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“nonstandard” administration routes do have occasional ED utility. 1,2 One
exception is the NSAIDs, for which PO administration is usually sufficient
(and difficult to improve upon).
This chapter focuses on the general approach to nonstandard routes for
analgesia delivery. For the most part, specific drugs and indications are left
for discussion elsewhere in the text. When a particular nonstandard administration
route is indicated in only a few situations, those conditions are
identified.
n Rectal
Comparative studies demonstrate that PR administration of either morphine
(0.2 mg/kg) or codeine (1 mg/kg) provides equivalent analgesia to that associated
with IM or PO dosing. 3–7 Acetaminophen and NSAIDs PR are also
equivalent to PO dosing of the same medications. The common co-administration
of sedatives with analgesics lends relevance to findings that efficacy of
PR midazolam exceeds that of PO administration of the benzodiazepine. 8–11
n Nasal
Nonstandard medication delivery 71
Analgesia administration by the IN route has been most successfully described
in the treatment of migraine headaches using sumatriptan (p. 243). 12,13 Utility
of IN butorphanol for migraine headache is more limited, with issues of both
efficacy and side effects. 14
Morphine, fentanyl (1.7 μg/kg), and sufentanil (0.05 μg/kg per puff) are
effective for IN administration. 15–20 Just as PR sedation is a viable adjunct to
PR analgesia, IN midazolam (0.2 mg/kg) is an effective means to comple-
21, 22
ment IN analgesia.
While not often used in the ED, IN salmon calcitonin may be useful for
some conditions seen in the ED. Among the indications for which this
approach has been found at least partially efficacious are vertebral compression
fractures and some of the neuropathies (in particular, phantom limb
pain). 23,24 Other information on these possible indications for IN therapy is
found in the relevant chapters of this text.