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Workman B. Safe injection techniques. Nurs Stand.. 1999; 13:(39)47-53

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pain management
medications
clinical skills
management

Best practice technique in intramuscular injection

02 July 2018
Features
02 July 2018
Volume 10 · Issue 7

Abstract

In each issue, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontlines, highlighting the importance of these skills and how to perform them. In this issue, Andrew Kirk discusses the administration of intramuscular injection in pre-hospital care in line with best practice.

Learning Points

  • Intramuscular injection is an important route for drug administration
  • All clinical skills should be re-visited to ensure correct technique and best practice is followed
  • Follow best practice technique to ensure optimal actions and to minimise patient discomfort

    • In this month's Clinical Skills article, best practice for the administration of intramuscular (IM) injections will be discussed. It is important to re-visit clinical skills as many are taught during initial training and then not re-visited. This can lead to poor practice and incorrect technique, which in turn can lead to patient discomfort and potential complications (Hunter, 2008; Malkin, 2008). An overview of injection sites, indications and complications will be provided with an evidence-based approach to best practice technique. Full critique of the injection sites will not be explored here owing to the overview nature of this article.

    It is important for patient care to ensure optimal effects of the medications administered, and to minimise the experience of any discomfort or pain. Within paramedic practice, examples of medications administered via the IM route include:

  • Glucagon
  • Adrenaline 1:1000
  • Benzyl Penicillin
  • Hydrocortisone.

    • Injection sites

    There are five known sites identified for intramuscular injections with differences in the literature in terms of which are recommended (Thomas and Monaghan, 2014) (Figure 1):

  • Ventro-gluteal site
  • Deltoid
  • Dorsogluteal
  • Rectus femoris
  • Vastus lateralis.
    • Figure 1. Five sites identified for intramuscular injection

    All sites have nerve innervation and blood supply; however only the dorsogluteal route is near to major blood vessels and nerves, and is therefore discouraged as a site for use (Ogston-Tuck, 2014). The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) (2017) and Caroline (2014) primarily recommend the antero-lateral aspects of the thigh or upper arm for administration for their ease of access and rapid absorption. The ventrogluteal site is widely recommended for IM injection owing to the minimal risk of damage to nerves and blood vessels; however, clinicians report infrequent use of this site because of an unfamiliarity with landmarks and difficulty in ensuring optimal patient positioning for administration (Cocoman and Murray, 2006; Wynaden, 2014; Strohfus et al, 2018). For multiple injections, varied sites should be used.

    Site landmarks

    Deltoid

    Locate the ‘nobbly’ acromium process at the tip of the shoulder and then move your fingers 2.5 cm down onto the deltoid muscle. The patient's arm should be placed relaxed across their waist. This site is easily accessible but is recommended only for a volume up to 1 ml (Rodger and King, 2000; Cocoman and Murray, 2006; Ogston-Tuck, 2014). The deltoid is the preferred site for older children (Anon, 2007; Ogston-Tuck, 2014).

    Ventro-gluteal

    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 the first and second fingers, pointing the forefinger towards the iliac crest. The injection site is then located within this V in the gluteus medius muscle when the forefinger and second finger are splayed (Ogston-Tuck, 2014) (Figure 2). Up to 5 ml can be administered here (Rodger and King, 2000).

    Figure 2. The ventrogluteal injection site is in the ‘V-shape’ shown above

    Rectus femoris

    Located halfway between the patella and superior iliac crest on the anterior surface of the thigh (Hunter, 2008; Ogston-Tuck, 2014). Up to 5 ml can be administered in the rectus femoris.

    Vastus lateralis

    A hand's breadth from the greater trochanter and also the patella on the lateral surface of the thigh (Hunter, 2008; Ogston-Tuck, 2014). Up to 5 ml can be injected in the vastus lateralis (Rodger and King, 2000). It is an easy site to access (Floyd and Meyer, 2007), and is the preferred site for younger children and infants (Workman, 1999; Anon, 2007; Ogston-Tuck, 2014).

    Site cleansing

    The literature provides conflicting information regarding the cleansing of the injection site, with many hospital trusts recommending that if the skin is visibly clean, there is no requirement to use an alcohol-based cleansing wipe (Hunter, 2008). With correct use of aseptic technique, clean hands and gloves, injections can be administered without the requirement to clean the site. Conversely, some authors advise use of a 70% isopropyl-alcohol-based wipe to clean the site for 30 seconds, and then allowing to dry for 30 seconds (Hunter, 2008; Ogston-Tuck, 2014). In this case, it is important to allow the site to fully dry, as injecting in a still-wet site could increase the risk of pain experienced and bacteria entering the site of insertion (Workman, 1999). For patients who are immunocompromised, skin disinfection is recommended (Ogston-Tuck, 2014). Clinicians should therefore follow guidance and policy provided at local level with regards to site preparation/cleansing.

