Contraindications to injection

Allergy to medicine

Lack of suitable injection site

Coagulopathy

Shock

Impairment of peripheral absorption

When pain after SubQ injection occurs

Same day

When pain after IM injection occurs

Day after

IM & SubQ syringe size

2 - 3 mL

Insulin syringes

Capacity of 1 mL & calibrated in units

TB syringes

Capacity of 1mL & calibrated in 0.01mL units

Allows for admin of very small amounts of potent drugs

SubQ injection needles

25G, 5/8 inch long

IM injection needle

20 - 25G, 1&1/2 inches long

(23G is a good choice)

Intradermal needle size

26 - 27G,  1/2 - 5/8 inch long

Determines length of needle

Size & weight of patient

Whether inj is subQ or IM

Determines gauge of needle

Viscosity of fluid being injected

Injection location for intradermal injections

Ventral forearm most commonly use

Can also use outer area of upper forearm or between scapulae on back for repetitive injections (like allergy skin tests)

Meds given intradermally

TB

Allergy Skin Tests

Botox®

Restylane®

Other dermal fillers

Meds given SubQ

Insulin

Heparin

MMR

Varivax

SubQ injection location

Into adipose tissue beneath skin

Outer aspects of the upper arm, anterior thigh, loose skin of lower abdomen, upper buttocks, & upper back

Meds inj IM

Immunizations

Trigger Point

Antibiotics

How to give Deltoid Muscle IM inj

Place four fingers across the deltoid muscle, with the top finger along the acromion process.

The injection site is two to three fingerbreadths below the acromion process.

How to give Dorsogluteal (Gluteus Medius) IM inj

Draw a line from the posterior superior iliac spine & greater trochanter of femur

Inject above and lateral to this line, avoiding the sciatic nerve

How to give Ventrogluteal

(gluteus medius & minimus) IM inj

Place heel of hand over greater trochanter.  Point thumb toward groin and fingers toward head.

Place index finger over ASIS & extend the middle finger along the iliac crest, forming a “V”

Inject in the center of the “V”

How to give Vastus Lateralis IM injection

• Most commonly used in pediatrics

• Anterolateral aspect of thigh 
• Extends from a handbreadth above the knee to a handbreadth below the greater trochanter of the femur
• Middle third of muscle is best for injection

Angle for administering Intradermal injection

15°

Angle for administering SubQ injection

45°

Angle to administer IM injection

90°

For pt comfort, do between 45 - 90°

Injection types to aspirate before injection

SubQ

IM

Injection types to Rub medication

SubQ

IM

Distinction of Z track injections

• Use with that irritate or discolor subQ (i.e., iron preps)
• Include 0.2 - 0.5 mL of air into the syringe
• Displace skin laterally by pulling it ~1/2 inch away from injection site
• Insert needle at 90°, pull back (ensure no blood aspirated)
• Have patient move around to facilitate absorption
• For >5mL med, divide solution into at least 2 sites

Complications of Z track injections

• Trauma to local muscle cells leads to elevated serum levels of enzymes (CPK) which can give false picture of MI
• Monitor response ~30 min for signs of anaphylaxis
• Instruct patient to report new onset of fever, joint pain, SOB, or rash
• Instruct patient to report tenderness, erythema, ecchymosis at inj site

Meds to admin for adult reaction to injection

0.3 - 0.5 cc epi 1:1000

25-5 Benadryl (used for in-office rxn)

Meds to admin for peds inj rxn

Given by weight

Epi subQ or IM

Benadryl po has slow impact

Emergency IM/IV

Managing adverse reactions to meds

May repeat in 15-30 min x 3 min

Steroids/bronchodilators

O₂, IV fluids

Resuscitative measures

Do not overlook GI manifestations of anaphylaxis (abdominal pain, nausea, vomiting, diarrhea)

Special considerations for injections with peds patients

• SubQ injections in anterolateral thigh of infants (largest muscle mass in infants) or deltoid area of older children
• IM sites preferred are anterolateral aspect of upper thigh, deltoid muscle in upper arm
• With vaccinations, can use deltoid & thigh when multiple injections administered, also consider both thighs

CAUTIONS with pediatric injections

NEVER use gluteal muscles as an injection site for children < 3 years old or those who have been walking less than 1 year

NEVER use buttock in children because of risk of sciatic nerve injury

Why arm veins are utilized for IV access

Most comfortable for patients

Easiest to secure for long-term therapy

Most accessible, especially:

Dorsal aspect of hand

Lower aspects of arm

Metacarpal & cephalic veins most frequently used

Base choice of IV site/vein on:

Prescribed therapy (bloods, meds)

Duration of action

Condition of the extremity & patient overall

Condition, size, location of veins

Indications & goals of IV catheter insertion

Administration of:

Fluids to correct volume depletion, burn injury, blood loss

Blood or blood products

Rapid & efficient delivery of meds:

Medical & surgical states

Emergency situations

Contraindications for IV access

• Avoid skin infection
• Do not insert distal to an area of preexisting thrombophlebitis
• Avoid lower extremity venipuncture in elderly patients or patients with PVD or vascular insufficiency

Local complications of IV Access

Thrombosis or throbophlebitis:

Avoid trauma at time of insertion

Tape cannula securely to prevent movement

Avoid inserting lines in close proximity to joints

Local infection

Tissue damage secondary to fluid infiltration

Systemic complications of IV access

• Catheter embolization - rare; shearing off distal portion of the catheter end by beveled needle tip
• Septicemia
• Pulmonary embolus - small blood clot may form near the IV site, dislodge, & travel through circulation until lodges in small capillary bed of lungs; avoid LE veins
• Air embolism - air remaining within IV tubing travels into the bloodstream; avoid by using careful attention to flushing all air lines before connection

