Intranasal diamorphine is described in much of the literature as a safe and effective analgesia which can be used for children with moderate and severe pain. In the emergency setting and on the wards, the use of intranasal diamorphine has increased as it is non-invasive with a rapid analgesic effect, few side effects and a rapid excretion of the medication, so that it can be used while more longer-acting medication is being prepared or for a short-term painful procedure such as applying a plaster of Paris to a fractured radius and ulna.

Diamorphine is a controlled drug and is subject to the Controlled Drugs Act 2006. It is a type of medicine called an opioid painkiller. It is also known as ‘medical heroin’. Opioids treat pain by mimicking the action of naturally occurring pain-reducing chemicals called endorphins, which are present in the brain and spinal cord and reduce pain by combining with opioid receptors. Diamorphine can be administered via a syringe or via a new atomizer product which has just been licensed. In this chapter we will discuss the syringe method as, due to the high cost of the atomizer, as yet it is not used in all hospitals.

• 1 vial of diamorphine (10 mg)
  
• saline for injection
  
• 1 ml syringe
  
• 1 needle
  
• 2 nurses
  
• saturation monitoring equipment.

• Children with moderate to severe pain (or mild pain where other analgesia is difficult to administer)
  
• Children over 1 year or 10 kg
  
• Can be used in children under 10 kg but must be under the supervision of a senior doctor.

• The nurse must have had training in the use of intranasal diamorphine.
  
• The drug must be prescribed by a doctor or using a patient group directive if available.
  
• Two nurses must prepare and administer the medication as it is a controlled drug.

• Calculations: weigh child if possible or use calculation methods as per Advanced Paediatric Life Support Manual.
  
• Dilute diamorphine with saline.
  
• Always give 0.2 ml into one nostril. This will give the child 100 micrograms/kg.

• The preparation has an unpleasant taste and often giving paracetamol directly after administering the medication helps to take the taste away. A small amount of fluid can be given but the child may require surgery, so reducing the amount of fluid ingested should be considered.
  
• Place the child in an upright position. Explain the procedure to the child, explaining that it does not taste nice and offer a solution to the child for this.
  
• Older children can be encouraged to sniff gently once the medication has been squirted into the nostril.
  
• Younger children can sit on the knee of the carer, who can tip the child back slightly to allow sufficient time for the medication to be absorbed by the mucosa.
  
• The medication starts to work in a few minutes although this can vary from child to child.
  
• Although side effects are rare, where possible, the child should have oxygen saturation monitoring on site. In reality, a child requiring this medication is frequently too agitated to tolerate monitoring and the practitioner should stay with the child, monitoring their colour or any signs of respiratory distress (heart rate, respiratory rate, saturations). This should be done for 30 minutes.
  
• Assess level of consciousness.

• Diamorphine works quickly but further analgesia is likely to be required.
  
• No other opioid should be given for 20 minutes after administration of diamorphine.
  
• Apply local anaesthetic if the child is likely to require cannulation.
  
• Diamorphine can be repeated after 30 minutes if required.
  
• Children tend to become calm and relaxed post administration.
  
• Reassess pain every 15 minutes until the child is pain-free.

• Two registered nurses must sign the Controlled Drugs book, including indicating the unused medication disposal.
  
• Two registered nurses are required to sign the drug chart.
  
• Document consent from carer and child.
  
• List nostril used.
  
• List pain score.

Intranasal diamorphine is an effective and reasonably non-­invasive analgesia. It is used frequently in the emergency department but its use could be much wider as it helps children cope with a variety of unpleasant procedures.