/

This booklet has been prepared by Wyeth

Laboratories vvith the hope that it vvill be

useful to students in various fields of medi-

cine vvhose responsibilities vvill ultimately

include the giving of intramuscular injections.

For those vvhose training is already an ac-

complished fact vve hope the booklet vvill

act as a refresher.

Everyone agrees that intramuscular injec-

tions should avoid major nerves and vessels,

but there is no universal agreement on speci-

fically preferred sites and procedures. This

booklet presents a selected cross section of

thinking on those sites and procedures most

generally accepted for adults and children.

Illustrations in this booklet are intended

primarily as an aid to general site orientation.

Specific procedures as described in the text

of the booklet are recommended in adminis-

tration of intramuscular injections.

We vvish to express our appreciation to

Daniel .J. Hanson, M.D., Department of Path-

ology and Research Institute, Mercy Hospital,

Toledo, Ohio, for permission to reprint a

portion of his article, "Intramuscular Injection

Injuries and Complications," to Philip S. Barba,

M.D., Adjunct Professor of Pediatrics, Temple

University School of Medicine, for his helpful

comments on pediatric intramuscular injec-

tions, and to Alice C. Cook, R.N., Senior In-

structor at The Memorial Hospital School of

Nursing, Wilmington, Delavvare, for her tech-

nical assistance and advice.

Intramuscular Injections

WYETH LABORATORIES Philadelphia, Pa. 19101

Table of Contents

Injections in General ..

Intramuscular Injections.

Precautions and Recommendations for Intramuscular Injections .

Intramuscular Injection Sites

Mid-Deltoid Area .

Gluteus Medius

Ventrogluteal Area

Vastus Lateralis ...

Intramuscular Injections in Infants and Children ..

Pediatric Intramuscular Injection Sites

Gluteal Region ..

Vastus Lateralis.

Deltoid .

Preparing for the Injection.

Orders for Medication

Preparation Steps for Injection With Prefilled TUBEX Sterile

Cartridge-Needle Unit.......... . .

Preparation Steps for Injection With Reusable Syringe

Giving the Injection .....

After the TUBEX Injection ...

After the Injection With a Reusable Syringe ...

Bibliography .

TUBEX in the Hospital .

4

5

6

8

10

12

14

16

18

20

22

24

25

26

27

28

30

31

32

34

TUBEX Closed Injection System Components . Inside back cover

4

Injections in general

Giving injections is a serious and important part of medicaltreatment. In a very real sense the same kind of preparationand caution employed in an operating procedure must beexercised in giving injections. Two foreign objects are be-ing introduced into the body, a hypodermic needle and themedication, and this should be done with as much precisionas a surgeon employs when using a scalpel. The accuracy ofthe choice of injection site and the excellence of the tech-nique of injection help control the effectiveness of the medi-cation. A misdirected injection or improper technique inadministering the injection may prevent medication fromacting most efficiently or, more important, may cause irrep-

arable damage.

A physician orders an injection for a patient only whenit is absolutely necessary or the manner of treatment mostsuited to the existing circumstances. Some of the reasons andadvantages for giving injections of medication (also referred

to as parenteral therapy) are:

1. To administer medication when the mentalor physical state of the patient may makeany other route difficult or impossible.

2. To achieve a quick response to the medica-

tion.

3. To guarantee the accuracy of the amountof medication received.

4. To obtain a sure response from the patient.

5. To prevent irritation of the digestive system,loss of medication through involuntary ejec-tion or destruction by digestive acids.

6. To anesthetize a specific area of the body.

7. To concentrate medication at a specific lo-

cation in the body.

Intramuscular injections

Intramuscular injections are given when a quick but pro-longed action is preferred to an immediate effect of shortduration. By injecting medication into the muscle a depositof medicine is formed which is gradually absorbed into theblood stream. When given properly, the intramuscular injec-tion is probably the easiest, safest, and best tolerated of theseveral types of injections.

Generally speaking, large quantities of medication are sel-dom injected into the muscles and a 2- or 2.5-cc. syringe willbe adequate for most treatments.

Medications for many intramuscular Injections are in anaqueous solution or in a suspension, while a few are in an oilsolution or suspension. When an aqueous suspension or oilsolution or suspension is administered, it is generally neces-sary to give the injection at a slower rate because of thethicker liquid.

5

Precautions and recommendations for Intramuscular Injections

Reprinted with the permission oj the author, Daniel J.Hanson, M. D., Department oj Pathology and ResearchInstitute, Mercy Hospital, Toledo, Ohio jrom "I ntramus-cular Injection Injuries and Complications" publishedin GP January, 1963.

