{"id":2877,"date":"2015-05-22T21:45:26","date_gmt":"2015-05-22T21:45:26","guid":{"rendered":"http:\/\/opentextbc.ca\/clinicalskills\/?post_type=chapter&p=2877"},"modified":"2021-06-09T16:00:25","modified_gmt":"2021-06-09T16:00:25","slug":"6-8-iv-push-medications-and-saline-lock-flush","status":"publish","type":"chapter","link":"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/6-8-iv-push-medications-and-saline-lock-flush\/","title":{"raw":"7.4 Intramuscular Injections","rendered":"7.4 Intramuscular Injections"},"content":{"raw":"Intramuscular (IM) injections deposit medications into the muscle fascia, which has a rich blood supply, allowing medications to be absorbed faster through muscle fibres than they are through the subcutaneous route (Malkin, 2008; Ogston-Tuck, 2014a; Perry et al., 2014). The IM site is used for medications that require a quick absorption rate but also a reasonably prolonged action (Rodgers & King, 2000). Due to their rich blood supply, IM injection sites can absorb larger volumes of solution, which means a range of medications, such as sedatives, anti-emetics, hormonal therapies, analgesics, and immunizations, can be administered intramuscularly in the community and acute care setting (Hunter, 2008; Ogston-Tuck, 2014a). In addition, muscle tissue is less sensitive than subcutaneous tissue to irritating solutions and concentrated and viscous medications (Greenway, 2014; Perry et al., 2014; Rodgers & King, 2000).\r\n\r\nThe technique of IM injections has changed over the past years due to evidence-based research and changes in equipment available for the procedure. An IM site is chosen based on the age and condition of the patient and the volume and type of medication injected. When choosing a needle size, the weight of the patient, age, amount of adipose tissue, medication viscosity, and injection site all influence the needle selection (Hunter, 2008; Perry et al., 2014; Workman, 1999).\r\n\r\nIntramuscular injections must be done carefully to avoid complications. Complications with IM include muscle atrophy, injury to bone, cellulitis, sterile abscesses, pain, and nerve injury (Hunter, 2008; Ogston-Tuck, 2014a). With IMs, there is an increased risk of injecting the medication directly into the patient's bloodstream. In addition, any factors that impair blood flow to the local tissue will affect the rate and extent of drug absorption. Because of the adverse and documented effects of pain associated with IM injections, always use this route of administration as a last alternative; consider other methods first (Perry et al., 2014).\r\n\r\nSites for intramuscular injections include the ventrogluteal, vastus lateralis, and the deltoid site. Literature shows inconsistency in the selection of sites for deep muscular injections: selection may be based on familiarity and confidence rather than on \u201cbest practice\u201d (Ogston-Tuck, 2014a). However, there is sufficient evidence that the ventrogluteal IM site is the preferred site whenever possible, and is an acceptable site for oily and irritating medications. The ventrogluteal site is free from blood vessels and nerves, and has the greatest thickness of muscle when compared to other sites (Cocoman & Murray, 2008; Malkin, 2008; Ogston-Tuck, 2014a). A longer needle with a larger gauge is required to penetrate deep muscle tissue. The needle is inserted at a 90-degree angle perpendicular to the patient's body, or at as close to a 90-degree angle as possible. Use a quick, darting motion when inserting the needle.\r\n\r\nAspiration<\/strong> refers to the action of pulling back on the plunger for 5 seconds prior to injecting medication (Ipp, Sam, & Parkin, 2006). Current practice in the acute care setting is to aspirate IM injections to check for blood return in the syringe. Lack of blood in the syringe confirms that the needle is in the muscle and not in a blood vessel. If blood is aspirated, remove the needle, discard it appropriately, and re-prepare and administer the medications (Perry et al., 2014). Recent research has found that there is no evidence to support the practice of aspiration, but despite policy changes, the procedure of aspiration continues to be taught and practised (Canadian Agency for Drugs and Technologies in Health, 2014; Greenway, 2014; Sepah, Samad, & Altaf, 2014; Sisson, 2015). Vaccinations and immunizations given by IM injections are never aspirated (Centers for Disease Control, 2015).\r\n\r\nThe Z-track method<\/strong> is a method of administrating an IM injection that prevents the medication being tracked through the subcutaneous tissue, sealing the medication in the muscle, and minimizing irritation from the medication.\u00a0Using the Z-track technique, the skin is pulled laterally, away from the injection site, before the injection; then the medication is injected, the needle is withdrawn, and the skin is released. This method can be used if the overlying tissue can be displaced (Lynn, 2011).\r\n

IM Injection Sites<\/h2>\r\nTable 7.7 describes the three injection sites for IM injections.\r\n\r\n\r\n\r\n\r\n\r\n\r\n
Table 7.7 Intramuscular Injection Sites<\/caption>\r\n
\r\n

