Intramuscular Injection

IM injection is a semester 2 station which has also appeared in semester 5 OSCE finals.
I have had the opportunity to re-learn this in clinical school (semester 6) in a little more detail, so I shall post this up here.

introduction - (for semester 2 students)

• an Intramuscular Injection is a substance injected directly into a muscle.
• drugs injected intramuscularly are absorbed into the muscle fairly quickly.
• Immunization is usually done on the deltoid (the shoulder muscle) because they are small in dose, and is highly soluble.
• Other medications such as analgesics, anti-emetics, immunoglobulin and pre-op medicine are injected into larger muscles (like the Gluteus Major, your buttocks) because they are caustic to tissue, can be thick in consistency and needs extensive blood supply for absorption.

there are 6 things you should really know about any type of injections. those are the precautions of injections.

• 6 precautions of injection
• right dose
• right patient
• right medication
• right site
• right time
• right documentation

so while carrying out the injection, always keep those 6 things in mind.
... that'll be enough for intro, so here we go.

Injection of Intramuscular Injections

Summary of events

1.       GIEP - special consideration on the explanation and identification of patient

2.       Washing hands

3.       Equipment check

4.       Preparation of medication from vial / ampoule

5.       Select injection site

6.       Don gloves.

7.       Locating and cleaning site

8.       Preparation of syringe for injection

9.       Injection of medication (not required to DO during pre-clinical OSCEs - only KNOW)

10.    Thank patient

11.    Wash hands

12.    Documentation of injection

13.    Finished. Leave.

GIEP - special consideration on the explanation and identification of patient

About 30% of marks comes from here.

·         Greet and introduce yourself.

·         Explain the procedure - include…

o    The procedure requires exposing the area needed for injection

o    The procedure involves a needle, and patient will experience discomfort.

o    That the patient has the right to stop any time if s/he feels TOO uncomfortable, but please do bear with me so I can help you.

·         Get permission.

·         Now, Identify the patient, and correlate his/her information with the document given. Verbalize this so that examiner will know what you are doing. - you may double check, by checking the patient’s tag on the wrist. (if s/he has any tag - it is there for a reason!) RIGHT PATIENT

Washing hands

Wash hands. Quick quick quick!

Equipment check

Another 30% of marks here.

Preparation of medication from vial / ampoule

Quite confusing - so please practice.

·         Check all the equipments - vocalize this.

o    Sterile medication vial / ampoule - RIGHT MEDICATION

o    Syringe - choose the correct size according to the dosage given. 

§  - BUT sometimes, it is a good idea to choose a syringe one size bigger than the required dose - for e.g. if you need to give 1 ml of medication, you may use 10ml syringe -

§  WHY? It reassures the patient when the medication dosage LOOKS small. A 1ml medication in a 1ml syringe, and 1ml medication in 10ml syringe has a different impression on the patient.

o    2 needles of the correct size - 21G to 23G needle for adult IM injection. 23G to 26G (with 1inch length) for children IM.

§  WHY 2 Needles?

·         One needle for extracting the medication from the vial / ampoule.

·         One needle for injection.

·         Needles must be separate due to the fact that the needle is considered BLUNT when it is used once, no matter it is used for injection or extraction.

o    Dry gauze / cotton ball

o    2 Antiseptic swab (alcohol swab)

§  One for injection site, one for medication vial / ampoule

o    Disposable Gloves

o    Sharps bin

·         Extraction of the medication into syringe

o    Don gloves

o    Open the needle wrapper halfway - so that you don’t touch the needle direcly, but hub is accessible.

o    Open wrapper of syringe.

o    Attach the hub of needle onto the syringe.

o    Put down the syringe for now, and pick up the vial/ampoule

§  Re-confirm the medication. Vocalize.

o    Remove sheath from the syringe and needle, and expose the needle.

o    Vial

§  Pop off vial top

§  Clean mouth of vial using antiseptic swab

§  Pull syringe to insert air into the barrel - the air is needed to break the vacuum in the vial.