RecornluendatioJJs

A local lesion of greater or lesser extent, dependingupon the material injected, is produced in the tissueseach time an injection is given. The operator must beaware of the differences in tissue toleration whenchoosing the substance to be injected and he mustcontrol the site of the resultant lesion by locating theneedle tip in a relatively silent intramuscular area.

Many cases of 'generalized anaphylactic and relatedreactions after intramuscular injection cannot bepredicted. However, most injection accidents are re-lated to tissue damage at the injection sites. Theseaccidents are preventable. When complications occur,they usually can be attributed to faulty injectiontechnique.

With the previously described facts in mind, severalpoints will be listed which are particularly importantin avoiding injection complications.

Select the Agent. When a choice is possible, selectthe agent which demonstrates the greatest tissuetoleration.

In the case of antibiotic injections, it has been shownthat procaine penicillin and oxytetracycline causethe least extensive reactions at the injection sites.Chloramphenicol succinate and tetracycline provokethe most severe necrotic lesions.

Choose the Proper Site. In adults, the recommendedsite of intramuscular injection is the upper outerquadrant of the gluteal area. The gluteal area is notsynonymous with the buttocks. A review of the anat-omy of the area will reveal that the term "buttocks"includes a zone of fat tissue inferior to the glutealmusculature adjacent to the posterior thigh.

In determining the injection site in the gluteal zone... the classic method of intersecting perpendicularlines may be dangerous, especially in the hands ofnonprofessional personnel, because of the absence

6

of well-defined landmarks locating the vertical line.H the vertical is drawn only slightly medial to theproper location, the intersection with the horizontalwill be located medial to the sciatic nerve. This willexpose the nerve to injection although the injectionmay be assumed to be given in the "upper outerquadrant."

We recommend a minor modification for the loca-tion of the injection site, using definite anatomiclandmarks. A line drawn from the posterior superioriliac spine to the greater trochanter of the femur islateral to and parallel with the course of the sciaticnerve. Any injection lateral and superior to this linewill be removed from the course of the sciatic nerveand will be within the region of the greatest glutealmass, as recommended by Hochstetter and others.

The deltoid and posterior triceps area should beavoided in adults when anything but the most non-irritating substance is injected. The muscle massesavailable for injection in these areas are generallynot as large as those in the gluteal areas and an in-jection which is only slightly misplaced may involvethe radial nerve. In addition, pain and tenderness aremore noticeable to the patient in this area.

Infants present a different problem. The gluteal areais extremely small and is composed primarily offat. There is only a poorly developed, small musclemass. An y injection in this area is dangerously closeto the sciatic nerve. A squirming, fighting child in-creases the danger of injecting into or adjacent to thenerve. In such patients, the lateral or anterior thighis recommended for intramuscular injections. Thesemuscles are better developed at birth and are far re-moved from any major nerves. Nathan, for similarreasons, used the deltoid area in infants with goodresults. The gluteal musculature develops with loco-motion and, therefore, may be used for injectionwhen the child has been walking for a year or more(usually at the age of 2 or 3). Individual evaluationof the musculature should be made and may indicatethe use of the thigh at an even older age. This loca-tion may also be used safely in adults although painis more noticeable than in the gluteal area.

Intramuscular injectionsites/the Mid-Deltoidarea

A site often chosen for its ease of access is thedeltoid area which can be employed when the pa-tient is in either a standing, sitting, orJprone posi-tion. While the deltoid muscle forms a fairly largetriangle on the shoulder prominence, the actualarea available to a shoulder injection is limited,since there are major bones, blood vessels andnerves to be avoided. The recommended bounda-ries of the injection area form a rectangle boundedby the lower edge of the acromion on the top toa point on the lateral side of the arm opposite the

axilla or armpit on the bottom. The two sideboundaries are lines parallel to the arm one-thirdand two-thirds of the way around the outer lateralaspect of the arm.Care should be taken to avoid not only the acro-mion, clavicle and humerus, but also the brachialveins and arteries and the radial nerve. It is rec-ommended that the number and size of injectionsmade at this site be limited. The area is small andcannot tolerate repeated injections and largequantities of medication.

