In each issue, Edge Hill University's paramedic training team focuses on clinical skills performed by frontline paramedics and emphasizes the importance of those skills and how to carry them out. In this issue, Andrew Kirk discusses best practices for the administration of intramuscular injections in prehospital care.
learning points
Intramuscular injection is an important route of drug administration.
All clinical skills should be checked to ensure proper technique and best practices are followed.
Follow best practice technique to ensure optimal intervention and minimize patient discomfort
This month's clinical capabilities article discusses best practices for administering intramuscular (IM) injections. It is important to review clinical skills as many are taught during initial training and not reviewed afterwards. This can lead to poor practice and incorrect techniques, which in turn can lead to patient discomfort and potential complications.hunter, 2008;Malekin, 2008🇧🇷 An overview of injection sites, indications, and complications is provided with an evidence-based best practice technique approach. A full critique of injection sites will not be explored here due to the general nature of this article.
It is important that patient care ensures optimal effect of the medication administered and minimizes the experience of discomfort or pain. In paramedical practice, examples of drugs administered IM are:
glucagon
Adrenaline 1:1000
(Video) Intramuscular Injection Techniques (Nursing Skills)selfishpenicilina
hydrocortisone.
injection sites
There are five known sites that have been identified for intramuscular injections with differences in the literature for which they are recommended (Thomas y Monaghan, 2014) (illustration 1):
Locales Belly-Gluteal
deltamuskel
Dorsogluteo
straight thigh
side residues.
(Video) Intramuscular Injection in Deltoid Muscle with Z-Track Technique
All sites have nerve innervation and blood supply; However, only the dorsogluteal pathway is close to major blood vessels and nerves and is therefore not a recommended application site (Ogston-Tuck, 2014). oRoyal Colleges Joint Ambulance Liaison Committee (JRCALC) (2017)micarolina (2014)The anterolateral sides of the thigh or upper arm are primarily recommended for administration due to easy accessibility and rapid absorption. The ventrogluteal injection site is generally recommended for IM injection due to minimal risk of nerve and blood vessel damage; However, clinicians report that this side is rarely used because they are unfamiliar with landmarks and have difficulty ensuring the optimal patient position for administration (Coman and Murray , 2006; Wynaden, 2014;Strohfus et al., 2018🇧🇷 Multiple sites must be used for multiple injections.
Places of interest
deltamuskel
Locate the "noble" acromion process at the point of the shoulder, then slide your fingers 1 inch down the deltoid. The patient's arm should be relaxed across their waist. This site is easily accessible, but is only recommended up to a volume of 1 mL (Roger y King, 2000;Coman and Murray , 2006;Ogston-Tuck, 2014🇧🇷 The deltoid is the preferred site of older children (Anonymous, 2007;Ogston-Tuck, 2014).
abdomen buttocks
Place the palm of the hand on the patient's opposite hip (greater trochanter). For example, the left hand on the right hip. Make a V shape with your index and middle fingers and point your index finger at the iliac crest. The injection site is located within this V in the gluteus medius muscle when the index and middle fingers are opened (Ogston-Tuck, 2014) (Figure 2🇧🇷 Up to 5 ml can be administered here (Roger y 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 in the rectus femoris.
lateral residues
On one side of the greater trochanter and also of the patella on the lateral surface of the thigh (hunter, 2008;Ogston-Tuck, 2014🇧🇷 Up to 5 ml can enter the vastus lateralis (Roger y King, 2000🇧🇷 It is an easily accessible website (Floyd y Meyer, 2007) and is a popular place for young children and babies (workers, 1999;Anonymous, 2007;Ogston-Tuck, 2014).
site cleaning
The literature contains conflicting information on cleaning the injection site, and many hospitals recommend that if the skin is visibly clean, an alcohol-based wipe should not be used (hunter, 2008🇧🇷 With the correct use of aseptic technique, clean hands and gloves, injections can be applied without the need to clean the injection site. On the other hand, some authors advise cleaning the area with a 70% isopropyl alcohol-based cloth for 30 seconds and then letting it dry for 30 seconds (hunter, 2008;Ogston-Tuck, 2014🇧🇷 In this case, it is important to allow the site to dry completely, since injecting into a site that is still moist can increase the risk of pain and the entry of bacteria into the injection site (workers, 1999🇧🇷 Skin disinfection is recommended in immunocompromised patients (Ogston-Tuck, 2014🇧🇷 Therefore, clinicians should follow locally provided guidelines and guidelines for site preparation/cleanup.