§  Insert air into vial

§  Pull out medication from vial

§  Leave the needle into the vial, and push out excess air from barrel.

o    Ampoule

§  Clean the ampoule neck

§  Tap the ampoule to make sure all the medication is below the neck

§  Wrap the ampoule neck with cotton swab

§  Break off the ampoule head, careful not to cut yourself.

§  Insert needle into ampoule and extract medication

§  Expel air from barrel.

o    Make sure you have the appropriate dosage, by holding the syringe vertically.

o    Done. Make sure you dispose the needle into sharps bin / leave in the vial

Select and clean injection site

RIGHT SITE

·         Select injection site, and ask / check for any…

o    Tenderness (palpate the area and ask for pain)

o    hardness

o    swelling

o    scarring

o    itching

o    burning

o    localized inflammation

·         Deltoid

o    3 cm below acromial process, on the lateral surface of deltoid muscle

·         Dorsogluteal

o    To find suitable postion -

§  Divide one buttock into 4 segments

§  From the center of 4 segments, (on the middle of buttock), draw another diagonal imaginary line towards the Posterior Superior Iliac Spine.

§  Inject on the mid-way between the diagonal line.

·         Clean the area of injection site.

o    Swab center first - rotate outwards

o    About 5 cm in diameter

o    Allow to dry

Injection of medication (not required to DO during pre-clinical OSCEs - only KNOW)

·         IM injections should be 90 degrees to the skin.

·         Hold syringe as you would hold a pen

·         Warn patient

·         Inject

·         Pull on syringe - see if blood is aspirated (to ensure you did not hit any vessels)

·         If blood is aspirated, pull out needle and re-locate injection site. Repeat with a different needle.

·         You may employ a Z-track technique if medication is caustic to subcutaneous or dermis

o    Used for haloperidol or vistaril

o    Also for coloured solutions, such as Iron solutions

Thank patient and documentation

·         Mention that you will document the injection. RIGHT DOCUMENTATION

Wash hands and leave

possible viva

·         When do you NOT use antiseptic swab?

o    BCG injection - because this involves injection of live-attenuated vaccine. If the antiseptic is used, it may kill off the bacterias.

·         How do you select injection site for IM injection?

o    Depending on…

§  Amount of medication

·         Small amount - can be injected on smaller muscles (deltoid)

·         Large amount - should be injected on larger muscle (dorsogluteal)

§  Consistency of medication

·         More soluble - can be injected on smaller muscles

§  Causticity of medication

·         More caustic - should be injected on larger, more vascularized muscles

§  Age of patient

·         Young patients should receive IM through dorsogluteal site

§  Skinny patients

·         May not be able to inject the deltoid muscle - too small.

ECG

·         Many types of ECG

o    Holter monitor

§  The patient wears it for a long time - when patient experience discomfort, they may press a button to record it.

o    Ambulatory ECG

o    12-lead ECG

·         When you see an ECG…

o    Look at the rhythm

§  Usually, there is a R-R variation - sinus arrhythmia.

§  If not - may be diabetic neuropathy (no SA node reaction to vagal stimulation)

o    Look at the rate

§  Fast method - divide 300 by the number of big boxes.

§  Accurate method - divide 1500 by number of small boxes

o    P wave

§  Shows SA node activity

§  Inversion of P-wave (junctional rhythm)

·         Sometimes P wave inside QRS

·         Inversion of P wave plus slow conduction is usually indicative of junctional rhythm

·         In a junctional rhythm, the conduction does NOT start from atrium. From AV node instead

§  Sometimes P wave is absent - junctional bradycardia

·         In junctional bradycardia, usually rate = 40 to 60

§  If P wave is present but sometimes missing / irregular / dysmorphic, the beat may originate from the atrium BUT not from SA node.

·         It may be a wondering pacemaker if the P wave is “misbehaving”

§  Saw-tooth appearance

·         Several P waves per QRS - atrium firing impulse rapidly, but each beat not getting permitted to enter the ventricles.

o    Atrial flutter.

o    In atrial flutter, you would like to count the PP- rate and RR rate ratio. - see if the heart block is varying  / uniform.

o    In atrial flutter - the saw-tooth pattern is nice and regular - NEW saw - as compared to atrial fibrillation - where you would have an OLD saw.