8

Acromion

Brachial vessels

100-lb. female

135-lb. female

210-lb. female

130-lb. male

180-lb. male

240-lb. male

9

Intramuscular injection sites/the GluteusMedius

Perhaps the most commonly considered site forinjections is the posterior gluteal area. In definingthis site for injection purposes care should begiven to restrict injections to that portion of thegluteus medius which is above and outside of adiagonal line drawn from the greater trochanterof the femur to the posterior superior iliac spine.Extreme caution should be observed to ensurethat the boundary line is maintained, avoiding thehazard of possibly injecting into either the sciaticnerve or the superior gluteal artery.

The patient should be lying face down. A "toe-in"position relaxes the muscles. The injection siteshould be clearly exposed. Under no circum-stances should there be any compromise withcorrect technic. Do not hurry, do not letmodesty tempt you to give this injection to a per-son who is bending over a table or with his cloth-ing only partially removed from the injection site.The needle is inserted perpendicular to the flatsurface on which the patient is lying-needle pene-tration should be on a direct back-to-front course.

10

Sciatic nerves

Greater trochanter of the femur

(not illustrated)

Gluteus rnaxirnus

Superior gluteal arteryr Gluteus medius

7/~ior superior iliac spine

100.lb. female 130-lb. male

135-lb. female

210-lb. female

180-lb. male

240-lb. male

11

Intramuscular injection sites / the Ventrogluteal area

The ventrogluteal area (von Hochstetter's site)has been accorded growing recognition as a siteremoved from major nerves and vascular struc-tures. The subcutaneous fatty layer is relativelyshallow and there is good gluteal muscle density.Because anatomical landmarks are easily identi-fiable around the ventral area of the glutealmuscles, this site is also recommended for injec-tions in children. Although especially suitable fora patient lying on his back, this site is also acces-sible with the patient lying prone, on his side,or standing.The patient should always be sufficiently exposedto enable adequate identification of anatomicallandmarks.

Ventrogluteal area(in triangle)

Greater trochanter of the femur

12

Palpate to find the greater trochanter, the anteriorsuperior iliac spine and the iliac cresLWhen inject-ing into the left side of the patient, place the palmof the right hand on the greater trochanter and theindex finger on the anterior superior iliac spine.(Use the left hand to delineate the site wheninjecting into the patient's right side.) Spread themiddle finger posteriorly away from the indexfinger as far as possible along the iliac crest, asshown in the straight-line drawing below. A "V"space or triangle between the index and middlefinger is formed. The injection is made in thecenter of the triangle with the needle directedslightly upward toward the crest of the ilium.

Iliac crest(not illustrated)

Posterior edge iliac crest

- J

100-lb. female

135-lb. female

210-lb. female

130-lb. male

180-lb. male

240-lb. male

13

Intramuscular injection sites/

Another site recommended for its relative safetyand freedom from major nerves and blood vesselsis the vastus lateralis. This injection area isbounded by the mid-anterior thigh on the front ofthe leg, the mid-lateral thigh on the side, a hand'sbreadth below the greater trochanter at the proxi-mal end and another hand's breadth above theknee at the distal end.

the Vastus Lateralis

Although it is easier to give an injection in thevastus lateralis when the patient is lying on hisback, it is acceptable to use this site when he is ina sitting position. The entire area should beexposed to permit identification of anatomicallandmarks pertinent to this site. This site mayalso be used for pediatric patients. See pages 20and 21 for specific recommendation.

Mid-portion vastus latera lis

Greater trochanter (not illustrated)

14

100-lb. female

135-lb. female

210-lb. female

130-lb. male

180-lb. male

240-lb. male

15

16

Intramuscular injections

in infants and children

Every precaution which applies when administering intra-muscular injections to adults also applies for infants andchildren-with one added precaution-the margin for erroris critically narrower!Current medical literature abounds with recommendationsstressing correct technic and proper site selection.Close examination of this literature permits inference ofthese basic guidelines for pediatric intramuscular injections:

Some notes to underscore

1. No injection should ever be given with the attitude ofcasual indifference or mechanical routine. Carefulattention to detail is mandatory for every injection-no matter who gives it.

2. Proper injection technic requires a sound knowledge ofthe anatomy involved. The terms used to describe theinjection site and pertinent landmarks must be under-stood precisely.

3. Major nerves and blood vessels must be avoided andinjection sites should be selected accordingly. Rotateamong useable sites when repeated injections arenecessary.

4. The entire injection area should be fully exposed to per-mit an unobstructed overall view of the injection site.

5. The target muscle should be large enough to accommo-date the medication to be injected. Medication de-posited into the belly of the muscle permits optimalabsorption. A relaxed muscle is highly desirable.