    Clinical Indications

    Indications for IM injection

    Indications for individual medications will necessitate when an IM injection is required. The IM route is used for medications needing rapid absorption (10–20 minutes) but prolonged duration of action (Ogston-Tuck, 2014). Drug volumes of 1–5 ml can be administered via the IM route (Workman, 1999). In certain instances, such as for hypoglycaemic patients, intravenous (IV) administration of Glucose 10% is preferred ahead of IM Glucagon; however, clinical and situational factors need to be considered prior to making the clinical decision.

    Contraindications

    Injection sites where oedema, inflammation, infection or skin lesions and poor perfusion are present should be avoided. The site must be well-perfused to ensure absorption of the medication into the muscle (Caroline, 2014; Thomas and Monaghan, 2014).

    Performing the procedure

  • Explain the injection process to the patient and gain their consent to undertake the procedure, if the clinical situation permits. Patients must be fully informed of the benefits and consequences of any necessary procedure (Thomas and Monaghan, 2014; Gaisford, 2017). Extra vigilance and reassurance are required, as many patients experience needle phobias
  • Consider your chosen site given the clinical need, the drug to be administered, the patient's age and pre-existing conditions, and the environmental setting (Malkin, 2008; Ogston-Tuck, 2014; Chadwick and Withnell, 2015)
  • Undertake the required medication checks in accordance with local/national policy. Ensure administration of the right drug to the right patient, and that it is the right dose at the right time via the right route (Workman, 1999)
  • Check for any allergies (Hunter, 2008)
  • Position the patient to ensure they are comfortable and they are in the optimum position for the site chosen for administration. Expose the chosen site and inspect the skin to ensure that it is suitable as an injection site—ruling out contraindications as detailed in the previous section
  • Wash hands and ensure gloves and apron are worn (Thomas and Monaghan, 2014)
  • Clean the site as per local trust policy. If cleansing the site, ensure that it is left to dry for 30 seconds (Workman, 1999)
  • Draw up the drug, or open and prepare pre-filled injection syringe
  • A needle should be chosen that will penetrate the tissue and reach the underlying muscle. Needle gauges 21 (green)–23 (blue) are suitable for most IM injections (Workman, 1999)
  • Stretch the skin to one side, or use the Z-tracking method, holding the skin with your non-dominant hand (Cocoman and Murray, 2006; Hunter, 2008) (Figure 3; Box 1)
  • 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 a dart in your dominant hand, quickly insert the needle at 90o to the skin (Anon, 2007; Hunter, 2008; Thomas and Monaghan, 2014)
  • Insert the needle up to the hub (Greenway, 2014)
  • Withdraw the plunger slightly and look for blood—this is to ensure you have not punctured a vein. While there is little evidence to support this, it is still recommended practice. If blood is evident, withdraw the needle and dispose in a sharps bin. Apply pressure to the injection site; explain to the patient what happened; and then select a new needle and injection site, and start again
  • If no blood is present, push the plunger to inject the drug slowly at a rate of 1 ml/10 seconds (Hunter, 2008). This reduces potential for pain
  • Once administered, wait 10 seconds to allow absorption/diffusion of the drug and then withdraw the needle, disposing it in a sharps bin (Workman, 1999; Ogston-Tuck, 2014; Thomas and Monaghan, 2014). Do not rub the site as this may cause medication to leak out (Workman, 1999). Place a plaster over the puncture site
  • Complete your documentation as per local/national requirements noting the drug name, dose given, route, time and patient details (Health and Care Professions Council, (HCPC), 2014)
  • Re-assess the patient to check for signs of a hypersensitivity response (Caroline, 2014).
    • Figure 3. Z-track technique

    Z-tracking

    The z-track technique minimises leakage of the drug at the site of injection, minimises pain (Workman, 1999; Chadwick and Withnell, 2015) and has fewer adverse effects (Strohfus et al, 2018). It is recommended for all injection sites (Rodger and King, 2000). Prior to injection insertion, the skin is stretched 2–3 cm to the side. The needle is then inserted, injection administered and, once removed, the skin is released (Floyd and Meyer, 2007). This locks the medication in by distorting the needle track pathway.

    Conclusion

    Intramuscular injections form part of the skill set for paramedics and it is important to regularly re-visit clinical skills to ensure best practice is followed. Clinical and environmental factors, along with individual patient requirements, will impact the chosen site and delivery of IM injection. Paramedics need to maintain the required underpinning knowledge of their skills to provide best practice and quality patient care.