·         Sometimes P wave occurs alone - without a QRS - if this happens uniformly, i.e. every 2 beats, or 3 beats, it is a heart block.

o    QRS complex

§  When QRS narrow (less than 3.5 small boxes), the impulse is proper in the ventricles - the arrhythmia is supraventricular

§  When QRS broad, the arrhythmia is ventricular arrhythmia (broad QRS complex tachycardia)

o    Tiny, vertical pulse just before a broad QRS complex - it may be a pacemaker artifact. (ventricular pacemaker artifact)

o    avR

§  is always negative in normal ECG - a positive AVR may suggest dextrocardia

o    ST segment

§  REGIONAL changes in ST segment suggests MI - if it is systemic, e.g. drugs, neurogenic, electrolyte etc the whole ECG changes.

§  Differential diagnosis of ST elevation

·         Intrinsic myocardial disease (e.g., myocarditis, ischemia, infarction, infiltrative or myopathic processes)

o    Contiguous leads elevations diagnostic

·          Drugs (e.g., digoxin, quinidine, tricyclics, and many others)

·          Electrolyte abnormalities of potassium, magnesium, calcium

·          Neurogenic factors (e.g., stroke, hemorrhage, trauma, tumor, etc.)

·          Metabolic factors (e.g., hypoglycemia, hyperventilation)

·          Atrial repolarization (e.g., at fast heart rates the atrial T wave may pull down the beginning of the ST segment)

·          Ventricular conduction abnormalities and rhythms originating in the ventricles

o    T wave

§  In the normal ECG (see below) the T wave is always upright in leads I, II, V3-6, and always inverted in lead aVR

§  The normal T wave is usually in the same direction as the QRS except in the right precordial leads e.g. V2

§  Also, the normal T wave is asymmetric with the first half moving more slowly than the second half.

§  Electrolyte changes

May be seen in the T-wave (tall, tenting T-wave in hyperkalemia etc )

Murmurs

In clinical schools (in Malaysia, at least) you will actually get to hear lots of murmurs, and you will see (if you take some time to look at them) lots of changes in the JVP

this is where we would need to actually comment on those murmurs and JVP findings, if we haven't already memorized everything about them (I know I haven't.)

murmurs


murmurs are reported according to their 4 main properties.

1. timing
2. site and radiation
3. loudness and pitch (grading if possible)
4. relationship to posture and respiration

the 4 characteristics will help us in determining just what kind of problem (usually valvular) are there, in the heart.

how do we know what is a systolic and diastolic murmur?

we palpate the carotid, for the pulsation. the heart sound that corresponds / occurs simulataneously with the pulsation is the S1, and any murmur that occurs between S1 and S2, is a systolic murmur.

now that we know what is systolic and what is diastolic, lets say the patient has a systolic murmur.

let us come up with a DD of a systolic murmur. 

• pansystolic
• VSD
• Tricuspid regurgitation
• mitral regurgitation
• ejection systolic
• pulmonary stenosis
• aortic stenosis
• HOCM
• fever / fit, young adults
• late systolic
• tricuspid regurgitation
• mitral regurge 
• prolapsed valve
• mitral Valve Prolapse

so how do we narrow this down? 

is is through the other maneuvers you could do, and also radiation.

systolic murmur

• pansystolic murmur (1st and 2nd heart sounds cannot be heard separately in all areas)
• is it left side (mitral regurge) or right (pulmonary regurge)? how to determine that?
• ask patient to breath in and out deeply
• a left-sided murmur (MR) will INCREASE in intensity with EXPIRATION as the venous return is reduced (as we breathe out, the intrathoracic pressure go down - making it easier for the left heart to pump blood)
• confirmed with M shaped P wave on ECG, and Echo.
• a right sided murmur (PR) will INCREASE in intensity with INSPIRATION as the venous return is increased (as we breathe in, intrathoracic pressure rises - pushing more blood into right heart)
• VSD will have no radiation - the murmur is heard throughout the precordium.
• confirmed by Echo and ECG - Right axis deviation & RBBB
  