6. The needle length should be adequate to deposit themedicament into the belly of the target muscle.

7. A slow rate of injection allows the relaxed muscle todistend and accommodate the medication deposit. Atoo-rapid rate of injection into a taut muscle can resultin expulsion of the medication from the muscle intosurrounding tissues, causing severe irritation andneedless patient discomfort.

8. Few children are completely cooperative. Since theymay struggle when least expected, it is important thatadequate measures be taken to keep the child stillduring the actual injection. Restraining the uncoopera-tive patient often requires two persons. Wheneverpossible a trained physician or nurse should assist.Office assistants or parents may be used when no oneelse is available to help.

17

Pediatricintramuscular injection sites/Gluteal Region

The gluteal region and the buttock are not syn-onymous. Each must be defined to establish theproper injection sites.Buttock refers strictly to the gluteal prominence.The buttocks are confined to one area of thegluteal region-the nates, clunes, "rump" or"seat." Injections should never be given into anyquadrant of the buttock.The gluteal region is much more expansive than

the buttock and extends forward to the anteriorsuperior iliac spine. When the musculature isadequately developed and proper technic is used,the gluteal region is a very suitable area for

injection.The gluteal region includes two distinct injection.sites: (1) the ventrogluteal area and (2) the pos-terolateral aspect of the gluteal region.

Ventrogluteal or von Hochstetter's site This site hasbeen described in detail on pages 12 and 13. Thosesame technics apply for pediatric injection pro-

cedures.

Posterolateral aspect of the gluteal region

1. The patient lies prone on a flat table surface.A "toe in" position relaxes the muscle.

2. Palpate to locate the posterior superior iliacspine and the head of the greater trochanter.The injection site must be superior andlateral to the imaginary line connectingthese two landmarks. The area above thehead of the trochanter and below the iliaccrest is most remote from major nerves

and vessels.

3. The syringe is held perpendicular to the flattable surface on which the patient is lying.The needle is directed on a straight back-to-

front course.

18

Gluteal region

Gluteus

Sciatic N.

Buttock

Post. sup. iliac spine

Gluteus medius M.

Sup. gluteal A.

Gluteus maximus M.

Inf. gluteal A.

Greater trochanterof femur

Sciatic N.

19

Pediatric intramuscular injection sites/ Vastus Lateralis

Vastus lateralls M.

The quadriceps femoris is the largest musclegroup in the anterolateral thigh. The vastuslateral is is the major muscle of this group and islocated on the most lateral aspect of the thighaway from major nerves and vessels. The anteriorsurface of the mid-lateral thigh is therefore a suit-able site for intramuscular injections in this area.Survey the overall size of the thigh and plan theneedle insertion depth accordingly. In very smallinfants, needle insertion to just a one-inch depthwill penetrate into the muscle belly.The infant lies on his back. Grasp the thigh andcompress the muscle tissue as shown. This helpsto stabilize the extremity and concentrates themuscle mass. Using the position shown, the leftarm helps to restrain the struggling patient.The needle penetrates the gathered muscle masson the lateral portion of the anterior thigh and isdirected on a front-to-back course. This is re-moved from the medial portion of the thigh wheremajor nerves and vessels are located among thedeeper layers of the muscle tissue.An alternate injection site in this area is theanterolateral surface of the upper thigh. Whenthis location is used, the needle is directed distallyand inserted obliquely at an approximate 45° angleto the horizontal and long axes of the leg. Theneedle should not penetrate deeper than one inch.Compressing the muscle tissues between the fingersamasses the musculature at the site of injection.

20

)/

, '

/'-'--:"":,I

II

I

II,,,

, I, I

, !I ,, ,

, I, ,I ,, ,

" ,, ':;.l~-\.)

Alternate site

/

Deep femoral A.

Sciatic N.

Femoral A. & V.

Rectus femoris M.

Vastus lateralis M.

21

Pediatric intramuscular injection sites / Deltoid

The deltoid muscle in infants and young childrenis shallow and can accommodate only a very smallvolume of the more fluid medications. Anotherlimiting factor is that repeated injections in thisarea are painful.The patient can sit, stand or lie down and this siteis still accessible. Whatever position is used, theentire shoulder and arm area should be exposedto permit full view of all pertinent landmarks.The injection should be given in the densest por-tion of the deltoid muscle-above the armpit andbelow the acromion in the posterolateral area,mid-way between the posterior axillary line andan imaginary line bisecting the lateral surface ofthe upper arm. Grasp the muscle mass at theinjection site and compress between the thumband fingers. The needle is inserted pointingslightly upward toward the shoulder.

