Intranasal Medication Administration (MAD)

Intranasal dosing is for when IV or IO access is not available or not quick enough. Use the concentrated drug and the labeled device. Split a dose between nostrils only when it is delivered by MAD.

Intranasal (IN) drugs go onto the nasal lining and into the circulation from there. A mucosal atomization device (MAD) turns the liquid into a fine mist, and that mist covers more of the lining than a drip does.

How It Works

• Absorption: the nasal mucosa takes the drug into the circulation. What it absorbs skips first-pass liver metabolism.
• Variable amount: some spray drains down the throat and gets swallowed. That makes the dose reaching the blood less predictable than a measured IV dose.
• Absorption limits: mucus, blood and vasoconstrictors can cut absorption of atomized off-label drugs. Suction the nostril or pick another route. The Baqsimi label found that a common cold with nasal congestion, with or without a decongestant, changed neither absorption nor glucose response.
• Concentration matters: the manufacturer says keep the volume low and the concentration high, and atomize the drug so it covers a broad surface.

Where It Fits

IN is a bridge route. Use IV or IO when they are quick and reliable. Once they are in, switch to them. For children with severe pain and no IV access, NAEMSP strongly recommends IN fentanyl over IV opioids. The NAEMSP pain guideline makes no intranasal ketamine recommendation. For seizure and hypoglycemia rescue, IN is one alternative to IM or IV dosing under local protocol.

Indications

• Opioid overdose with respiratory depression, when IV or IO access is not in place (naloxone)
• Severe hypoglycemia in a patient with diabetes who cannot safely swallow, when IV dextrose is not immediate (glucagon, age 1 year and older)
• Seizure cluster in epilepsy patients 12 years and older (Nayzilam, labeled); prolonged seizure without IV access, per protocol (midazolam injection, off-label route)
• Acute pain in a child without IV access, per protocol (fentanyl, off-label; NAEMSP strong recommendation)

Absolute Contraindications

• Known hypersensitivity to the drug or a product component
• Glucagon (Baqsimi): pheochromocytoma (risk of a substantial rise in blood pressure) and insulinoma (risk of hypoglycemia)
• A blocked or bleeding nostril that cannot be cleared, when another route is available

Relative Contraindications & Cautions

• Mucus, blood or vasoconstrictor in the nostril with atomized off-label drugs: reduced absorption; suction or choose another route
• Opioid or benzodiazepine given together: profound sedation, respiratory depression, coma and death (boxed warnings for midazolam); additive respiratory depression
• Opioid dependence: naloxone can bring on withdrawal
• Glucagon with depleted liver glycogen (prolonged fasting, alcohol, adrenal insufficiency): less effective; IV dextrose per protocol

Consider an Alternative

• IV or IO access when it is quick: titration gets easier and onset gets more predictable (IV Insertion, IO Access)
• Glucose: IV or IO dextrose when it can be given at once, per protocol. Baqsimi carries a label for diabetes only. Other patients need dextrose per protocol

Team Roles During the Procedure

• Operator: draws up, attaches the device and delivers the dose
• Drug verifier: reads drug, mg or mcg, mL and concentration aloud
• Monitor: breathing rate, SpO₂, waveform EtCO₂ and level of consciousness
• Recorder: time of dose, device count, nostril used and response

Patient Check

• Nasal airway: look for blockage, drainage, bleeding and recent nasal surgery or trauma before choosing the nostril
• Mental status and breathing: baseline level of consciousness, respiratory rate and SpO₂ before any sedating drug
• Weight: pediatric, fentanyl and ketamine doses are weight-based. Use a current weight or a length-based estimate
• Opioid or sedative exposure: recent drugs, dependence and co-ingestants all change the dose and the monitoring

Physiologic Risk

Sedating drugs, opioids and benzodiazepines can all depress breathing. Get ventilation support ready before the dose. Keep naloxone on hand for opioid-related depression.

Nasal Target

Seat the tip snugly against the nostril. Aim it slightly up and outward, toward the top of the ear. That angle covers the turbinates and olfactory mucosa (manufacturer technique). A split MAD dose uses both nostrils. A labeled spray goes in whole, in one nostril.

Nasal Obstruction and Drainage

• Mucus or blood: suction the nostril first (manufacturer)
• Drug running out of the nostril or down the throat: treat the dose as uncertain. Repeat only per protocol, with a new device

Equipment

Patient Positioning & Preparation

Hold the head and neck steady, with the free hand on the occiput. That lets the tip seat against the nostril.

Treat these doses as typical references. Check them against local protocol and the current drug labeling. Doses vary by protocol; follow local protocols and medical direction.

Phase 1: Prepare

1. Confirm drug, dose and route: state the drug, mg or mcg, and mL aloud; check the label and concentration.
2. Choose the concentrated form: use the smallest volume that holds the dose.
3. Draw up the dose plus dead space: add 0.15 mL for MAD100, MAD110, MAD130 or MAD140 (0.06 mL for MAD300).
4. Attach the device: connect the MAD to the syringe by luer lock; remove the vial adapter cap if used.

