeat dose after ten minutes if necessary. If the patient still needs pain management, the last dose should be given IV.

Contraindications to IN Fentanyl therapy obviously include nasal blockages.

It is important to push briskly. On a patient where I drew up 1 ml and tried to only give half in one nostril, I pushed too tentatively and saw some of the med run out of the nose. Practicing with saline, I could see a brisk push aerosolizes the fluid quite nicely, where a less than brisk doesn’t turn it into so many tiny droplets. The tinier the droplets the more easily absorbed, and less to run out of the nose.

Now I make certain to tilt their head back and always push as briskly as possible.

I’m interested in hearing other people’s experience with IN Fentanyl.


  • another medic says:

    What intranasal device are you using? I am interested in bringing this up with my company, as we currently have IN admin in our protocols but no means to administer it.

  • medicscribe says:

    LMA MAD Nasal by Wolfe Tory Medical. I think they are about $1 each. They screw on the end of a syringe. They work great.

  • another medic says:

    Well I feel stupid. Just asked a supervisor and it turns out we’ve had them for a few months. I will be giving it a try the next time I have a chance!

  • Christopher says:

    I lobbied for its addition to our service last year and it has been well received (along with intranasal versed). I have the bulk of the document we presented on my website if other services would like to present the data to their medical director. There are a number of our meds which can work IN, so it’s nice to have another mode of access!

  • Student Paramed says:

    The state where I will be working (Victoria, Australia) has been using it for a while – often used for paediatrics (as ALS cannot cannulate children). We also add 0.1ml to the initial dose to account for dead space in the atomiser, and don’t forget to use any additional morphine with caution.

  • More effective pain control via a simple method with less risk of sticks = this is how EVERYTHING should work!

  • VAPhireMedic says:

    We recently got it in our protocols down at one of my agencies in Central VA and I had the chance to use it not too long after it was placed in service. Our patient was a young adult female who had a small (1/2″ diamater) stick impaled in her thigh. Both me and my supervisor attempted IV access (she had no veins to start with and on top of that it was a cold day and she had been outside in shorts and a tshirt) because our protocol states that IN must be used as a secondary treatment to failed IV access. I gave 50mcg in each nostril for a total of 100mcg with no complications except for some slight discomfort by the patient. The issue we had is that the patient did not expierience any pain relief until about 15-20 minutes later when we arrived at the ED. I’ve talked to several other paramedics at the agency that have used the IN Fentanyl and have had the same problem, all reporting action times of 15-20 minutes…any others had this issue?

  • akroeze says:

    I have used it once on a patient with an elbow dislocation. In less than 3 minutes after my first dose she was virtually pain free.

    I have alot more experience with IN Midazolam for seizures and and over all very pleased with the route as an option.

  • medicscribe says:

    Interesting. I need to log some more patients, but the literature says 3 minutes. When I have given it IV, i have had patients that didn’t get an early benefit, and I have to redose them. Comparing Fentanyl with morphine, generally fentanyl works much quicker, but I do find I end up giving much more porpotionately than i do morphine. If 100 mcgs of fentanyl is the relative same as 10 mg MS, i am giving 150 mcgs of fentanyl on average, where i rarely gave more than 10 of morphine. But perhaps that is because i continually get more aggresive with my management of pain.

  • medicscribe says:

    I have never used the IM Midazolam because we don’t carry the right concentraion. We have 5 mg in 5cc. We need to get the 5mg in 1 cc concentration.

  • Almost Jesus says:

    If I remember correctly, you mentioned in other posts that you cannot RSI but can nasally intubate. In paramedic school, we had an atomizer and I took some cardiac lidocaine and drew it up, gave myself a squirt in each nostril and the rest of the balence in my mouth (for back of the throat analgesia) and I was able to walk around freaking everyone out by passing a suction catheter in my nose. I had no pain and only a little pressure towards the back of the sinus, definitely much better than when I put in a NPA without.
    Maybe your service should look into adding that to your nasal intubation guidelines. I was quite impressed.