22

Brachial plexus

Deltoid M. ~...:;..

Axillary N.

Median & Ulnar N.

Deep brachial A.

Radial N.

Brachial A.

)

23

Preparing for the injection

THE NURSE

Before preparing and gIVIng an injection thenurse should be thoroughly familiar with the writ-ten medication order and any special instructionsor precautions necessary. As in any other medicalprocedure, washing of hands before preparing amedication and the use of sterilized equipmentare "musts".

THE INSTRUMENTS AND MEDICATION

When giving an injection with a prefilled TUBEX@Sterile Cartridge-Needle Unit, the only equip-ment preparation required is as follows: Selectthe correct premeasured, prefilled cartridge-needle unit. Mark the patient's name and roomon the medication envelope before enclosing theTUBEX.Place envelope, the TUBEX@HypodermicSyringe and a disposable TUBEX@Isopropyl Alco-hol Sponge on a tray to take to the patient's room.

In instances where an empty TUBEX Sterile

24

Cartridge-Needle Unit or where a reusable syringeis used, additional preparation is necessary. First,the empty syringe must be assembled. After thevial of medication has been selected and the sealsterilized with alcohol, the needle is then insertedthrough the seal, the plunger of the syringe de-pressed to expel the air into the vial, and the cor-rect amount of medication withdrawn into the syr-inge. The needle is then withdrawn from the vialand, in the case of an empty TUBEX SterileCartridge-Needle Unit, the rubber needle-sheathis replaced in order to maintain sterility.

THE PATIENT

When preparing the patient for the injection, anattitude of confidence and quiet efficiency in whatyou are doing will generally help to set patientsat ease and instill a greater degree of cooperation.Screening and keeping the patient covered asmuch as possible will prevent both uneasiness andpossible chills.

Orders for medications

DOSAGE AND APPLICATION:

Abbreviation

aa .

ad lib .

c .ce .

Gm. (use capital G) .

gr .

gtt .

m .

q.s .

a .s .3.. .

:3 ..•...•.........•....•....•.....•.....•...•...........................•....•...•..•.

TIME OF ADMINISTRATION:

Abbreviation

a.c .b.i.d .

H .

h.S .

o.d .

D.n.

p.c .

p.r.n .

qh (q3h, q4h, etc.) .

q.i.d. (or 4i.d.) .

si op. sit .

stat .

t.i.d .

HOURS:

Abbreviation

Derivation

ana .

ad libitum .

cum .

cubic centimeter .

Gram .

g ra n u m .

gutta .

minim .

quantum sufficit .

rec ipe .

sine .

drach ma .

uncia .

Derivation

ante ci bum .

bis in die .

hora .

h0 ra 5om n i .

omni d ie ~ .

om ni nocte .

post cibum .

pro re nata .

quaque hora .

quater in die .

si opus sit .

stati m .

te r in die .

Usual Times

English

of each

freely as desi red

with

cubic centimeterGram

grain

drop

minim

a sufficient amount

take

without

dram

ounce

English

before meals

twice a day

hour

bed time

daily or once daily

every night

after meals

whenever necessary (dosemay be repeated)

every hour (3, 4, etc.)

fou r ti mes a day

if necessa ry

immediately

three times a day

a.c .b.i.d .

o.d .

D.n.

p.c .

q.i.d .

q.2.h .

q.3.h .

qA.h .

t.i.d .

one-half hour before a meal

10 A.M. and 4 P.M.

10 A.M.

8 P.M.one hour after a meal

8 A.M. ,12 noon, 4 P.M., 8 P.M.

6 A.M. and on even hours day and night

6- 9. 12- 3, etc., day and night

8. 12- 4- 8, etc., day and night

usually keyed to meals or specifically designated

25

~

Prefilled TUBEX@Preparation steps for injection with St .1 C t.d N dl U .ten e ar n ge- ee e n I

1. Read the medication order.

2. Select the TUBEXunit required.

3. Write patient's name and room number on envelope and enclose TUBEXcartridge.

4. Place TUBEX Sterile Cartridge-Needle Unit, TUBEX@Hypodermic Syringe and TUBEX@Isopropyl

Alcohol Sponge on tray to take to patient.

TO LOAD THE TUBEX HYPODERMIC SYRINGE

5. Grasp barrel of syringe in one hand. With theother hand, pull back firmly on plunger andswing the entire handle-section downward so thatit locks at right angle to the barrel.