clinical indications
Indications for IM injection
Individual drug indications are required when IM injection is required. The IM route is used for drugs that require rapid absorption (10-20 minutes) but a long duration of action.Ogston-Tuck, 2014🇧🇷 Drug volumes of 1 to 5 ml can be administered IM (workers, 1999🇧🇷 In certain cases, such as in patients with hypoglycemia, intravenous (IV) administration of 10% glucose is preferred over IM glucagon; however, clinical and situational factors should be considered before making a clinical decision.
contraindications
Injection sites with oedema, inflammation, infection or skin lesions and poor perfusion should be avoided. The site must be well supplied with blood to ensure drug absorption into the muscle (carolina, 2014;Thomas y Monaghan, 2014).
executing the procedure
Explain the injection procedure to the patient and obtain their consent to perform the procedure if the clinical situation allows. Patients must be fully informed about the benefits and consequences of all necessary interventions (Thomas y Monaghan, 2014;Gaisford, 2017🇧🇷 Special vigilance and safety is required since many patients have a phobia of needles.
Consider the site chosen based on clinical need, the drug to be administered, the patient's age, medical history, and setting (Malekin, 2008;Ogston-Tuck, 2014;Chadwick and Withnell, 2015)
Carry out required drug checks in accordance with local/national guidelines. Make sure the right drug is given to the right patient and that it is the right dose at the right time in the right way (workers, 1999)
Check for allergies (hunter, 2008)
Position the patient so that they are comfortable and in the optimal position for the chosen site of administration. Expose the selected 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 your hands and be sure to wear gloves and an apron (Thomas y Monaghan, 2014)
Sanitize the site in accordance with the local trust policy. When cleaning the stain, allow it to dry for 30 seconds (workers, 1999)
Aspirate the medication or open and prepare the pre-filled syringe
(Video) Glute injection - Everything You Need To Know - Dr. Nabil EbraheimA needle must be chosen that penetrates the tissue and reaches the underlying muscle. Needle sizes 21 (green)–23 (blue) are suitable for most IM injections (workers, 1999)
Pull the skin to the side or use the z-follow method while holding the skin with your non-dominant hand (Coman and Murray , 2006;hunter, 2008) (figure 3;)
Inform the patient that they may feel a sharp scratch. Do not tell the patient that it will not hurt (carolina, 2014)
Holding the injection like an arrow in your dominant hand, quickly insert the needle at a 90 degree angle to the skin (Anonymous, 2007;hunter, 2008;Thomas y Monaghan, 2014)
Insert the needle into the hub (Greenway, 2014)
Pull back slightly on the plunger and check for blood, to make sure you have not punctured a vein. Although there is little evidence for this, it is still a proven method. If blood is seen, remove the needle and dispose of it in a trash can. Apply pressure to the injection site; explain to the patient what happened; Then choose a new needle and injection site and start over
If there is no blood, press the plunger to slowly inject the medication at a rate of 1 mL/10 seconds (hunter, 2008🇧🇷 Reduces the potential for pain
After administration, wait 10 seconds to allow drug absorption/diffusion, then remove the needle and dispose of it in puncture-resistant trash (workers, 1999;Ogston-Tuck, 2014;Thomas y Monaghan, 2014🇧🇷 Do not rub the area as this can cause the medicine to escape (workers, 1999🇧🇷 Put a bandage on the puncture site
(Video) APhA Injection Technique Video 2018Complete your documentation in accordance with local/national requirements, noting the name of the medicine, the dose administered, the type, the time and the details of the patient (Health and Care Professions Council (HCPC), 2014)
Reassess the patient for signs of a hypersensitivity reaction (carolina, 2014).
Conclution
Intramuscular injections are part of the paramedic's skill set and it is important to regularly review clinical skills to ensure best practice is being followed. Clinical and environmental factors, as well as the individual needs of the patient, affect the site chosen and the administration of the IM injection. Paramedics must maintain the necessary knowledge of their skills to provide best practice and quality patient care.