In each issue, Edge Hill University's Paramedic Training Team focuses on the clinical skills performed by paramedics on the frontline, emphasizing the importance of those skills and how to perform them. In this issue, Andrew Kirk discusses best practice administering intramuscular injections in the prehospital setting.
learning points
Intramuscular injection is an important route of drug delivery
All clinical skills should be checked to ensure proper technique and best practices are being followed
Follow best practice technique to ensure optimal intervention and minimize patient discomfort
This month's Clinical Skills article discusses best practices for administering intramuscular (IM) injections. It is important to revisit clinical skills as many are taught during initial training and then not revisited. This can lead to poor practice and technique, which in turn can lead to patient discomfort and possible complications (Hunter, 2008;Malekin, 2008). An overview of injection sites, indications and complications is provided using an evidence-based best practice technique approach. A full critique of injection sites will not be explored here due to the review nature of this article.
It is important to patient care to ensure optimal efficacy of the medication administered and to minimize the experience of discomfort or pain. In paramedic practice, examples of drugs administered via the IM route include:
Glucagon
Adrenalin 1:1000
(Video) Intramuscular Injection Techniques (Nursing Skills)Benzylpenicillin
Hydrocortisone.
injection sites
There are five known sites that have been identified for intramuscular injections, with discrepancies in the literature regarding which recommended (Thomas and Monaghan, 2014) (illustration 1):
Stomach and buttocks
Deltamuskel
Dorsogluteal
straight thigh
Side drop.
(Video) Intramuscular Injection in Deltoid Muscle with Z-Track Technique
All sites have nerve innervation and blood supply; however, only the dorsogluteal route is near major blood vessels and nerves and is therefore not a recommended application site (Ogston-Tuck, 2014). ThatJoint Royal Colleges Ambulance Liaison Committee (JRCALC) (2017)andCaroline (2014)recommend mainly the anterolateral sides of the thigh or upper arm for administration because of their easy access and rapid absorption. The ventrogluteal site is generally recommended for IM injection due to minimal risk of damage to nerves and blood vessels; However, physicians report that this side is rarely used because they are unfamiliar with landmarks and have difficulty ensuring optimal patient positioning for administration (Cocoman and Murray , 2006; Wynaden, 2014;Strohfus et al., 2018). Different sites should be used for multiple injections.
Site landmark
Deltamuskel
Locate the "nobby" acromial process at the tip of the shoulder, then move your fingers 1 inch down onto the deltoid. The patient's arm should be relaxed across their waist. This site is easily accessible, but is only recommended for volumes up to 1mL (Rodger and King, 2000;Cocoman and Murray , 2006;Ogston-Tuck, 2014). The deltoid is the preferred site for older children (Anonymous, 2007;Ogston-Tuck, 2014).
abdomen buttocks
Place the heel of your hand on the patient's opposite hip (greater trochanter). For example left hand on right hip. Make a V-shape with your first and second fingers and point your index finger at the iliac crest. The injection site is located within this V in the musculus gluteus medius when the index and middle fingers are spread (Ogston-Tuck, 2014) (Figure 2). Up to 5 ml can be administered here (Rodger and King, 2000).
straight thigh
Located midway between the patella and the superior iliac crest on the front surface of the thigh (Hunter, 2008;Ogston-Tuck, 2014). Up to 5 ml can be administered into the rectus femoris.
Side drop
A hand's breadth from the greater trochanter and the kneecap on the lateral surface of the thigh (Hunter, 2008;Ogston-Tuck, 2014). Up to 5 ml can enter the vastus lateralis (Rodger and King, 2000). It is an easily accessible site (Floyd und Meyer, 2007) and is the preferred site for younger children and infants (workers, 1999;Anonymous, 2007;Ogston-Tuck, 2014).
site cleaning
The literature contains conflicting information on cleaning the injection site, with many hospital associations recommending that if the skin is visibly clean, an alcohol-based wipe should not be used (Hunter, 2008). With proper use of aseptic technique, clean hands and gloves, injections can be given without cleaning the injection site. Conversely, some authors recommend cleaning the site with a 70% isopropyl alcohol-based wipe for 30 seconds and then allowing it to dry for 30 seconds (Hunter, 2008;Ogston-Tuck, 2014). In this case, it is important to allow the site to dry completely, as injecting into an area that is still wet could increase the risk of pain and the introduction of bacteria into the injection site (workers, 1999). Skin disinfection is recommended for immunocompromised patients (Ogston-Tuck, 2014). Therefore, clinicians should follow the guidelines and guidelines provided locally regarding site preparation/cleaning.