6. Insert TUBEX Sterile Cartridge-Needle Unit,needle end first, into the barrel. Engage needleferrule by rotating it clockwise in the threads atfront end of syringe.

7. Swing plunger back into place and attach endto the threaded shaft of the piston. Hold the metalsyringe barrel-not the glass cartridge-with onehand and rotate plunger until both ends of TUBEXSterile Cartridge-Needle Unit are fully, but lightly,engaged. To maintain sterility, leave the rubbersheath in place until just before use.

TO ADAPT 2.CC. SYRINGE TO I.CC. TUBEX

The 2-cc. syringe can be used for a l-cc. TUBEX.Engage both ends of TUBEX and push the slidethrough so the number "1" appears. After use,the syringe automatically resets itself for 2-cc.

TUBEX.

26

P t. t f .. t. 'th/ Reusablerepara Ion s eps or InJee Ion WI S'.ynnge

I. Read the medication order.

2. Obtain multiple-dose vial of medication.

3. Using forceps remove the syringe barrel and plunger from the sterile boats.

4. Insert plunger into the syringe barrel.

5. Using forceps remove needle from the sterile tray and attach securely to the syringe.

6. Using alcohol-saturated swab, clean the seal of the multiple-dose vial of medication.

7. Pull syringe plunger out to the graduation which corresponds to the amount ofmedication ordered.

8. Penetrate the vial seal with needle and invert syringe and vial so that the vial is on top,taking care that the needle tip is still in the medication.

9. Depress the plunger on syringe all the way in order to expel the air into the vial.

10. Pull out on syringe plunger until the desired amount of medication has been withdrawn.

II. Withdraw the needle from the vial.

12. Return multiple-dose vial to cabinet.

13. Write patient's name and room number on card.

14. Place card, reusable syringe, and alcohol swab on a sterile tray to take to the patient's room.

IS. Cover tray to maintain sterility.

NOTE:

When empty TUBEX@ Sterile Cartridge-Needle Units are used with multiple-dose vials, thesteps of preparation are similar to those for reusable syringes. Assembly is not as time con-suming or complicated, since the TUBEX cartridge is merely secured into the TUBEX syringeand the rubber sheath removed. Sterility is maintained after the cartridge-needle unit has beenfilled by replacing the rubber needle-sheath until about to give the injection.

27

Giving the intramuscular injection

Giving medication by means of the TUBEX@Closed

Injection System or a reusable syringe is basically

the same. These illustrations show the technic

of injection with the draped ventrogluteal site

used as an example.

1. Using an alcohol sponge or swab, cleanse anarea approximately two inches square around theproposed injection site.

2. With the index and thumb of the left handspread or tense the skin in the injection area.

28

3. Holding the barrel of the syringe in the righthand in a dart or pencil grip, introduce the needleinto the skin with a quick thrust.

4. Once the surface of the skin has been punc-tured by the needle, the remainder of the pene-tration of the needle through the skin and intothe muscle should be with a firm and steady pres-sureo I n the case of average or heavy patients itis preferable to retain the pressure on the skinaround the injection site with the thumb andindex fingers of the left hand for the entire timethe needle is being inserted. In thin patients, onthe other hand, it is often preferable to releasethe pressure of the left hand once the puncturehas been made, and change to a slight pinchinggrip in order to firm the injection site and avoidthe possibility of going too deep and striking abone, nerve or blood vessel.

5. Once the desired depth of insertion has been

reached, steady the syringe tip with the left hand

and with the right hand pull back or out on the

plunger approximately one-quarter inch for a few

seconds, to see if any blood can be aspirated

back into the syringe. Should blood appear in the

syringe, the needle should be withdrawn and a

new injection site selected.

6. If no blood appears, the position of the fingers

on the right hand can be shifted so that the

thumb covers the head of the plunger and the

index and middle fingers are hooked under the

side grips on the syringe barrel. With a firm pres-

sure on the thumb move the plunger downward

into the syringe as far as it will go. (The small air

bubble that is last to disappear is an important

part of the injection, since it helps to spread the

medication, clear the medicine from the needle,

seal the injection site and prevent tracking of the

medication as the needle is withdrawn.)

7. After the medication has been injected, apply

pressure against the injection site with the

alcohol sponge in the left hand as the needle is

withdrawn by the right hand; this reduces the

risk of medication leaking into the subcutaneous

tissues and possibly forming abscesses.

8. Then proceed to cleanse the injection site,

by massaging the area with the sponge to remove

any blood or medication that might be present.

If rapid absorption is desired, the massaging

should be continued for about two minutes.