Phase 2: Perform

5. Stabilize the head: hold the occiput with the free hand.
6. Seat the tip: place it snugly in one nostril, aimed slightly up and outward.
7. Deliver half (MAD-delivered doses only): briskly compress the plunger to deliver half the dose.
8. Deliver the rest: move the device to the opposite nostril and give the remainder if the dose is split. A labeled spray is never split: one device, one nostril.

Phase 3: Confirm & Secure

9. Start the timer: note the time and the device count.
10. Reassess: breathing rate, SpO₂, waveform EtCO₂ and level of consciousness (see Confirmation & Monitoring).
11. Repeat only by protocol: use a new device and the interval set by the drug (naloxone 2–3 min; glucagon 15 min; Nayzilam 10 min, max 2 doses per episode).

Alternative Technique: Suction and Route Change

Mucus or blood blocking the nostril? Suction it, then dose the other nostril, or switch to IV, IO or IM under protocol.

Primary Confirmation

The clinical effect is the test. Breathing returns after naloxone. Seizure activity stops after midazolam. Glucose rises after glucagon. For analgesics, look for calmer, arousable behavior with stable breathing.

Secondary Confirmation

• Pulse oximetry and waveform capnography for any sedating drug
• Point-of-care glucose for glucagon
• Level of consciousness (AVPU or GCS) at each reassessment

Ongoing Monitoring

• SpO₂ and waveform EtCO₂ continuously after any sedating drug, until awake
• Respiratory rate and depth at each reassessment
• Watch for resedation after naloxone. Watch for prolonged sedation after midazolam

Pediatrics

• Glucagon (Baqsimi): 3 mg labeled for diabetes, age 1 year and older; not established under 1 year
• Midazolam nasal spray (Nayzilam): labeled for epilepsy patients age 12 years and older; not established under 12 years
• Fentanyl: 1.5 mcg/kg, max 75 mcg (per fentanyl page); most trials used 1.5 mcg/kg in children aged 1–16 years (Serra 2023 review)
• Ketamine: not an established analgesic. One ED trial used 1.5 mg/kg IN to reduce IM-injection pain; vomiting 16.7% vs 4.2% with placebo; hypoventilation in 7%
• Midazolam injection: no verified IN dose here. The 0.1 mg/kg cohort dose was linked to more redosing. Set the protocol dose with medical direction

Dose by weight, and get a second check. See Weight-Based Dosing, Pediatric Vascular Access and Pediatric Airway.

Older Adults

• In older adults, sedating drugs cause more respiratory depression. Use the protocol dose and reassess more often

Pregnancy, Lactation and Head Trauma

This page does not review pregnancy or lactation. Check each drug's label for both. For facial or skull-base trauma, no source was verified. Follow local protocol and medical direction.

Opioid-Dependent Patients

• Naloxone can bring on withdrawal. Titrate to breathing, not to full alertness
• Expect sedation to come back if the naloxone wears off first

Immediate Aftercare

• Keep SpO₂ and waveform EtCO₂ on until the patient is awake and breathing well
• Keep the patient on their side if vomiting is likely

Ongoing Maintenance

• Reassess every 5–10 minutes or per protocol
• Keep sharps and used devices in a sharps container; do not reuse any device

Transport Considerations

• Expect resedation in transit after naloxone. Keep ventilation support ready
• Monitor SpO₂ and EtCO₂ through noise and motion. Confirm the monitor alarms are on

Pearls

• Atomize, don't drip: a mist covers the turbinates. A drip runs down the throat.
• Split only MAD doses: a split MAD dose uses both nostrils. A labeled spray goes in whole, in one nostril.
• Concentrate it: the smallest volume that holds the dose gives the best absorption.
• Count the dead space: it is 0.15 mL for MAD100, MAD110, MAD130 and MAD140.

Common Pitfalls

• Forgetting dead space: the fix is to draw up the dose plus device dead space.
• Reusing a device: use a new device for every dose. Glucagon devices are single-dose.
• Units by habit: say mcg and mL for fentanyl, and mg and mL for midazolam.
• Assuming a set onset: reassess at the interval the drug and the protocol set.

Skill Maintenance

• Drill device assembly and dead-space math on a trainer every quarter
• Rehearse the double-check out loud: drug, mg or mcg, mL and concentration
• Run simulated cases that include a sedation check and ventilation support
• Debrief every drill on volume, nostrils used, device count and timing

Patient & Family Teaching

• Show caregivers how to give the naloxone and glucagon nasal products. Tell them to call 911 after the first dose
• Tell caregivers a used device is single-dose. It must not be reused
• Tell them a second device may be needed at the labeled interval