Site<\/b><\/p>\r\n<\/td>\r\n

\r\n

\u00a0Additional Information<\/strong><\/p>\r\n<\/td>\r\n<\/tr>\r\n

Ventrogluteal\u00a0<\/strong><\/td>\r\nThe site involves the gluteus medius and minimus muscle and is the safest injection site for adults and children. The site provides the greatest thickness of gluteal muscles, is free from penetrating nerves and blood vessels, and has a thin layer of fat.\r\n\r\nTo locate the ventrogluteal site, place the patient in a supine or lateral position (on their side). The right hand is used for the left hip, and the left hand is used for the right hip. Place the heel or palm of your hand on the greater trochanter, with the thumb pointed toward the belly button. Extend your index finger to the anterior superior iliac spine and spread your middle finger pointing towards the iliac crest. Insert the needle into the V<\/em> formed between your index and middle fingers. This is the preferred site for all oily and irritating solutions for patients of any age.\r\n\r\nNeedle gauge is determined by the solution. An aqueous solution can be given with a 20 to\u00a025 gauge needle. Viscous or oil-based solutions can be given with 18 to 21 gauge needles.\r\n\r\nThe needle length is based on patient weight and body mass index. A thin adult may require a 16 mm to 25 mm (5\/8 to 1 inch) needle, while an average adult may require a 25 mm (1 inch) needle, and a larger adult (over 70 kg) may require a 25 mm to 38 mm (1 to 1 1\/2 inch) needle. Children and infants will require shorter needles. Refer to the agency policies regarding needle length for infants, children, and adolescents.\r\n\r\nFor the ventrogluteal muscle of an average adult, give up to 3 ml of medication.\r\n\r\n[caption id=\"attachment_6476\" align=\"aligncenter\" width=\"300\"]\"ventrogluteal<\/a> Ventrogluteal intramuscular injection site[\/caption]<\/td>\r\n<\/tr>\r\n
Vastus lateralis\r\n\r\n <\/td>\r\nThe vastus lateralis is commonly used for immunizations in children from infants through to toddlers. The muscle is thick and well developed. This muscle is located on the anterior lateral aspect of the thigh and extends from one hand's breadth above the knee to one hand's breadth below the greater trochanter. The middle third of the muscle is used for injections. The width of the muscle used extends from the mid-line of the thigh to the mid-line of the outer thigh. To help relax the patient, ask the patient to lie flat with knees slightly bent, or have the patient in a sitting position.\r\n\r\nThe length of the needle is based on the patient\u2019s age, weight and body mass index. In general, the recommended needle length for an adult is 25 mm to 38 mm (1 to 1 1\/2 inch). The gauge of the needle is determined by the type of medication administered. Aqueous solutions can be given with a 20 to 25 gauge needle; oily or viscous medication should be administered with 18 to 21 gauge needles. A smaller gauge needle (22 to 25 gauge) should be used with children. The length will be shorter for infants and children; see agency guidelines.\r\n\r\nThe maximum amount of medication for a single injection is 3 ml.\r\n\r\n[caption id=\"attachment_6475\" align=\"aligncenter\" width=\"230\"]\"Vastus<\/a> Vastus lateralis intramuscular injection site[\/caption]<\/td>\r\n<\/tr>\r\n
Deltoid muscle<\/td>\r\nThe deltoid muscle has a triangular shape and is easy to locate and access, but is commonly underdeveloped in adults. Begin by having the patient relax the arm. The patient can be standing, sitting, or lying down. To locate the landmark for the deltoid muscle, expose the upper arm and find the acromion process by palpating the bony prominence. The injection site is in the middle of the deltoid muscle, about 2.5 to 5 cm (1 to 2 inches) below the acromion process. To locate this area, lay three fingers across the deltoid muscle and below the acromion process. The injection site is generally three finger widths below, in the middle of the muscle.\r\n\r\nSelect needle length based on age, weight, and body mass. In general, for an adult male weighing 60 to 118 kg (130 to 260 lbs), a 25 mm (1 inch) needle is sufficient. For women under 60 kg (130 lbs), a 16 mm (5\/8 inch) needle is sufficient, while for women between 60 and 90 kg (130 to 200 lbs), a 25 mm (1 inch) needle is required. A 38mm (1 1\/2 inch) length needle may be required for women over 90 kg (200 lbs) for a deltoid IM injection.\r\n\r\nRefer to agency policy regarding specifications for infants, children, adolescents, and immunizations.\r\n\r\nThe maximum amount of medication for a single injection is generally 1 ml. For immunizations, a smaller 22\u00a0to 25 gauge needle should be used.\r\n\r\n[caption id=\"attachment_6473\" align=\"aligncenter\" width=\"224\"]\"\"<\/a> Deltoid intramuscular injection site[\/caption]\r\n\r\n[caption id=\"attachment_6068\" align=\"aligncenter\" width=\"300\"]\"Deltoid<\/a> Deltoid IM injection site[\/caption]<\/td>\r\n<\/tr>\r\n
Data source: Berman & Snyder, 2016; Davidson & Rourke, 2014; Ogston-Tuck, 2014a; Perry et al., 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n
Special Considerations:<\/h5>\r\n