9. After the injection has been given, it is im-

portant that all the information be recorded on

the patient's chart. This should include: the hour

of injection, name of the medication, amount and

strength, method of administration, specific site

including which side of the body, any unusual

reaction and your signature. No injection is com-

plete until this has been done.

29

30

After the injection with/ TUBEX

1. Return used TUBExand tray to nursing station.

TO REMOVE EMPTY TUBEX@

2. Replace sheath, using a twisting motion toavoid snagging. To disengage plunger from pistonhold the glass cartridge and rotate the plungercounterclockwise. When plunger is disengaged,pull back firmly on plunger and swing the entirehandle section downward. Do not pull plunger backbefore disengaging or syringe will jam. RotateTUBEx Cartridge-Needle Unit counterclockwise todisengage at front end of syringe and remove from

synnge.

3. Before discarding, the sheath-covered needleshould be bent to seal the lumen in order to dis-courage pilferage or reuse. The syringe, never

having come in contact with patient or medication,is returned to storage.

NOTE: Used TUBEx Cartridge-Needle Units shouldnot be employed for successive injections or asmultiple-dose containers. They are intended to beused only once and discarded.

After the injection witya Reusable Syringe

I. Return used syringe and tray to nursing station.

2. Fill, eject and rinse syringe with tap water.

3. Disassemble needle from syringe.

4. Fill syringe with detergent or blood solvent and let stand for at least 30 minutes.

5. Place needle in sterilizer for 30 minutes at 250 degrees Fahrenheit to decontaminate andrender safe for handling.

6. Brush syringe barrel interior, plunger and tip with low-sudsing, nonetching detergent.

7. Rinse syringe parts twice in tap water and once in a tray of distilled water.

8. Clean inside of needle hub with a water-saturated cotton swab containing blood solvent or detergent.J

9. Pass a stylet through the interior of the needle to remove any skin tissue, rubber vialstopper cores, blood or foreign matter.

10. Check needle for sharpness and, if needed, resharpen properly and repeat cleaning process.

II. Rinse entire needle with tap water, including ejecting through the needle with a syringe.

12. Repeat the flushing of the needle with a syringe filled with distilled water.

13. Place syringe and needle in individual paper wrappers and then into a tray ready for sterilizing.

14. Put tray into steam sterilizer, close sterilizer door and set the temperature at 250 degreesFahrenheit for 30 minutes.

15. At the end of 30 minutes open the sterilizer door slightly and allow the needle and syringeto cool and dry for 15 minutes before removing.

16. Store sterile injection equipment in sterile tray or "boats" until required for use.

31

32

BIBLIOGRAPHY

1. American Academy of Pediatrics: Report of the Committee on theControl of Infectious Diseases 1966 (Red Book), Ed. 15,Evanston, Ill., p. 4.

2. Broadbent, T. R.; Odom, G. L., and Woodhall, B.: Peripheralnerve injuries from administration of penicillin; report of fourclinical cases, 1. Am. Med. Assoc. 140:1008 (July 23) 1949.

3. Brown, L. B., and Nelson, A. R.: Postinfectious intravascularthrombosis with gangrene, Arch. Surg. 94:652 (May) 1967.

4. Butters, A. G.: Intramuscular injections (Correspondence), Brit.Med. J. 2:1362 (Nov. 18) 1961.

5. Cates, H. A.: Primary Anatomy (Basmajian, J. V., [ed.]), Ed. 4,Baltimore, Williams and Wilkins Co., 1960.

6. Combes, M. A.; Clark, W. K.; Gregory, C. F., and James, lA.:Sciatic nerve injury in infants; recognition and prevention ofimpairment resulting from intragluteal injections, J. Am. Med.Assoc. 173:1336 (July 23) 1960.

7. Curtiss, P. H., Jr., and Tucker, H. l: Sciatic palsy in prematureinfants; a report and follow-up study of ten cases, J. Am. Med.Assoc. 174:1586 (Nov. 19) 1960.

8. Gellis, S. S. (ed.): Year Book of Pediatrics, 1965-66, Chicago,Year Book Medical Publishers, pp. 374, 375; 433-435.

9. Gilles, F. H., and French, J. H.: Postinjection sciatic nerve pal-sies in infants and children, J. Pediat. 58:195 (Feb.) 1961.

