Page 43 - JSOM Fall 2023

effects with ketamine (hallucinations and altered thoughts and TABLE 3 Use of Intranasal Analgesia Among the 256* Responding
feelings). More than half (n = 25; 53.1%) of our sample stated Physicians
that additional analgesics were needed despite INA and were Yes No Total
delivered intravenously by 92% (n = 23) of the respondents. Variable (%)** (%)** (%)** p-value
Years of practice
INA was significantly associated with physicians who received <5 years 13 73 86
additional training in emergency medicine (p < .001), worked (5.1) (28.5) (33.6)
shifts on regular basis (p < .001), or supported highly opera- >5 years 34 136 170 NS
tional units (p < .01) (Table 3). (13.3) (53.1) (66.4)
Additional training in emergency medicine
Respondents were overwhelmingly interested in following a No 8 89 97
training course on INA (n = 235; 90.7%) and using this tech- (3.1) (34.8) (37.9)
nique in France and during deployments (n = 218; 84.1%). Yes 39 120 159 <.001
(15.2) (46.9) (62.1)
Almost half of the physicians (n = 129; 49.8%) felt that nurses Emergency medicine shifts on a regular basis
could be trained to administer IN with an additional 70 (27%) No 12 95 107
placing it into the skill set of the combat medic. Only a few (4.7) (37.1) (41.8)
(n = 19, 7.3%) felt that the use of IN should be stricter to Yes 35 114 149 .0139
physician use only. (13.7) (44.5) (58.2)
If yes, how often?
Discussion 0–4/month 26 99 125
(10.1) (38.7) (48.8)
The nasal mucosa is a highly vascularized exchange surface >5/month 9 1 24 NS
estimated at 120–150cm². Factors such as a severely deviated (3.5) (5.8) (9.3)
5
nasal septum, vasoconstrictors, or intranasal hemorrhage can Number of deployments
6
reduce its exchange function. The IN route requires high-
185
37
222
quality medication spraying with good distribution over the 1–5 times (14.4) (72.3) (86.7)
entire nasal mucosa, while avoiding exceedingly large drop- >5 times 10 24 34 .094
lets or overall volume. In addition, the mucous membrane ab- (3.9) (9.4) (13.3)
sorption threshold corresponds to approximately 0.5mL per Units
5
nostril. A specific nasal spray is already available (Mucosal
92
66
26
Atomization Device, https://www.teleflex.com/usa/en/product Highly operational**** (10.1) (25.8) (35.9) .0038
-areas/anesthesia/atomization/mad-nasal-device/index.html). Regular 21 143 164
Adapted for use with a syringe, this device provides a fine mist (8.2) (55.8) (64)
of particles, 30–100 microns in size, and a better medication *Three surveys were incomplete on the “Use of intranasal analgesia”
bioavailability. The efficacy and onset of action of the INA section.
7
depends on the nasal mucosa absorption, which is in turn de- **With respect to the number of responses in the sample (256).
termined by the size of the droplets (device- dependent), the ***>2-month duration
medication pH, and the liposoluble nature of the medication. ****Including: Special Forces, Paratroopers, Air Force air ambulance,
Ketamine*, sufentanil, and fentanyl are rapid and effective Air Force heliborne search and rescue, Navy medical bay, mountain
troops, Paris and Marseille Fire Brigades, and Civil Security.
IN analgesics with no significant adverse effects and are com-
monly used in civilian settings (Table 4). 8–20
TABLE 4 Main Characteristics of Ketamine, Sufentanil, and
Fentanyl 8–20
The November 2020 TCCC updates recommended the use of
100µg fentanyl and 50–100mg ketamine for INA in military Characteristics Ketamine Sufentanil Fentanyl
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environments. When this study was performed, no French Bioavailability ≈ 40% ≈ 80% ≈ 90%
scientific committee had published recommendations regard- Intranasal dose 0.5–0.75mg/kg 0.4–0.7µg/kg 1.5µg/kg
ing intranasal analgesia. Sufentanil, fentanyl, and ketamine (titration)*
were off-label for this route of administration. Onset of action <10 min**
Duration of action 30–60 min** (dose-related)
The majority of the responding physicians reported being Most common Psychodysleptia*** Hypotension and/or
familiar with INA, although few had a perfect score on the side effects respiratory depression
knowledge MCQs. Most of the respondents expressed an in- *Loading dose of 0.3µg/kg, then 0.15µg/kg at 10 then 20 minutes (if
terest in taking a specific INA training course. Training with the Numerical Rating Scale >3)
standardized protocols should be implemented as part of in- **No significant difference
***Psychodysleptia: hallucinations and altered thoughts and feelings
ternship training or prior to deployment as part of the current
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French TCCC training. Continuing professional education
should also be offered. More than half of our study group had a small proportion of our surveyed physicians had practical
a degree in emergency medicine. This qualification is funda- experience with INA. As expected, those assigned to highly
mental for military physicians. It gives them an indispensable operational units mastered INA and had used it significantly
level of autonomy in remote setting deployments, as the evacu- more than their counterparts.
ation time to the nearest forward surgical team can sometimes
3
be 6–12 hours. Practicing emergency medicine on a regular Ketamine was the most frequently used medication, as mono-
basis is essential for improving one’s knowledge in INA. Only therapy or in association with midazolam. It is a common
Intranasal Analgesia in French Armed Forces | 41