Clinical indications
Indications for IM injection
Indications for individual drugs require when IM injection is required. The IM route is used for drugs that require rapid absorption (10–20 minutes) but a prolonged duration of action (Ogston-Tuck, 2014). Drug volumes of 1–5 mL can be administered intramuscularly (workers, 1999). In certain cases, e.g. in hypoglycaemic patients, intravenous (IV) administration of glucose 10% is preferred prior to intravenous administration of glucagon; however, clinical and situational factors must be considered before making a clinical decision.
contraindications
Injection sites with edema, inflammation, infection or skin lesions and poor perfusion should be avoided. The site must be well supplied with blood to ensure absorption of the drug into the muscle (Caroline, 2014;Thomas and Monaghan, 2014).
implementation of the procedure
Explain the injection procedure to the patient and obtain their consent to perform the procedure if the clinical situation permits. Patients must be fully informed about the benefits and consequences of any necessary intervention (Thomas and Monaghan, 2014;Gaisford, 2017). Particular vigilance and reassurance are required as many patients suffer from needle phobias
Consider the site you choose, considering clinical need, the drug to be administered, the patient's age and medical history, and environmental conditions (Malekin, 2008;Ogston-Tuck, 2014;Chadwick and Withnell, 2015)
Conduct required drug controls according to local/national guidelines. Ensure the right drug is given to the right patient and that it is the right dose at the right time on the right path (workers, 1999)
Check for allergies (Hunter, 2008)
Position the patient so that they are comfortable and in the optimal position for the site chosen for administration. Expose the chosen site and examine the skin to ensure that it is suitable as an injection site - rule out contraindications as described in the previous section
Wash hands and ensure gloves and apron are worn (Thomas and Monaghan, 2014)
Sanitize the site according to the local trust policy. When cleaning the spot, make sure to let it dry for 30 seconds (workers, 1999)
Draw up the medication or open and prepare the pre-filled injection syringe
(Video) Clinical Skills: Administering VaccinationsA needle should be chosen that will penetrate the tissue and reach the underlying muscle. Needle sizes 21 (green)–23 (blue) are suitable for most IM injections (workers, 1999)
See AlsoBuilding these eating and exercise habits will help you lose weight quickly but surelyWhat is the best over the counter medication for arthritis - ArthritisDaily.netCan You Lose Belly Fat By Riding A Stationary Bike?Reactivated viruses could be to blame for these 17 long-distance COVID ridersStretch the skin to one side or use the z-tracking method by holding the skin with your non-dominant hand (Cocoman and Murray , 2006;Hunter, 2008) (Figure 3;)
Inform the patient that they may feel a sharp scratch. Do not inform the patient that it will not hurt (Caroline, 2014)
Holding the injection like an arrow in your dominant hand, quickly insert the needle at a 90o angle to the skin (Anonymous, 2007;Hunter, 2008;Thomas and Monaghan, 2014)
Insert the needle to the hub (Greenway, 2014)
Pull the plunger back slightly and look for blood - to make sure you haven't punctured a vein. Although there is little evidence to support this, it is still recommended. If blood is visible, withdraw the needle and discard it in a sharps bin. Apply pressure to the injection site; explain to the patient what happened; Then choose a new needle and injection site and start again
If there is no blood, push the plunger to slowly inject the drug at a rate of 1mL/10 seconds (Hunter, 2008). This reduces the potential for pain
After administration, wait 10 seconds to allow drug absorption/diffusion, then withdraw needle and discard in a waste bin (workers, 1999;Ogston-Tuck, 2014;Thomas and Monaghan, 2014). Do not rub the site as this may cause medication to leak (workers, 1999). Put a plaster on the puncture site
(Video) Locating the site for a Ventrogluteal Injection - Clinical Skills | @LevelUpRNComplete your documentation according to local/national requirements, noting drug name, dose administered, route of administration, time and patient details (Health and Care Professions Council (HCPC), 2014)
Reassess the patient for signs of a hypersensitivity reaction (Caroline, 2014).
Conclusion
Intramuscular injections are part of the skill set of paramedics and it is important to review clinical skills regularly to ensure best practices are being followed. Clinical and environmental factors, along with the individual patient's needs, will affect the site and delivery of the IM injection chosen. Paramedics must have the necessary basic understanding of their skills to provide best practices and quality patient care.