• mid-systolic murmur (between S1 and S2, but both heart sounds heard clearly apart)
• Aortic stenosis
• cold extermities
• slow-rising pulse
• low BP
• low Pulse pressure
• HOCM
• JVP has high a wave, 
• thrillss and murmur at left sternal edge
• Aortic sclerosis
• more common in elderly with Atherosclerosis
• plumonary high flow
• typical in young women
• benign if no pulmonary hypertension
• ASD
• pulmonary stenosis
• low pulse
• increased JVP
• left parasternal heave

diastolic murmur

• mitral stenosis
• tapping apex
• rumbling in character
• mireal stenosis with pliable valve
• opening snap
• aortic regurgitation
• increased BP
• increased pulse pressure
• collapsing pulse
• displaced apex

GALS Screening

GALS Screen

GALS stands for;

Gait
Arms
Legs
Spine

this is a systematic approach to a rheumatological system examination.

Order of examination - throughout the GALS screen

o    ask

o    Look

o    Feel

o    Move

Ask

o    Stiffness / pain  in any joints

o    Climb up / down stairs with ease?

o    Can you clothe yourself?

Gait

o    Walking rhythm

o    Pelvis and arm symmetry

o    Normal stride length

o    Ability to Turn quickly

Arms

o    Shoulder joint

§  Scars

§  Deformities

§  Normal muscle bulk

§  External rotation of shoulder

§  Full elbow extension

o    Hands

§  inspection

·         Swelling

·         Interosseous muscle wasting

o    Disuse atrophy

·         Swelling in PCP, MCP etc

·         Thenar and hypothenar wasting

o    Carpal tunnel $

·         Palmar erythyma

o    Occurs in 30% of RA patients

§  Palpation

·         Feel temperature

·         Squeeze the MCP joints

o    Any tenderness - inflammatory joint pathology

·         Press / feel individual joints

o    Cystic

§  Ganglion, abscess

o    Bony

§  Nodes (herbaden’s, bouchard’s)

o    Boggy

§  cynovitis

§  movement

·         Ask to make tight fist

·         OK sign

o    Nails

§  Psoriasis

§  Vasculitis

·         SLE

o    Elbows

§  Psoriatic patches

§  Rheumatic nodules

§  Straighten elbow

o    Compound

§  Hand to head

§  External rotation of shoulder

Legs

·         Feet

o    Metatarsal squeeze

o    Any eythyma

o    Swelling

o    Deformities

o    Callosities of sole

o    crepitus

·         Knees

o    Scars

o    Deformity

·         Knees

o    Feel for any bulge

o    Flexion of knees

o    Flex knees - and rotate externally - test pelvic joint

Spine

·         Kyphoscoliosis

·         Symmetrical muscle bulk

·         Level of iliac crest

·         Side

o    Curvature - scoliosis

o    Lumbar spine and hip flexion

·         Front 

• o     Lateral cervical flexion

o    Hyperalgesic response of fibromyalgia

·         Movement

o    Shober’s test

it is also good to know the RA criteria - 

The 2010 ACR-EULAR classification criteria for rheumatoid arthritis

	Score
Target population (Who should be tested?): Patients who have at least 1 joint with definite clinical synovitis (swelling)* with the synovitis not better explained by another disease†
Classification criteria for RA (score-based algorithm: add score of categories A–D; a score of ≥6/10 is needed for classification of a patient as having definite RA)‡
A. Joint involvement §
1 large joint¶	0
2-10 large joints	1
1-3 small joints (with or without involvement of large joints)#	2
4-10 small joints (with or without involvement of large joints)	3
>10 joints (at least 1 small joint)**	5
B. Serology (at least 1 test result is needed for classification)††
Negative RF and negative ACPA	0
Low-positive R/F or low-positive ACPA	2
High-positive RF or high-positive ACPA	3
C. Acute-phase reactants (at least 1 test result is needed for classification)‡‡
Normal CRP and normal ESR	0
Abnormal CRP or abnormal ESR	1
D. Duration of symptoms§§
<6 weeks	0
≥6 weeks	1