Intramuscular injection

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Intramuscular injections are administered to the muscle fascia. This has a good blood supply and hence a faster rate of absorption than the subcutaneous route but also allows a reasonably prolonged action.

Introduction

• Wash hands; Introduce self; Patient’s name, DOB and wrist band; Explain procedure and obtain consent
• Allergy check: check for allergies with patient and on drug chart
• Prescription check: check the prescription drug and dose, and confirm the name and DOB are correct (check with patient and their wristband)
• Look up drug in Injectable Medicines book to determine volume of sterile water/saline required to reconstitute drug (if it is in powder form)

Preparation 

• Wash hands 
• Clean tray
• Gather equipment around tray (think through what you need in order)

• Wash hands
• Open packets and place neatly in tray, keeping items in plastic parts of packets (without touching the instruments themselves)
• If the drug is in powder form:
  • Wash hands, put on apron and extra pair of gloves
  • Snap top off sterile water/saline vial
  • Put drawing-up needle on syringe, hold sterile water/saline vial upside-down and draw up required amount for reconstitution (plus a bit extra)
  • Expel air and some water to leave the exact amount needed for reconstitution
  • Flick top off drug vial 
  • Insert needle and inject the sterile water/saline. Twist the vial back and forth on end of needle until drug powder is fully dissolved.
  • Draw up drug solution while the vial is upside-down
  • Remove and dispose of drawing-up needle in sharps bin and replace with injection needle (leave sheath on)
  • Expel air from syringe and place back into syringe packet in tray
  • Discard waste; then discard gloves and apron; wash hands 
• If the drug is in liquid form:
  • Wash hands, put on apron and extra pair of gloves
  • Put drawing-up needle on syringe and fill with approximately the same volume of air as in the drug vial if drug vial contains a vacuum
  • Flick/snap top off drug vial
  • Insert the needle into the vial, and inject the air into the airspace if drug vial contains a vacuum
  • Draw up drug solution while the vial is upside-down
  • Remove and dispose of drawing-up needle in sharps bin and replace with injection needle (leave sheath on)
  • Expel air from syringe and place back into syringe packet in tray
  • Discard waste; then discard gloves and apron; wash hands 
• Walk to patient (with tray and sharps bin)

Procedure

Exposure

• Wash hands
• Expose injection site:
  • Mid-deltoid: inject (from laterally) into middle third of the deltoid region (3 fingerbreadths down from acromion)
  • Vastus lateralis: inject (from laterally) into the upper part of the middle third of thigh
  • Dorsogluteal: inject (from posteriorly) into upper outer part of the upper outer quadrant of the buttock (to avoid sciatic nerve)

In children: use deltoid if >12 months; use vastus lateralis if <12months; do not use gluteus maximus in infants as sciatic nerve not fixed. Ask parent to hold child securely in cuddle position (child sideways on knee) or straddle position (child facing towards parent straddled on their lap).

Injection

• Wash hands
• Put on gloves
• Sterilise area using skin-cleansing wipe (clean for 30 seconds, then allow to air-dry for 30 seconds) – optional
• With the thumb and index finger of your non-dominant hand, stretch the skin at the injection site
• Holding the syringe (like a dart) between the thumb, index and middle fingers of your dominant hand, quickly insert the needle at a right angle to the skin 
• Using your dominant hand to securely hold the syringe in place (resting against the patient), use your non-dominant hand to:
  • Pull back on the top of the syringe (to confirm you are not in a blood vessel) – optional
  • Slowly, inject the drug
• Gently but briskly remove the needle and immediately dispose of it (with syringe) in the sharps bin
• Wipe the injection site and press over it firmly with gauze, before applying tape

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

To complete

• Thank patient and restore clothing
• Discard waste and clean tray; then discard gloves; wash hands
• Sign on the drug chart that the drug has been administered

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