10. Gray, H.: Anatomy of the Human Body (Goss, C.M. [ed.]), Ed.27, Philadelphia, Lea and Febiger, 1959.

11. Hanson, D. l: Intramuscular injection injuries and complica-tions, GP 27:109 (Jan.) 1963.

12. Hanson, D. 1.: Acute and chronic lesions from intramuscularinjections, Hosp. Formulary Management 1:31 (Sept.) 1966.

13. Hill, L. F.: Sites for intramuscular injections (Editor's Column),1. Pediat. 70:158 (Jan.) 1967.

14. Hill, L. F.: Complication resulting from an intramuscular injec-tion (Letters to the Editor [reply]), 1. Pediat. 70:1012 (June)

1967.

15. Hughes, W.: Pediatric Procedures, Philadelphia, W. B. SaundersCo., 1964, pp. 87-98.

16. Hughes, W. T.: Complication resulting from an intramuscularinjection (Letters to the Editor), J. Pediat. 70:1011 (June) 1967.

17. Intramuscular injections (Editorial), Brit. Med. J. 2:758 (Sept.16) 1961.

18. Knowles, J. A.: Accidental intra.arterial injection of penicillin,Am. J. Diseases Children 111 :552 (May) 1966.

19. Kolb, L. C., and Gray, S. J.: Peripheral neuritis as complicationof penicillin therapy, J. Am. Med. Assoc. 132:323 (Oct. 12)1946.

20. Lachman, E.: Applied anatomy of intragluteal injections, Am.Surgeon 29:236 (March) 1963.

21. Lloyd.Roberts, G. C., and Thomas, T. G.: The etiology ofquadriceps contracture in children, J. Bone and Joint Surg.46B:498 (Aug.) 1964.

22. Matson, D.: Early neurolysis in treatment of injury of peripheralnerves due to faulty injection of antibiotics, New Eng!. J. Med.242:973 (June 22) 1950.

23. Morris, H.: Human Anatomy (Schaeffer, J.P. [ed.]) , Ed. 11, NewYork, Blakiston Div. McGraw-Hill, 1953.

24. Scheinberg, L., and Allensworth, M.: Sciatic neuropathy ininfants related to antibiotic injections, Pediatrics 19:261(Feb.) 1957.

25. Shaw, E. B.: Transverse myelitis from injection of penicillin,Am. J. Diseases Children, 111 :548 (May) 1966.

26. Spinal cord damage from injection of penicillin (Editorials), J.Am. Med. Assoc. 196:730 (May 23) 1966.

27. Talbert, J. L.; Haslam, R. H. A., and Haller, J. A., Jr.: Gangreneof the foot following intramuscular injection in the lateralthigh: a case report with recommendations for prevention, J.Pediat. 70:110 (Jan.) 1967.

28. Turner, G. G.: The site for intramuscular injection, Brit. Med.J. 2:56 (July 8) 1944.

29. Wolf, 1. J.: A two-stage "controlled" intramuscular injectiontechnic, Clin. Pediat. 7:230 (April) 1968.

30. Zelman, S.: Notes on techniques of intramuscular injection; theavoidance of needless pain and morbidity, Am. J. Med. Sci.241 :563 (May) 1961.

33

Closed Injection System, Wyeth

TUBEX., Sterile Cartridge-Needle Unit, Wyeth

NON-REACTING GLASS CARTRIDGE

CONTAMINATION-PREVENTING

NEEDLE SHEATH

SUPER-SHARP, SILICONIZED,

STAINLESS STEEL NEEDLE

TUBEX., Hypoderrnlc Syringe, Wyeth

STURDY, STAINLESS, UNBREAKABLE SYRINGE

Disposable Alcohol Sponge, Wyeth

PRINTED IN U.S.A.~COOE5923R5

Wyeth Laboratories • Philadelphia, Pa. 19101

CTO~MAY,j1969

This pamphlet on the intramuscular injection of medicines was what was called a “detail” pamphlet. Its main purpose in life was to promote the use and sale of a particular product. These had useful information in them, In fact I cannot remember if I was given these for a particular class while in school, while on rotation in a hospital so I wouldn’t be a complete klutz, while on internship, or because I was lowest in seniority and was therefore delegated to deal with the sales people. The information in this pamphlet, once one ignores the product specific verbiage, is useful and worth having. One never knows when one might just have to give an injection in an emergency situation, refer to earlier comment about not looking like a complete klutz. Also, with the advent of just about any partially trained person giving injections for allergies, Flu vaccinations and the like, maybe it would just be a good idea to know if it is being done right. These particular documents are not seen much anymore, they were well made, high quality, and durable, pretty much pricing them out of existence, particularly since they were handed out free. The cynical might say also because they were useful.

咸