Over the needle catheter (angiocath)

Most commonly used

Sizes range from 14G - 24G (even #)

Inserted at 15 - 30° angle

Butterfly needle catheter

Small vein

Sizes range from 19G to 25G (odd #s)

Leave needle in patient (consider comfort)

May be easier for blood draws

Twincath

Double catheter set up with one cath inside another, allowing two lines with one stick

Especially useful for patient that will be on thrombolytics

Most common complication of any IV therapy

Phlebitis

Vein appears indurated, tender, erythematous,

hardened, and warm to the touch

Remove IV line immediately

Oral analgesics, warm/moist soaks to the

area can relieve any discomfort

AEs of IV catheterization

Burning

Stinging

Redness

Bleeding

Swelling

Phlebotomy is part of a treatment plan for

Polycythemia vera

Primary purpose of phlebotomy

To obtain a sample of blood for diagnostic testing

Ways to obtain a blood sample

Vacutainers

Syringes

Infusion sets

Types of phlebotomy access

Capillary

Venipuncture

Intraosseous (emergent use only)

Capillary Blood Draw Sites

2nd to 4th fingers (palmar aspect,

laterally) - Adults

Earlobes (few capillaries, differences

in cell concentration) - Adults

Great toe or heel (avoid lateral aspect - plantar artery)

- Infants (<1 year old)

- Usually don't use on an adult, but use if you can't get anywhere else

Uses for capillary blood draws

Blood gas (PH & PaCO₂ are accurate; PaO₂ differs from arterial blood reading)

CBC

Blood glucose

Hematocrit

Specialized test example: PKU

Blood typing

Large vacutainer tubes

10 - 15 mL

Small vacutainer tubes

6 mL

Plasma

Whole blood - blood cells & platelets

Serum

Plasma - (fibrinogen + clotting factors)

Preferred Upper Extremity Venipuncture Sites

Median Cubital vein

Cephalic vein

Basilic vein

Lower extremity preferred venipuncture sites

Femoral vein

Central venous preferred venipuncture sites

Internal/external jugular veins

Subclavian vein

Femoral vein

For venipuncture avoid unless absolutely necessary

Proximal to IV or hep lock

AV fistulas/shunts

Edema

Skin infections/rashes

Surgical procedures

s/p mastectomy (ipsilateral side)

Underlying trauma or burns

Benefits of different venipuncture sites:

Antecubital fossa

Dorsum of hand

Femoral vein

Internal Jugular/ Subclavian

External Jugular

Antecubital fossa good for blood collections

Dorsum of hand good for IV infusions

Femoral vein last resort for blood collections

Contraindicated in children

Internal Jugular/ Good for long term infusions, may Subclavian be used for collections with central line cath

External jugular Short term emergency use only

Types of Blood Culture Tubes/Bottles

Yellow isolator tubes

Blue cap aerobic

Purple cap anaerobic

Removal of needle, tourniquet, & venipuncture tube

1st: Release tourniquet

2nd: Venipuncture tube from needle

3rd: Remove needle

Obtaining blood with vacutainer system

Anchor tube holder & then push into tube to begin collection

Obtaining blood with syringe/needle combo

Gently pull back on plunger and allow blood to fill barrel of syringe, excessive pressure leads to hemolysis

Obtaining blood using butterfly

Advance tube or pull plunger on syringe when

blood is noted in the tubing

Femoral anatomy to remember in sticks:

Locate artery first by pulse

Then vein is medial to artery

Stand on same side as vein to be tapped

Use of >25G needles

Not indicated except in very small children due to hemolysis

Complications of venipuncture

Pyrogenic infection

Superficial thrombophlebitis

Air embolism

Nerve injury

Arterial puncture

Cellulitis

Phlebitis

Thrombosis

Vein laceration

Hemorrhage or hematoma

Vasovagal syncope

Maximum amount of time to leave a tourniquet on

2 minutes

Angle of insertion of venipuncture needle

15 - 30°

At the straightest section of the vein

Order of choice and characteristics of

best veins for venipuncture

Median cubital → Cephalic → Basilic

• Median cubital: usually largest vein in antecubital
• Cephalic: large, easily palpated, but poorly anchored; most lateral
• Basilic: easy to palpate, not well anchored, very close to brachial artery & median nerve; most medial

Use of syringes for venipuncture

When patients veins are small or fragile and Vacutainer tubes may cause the veins to collapse

Collecting blood for cultures

Use syringe with a 20-21G needle or butterfly

Use of butterfly infusion set for venipuncture

Hand & foot may be considered as sites

Angle of insertion is smaller than with other methods

Draw blood slowly & carefully

Follow up care for venipuncture

Advise patient may experience some minor discomfort & discoloration at site 38-72 hours

Keep site clean/dry to prevent infection

Educate about signs of infection & phlebitis

Advise to call or return to office if signs are evident

Conditions that may be diagnosed with use of arterial puncture in acute dysfunction in CO₂/O₂ exchange or acid-base balance

Asthma

Suspected pulmonary thromboembolism

Idiopathic coma

Suspected drug OD

Shock states

Cardiac arrhythmias refractory to medical intervention

Chronic conditions that affect CO₂/O₂ exchange or acid-base balance monitored by use of arterial puncture

COPD

Pts on long term O₂ when changes in status occur & periodically to document status

Indications for arterial puncture

• Assessment of level of dissolved gases for diagnostic or therapeutic purposes
• Dx of acute dysfxn in CO₂/O₂ exchange or acid-base balance
• Monitoring severity & progression of documented disease process in patients with a chronic condition that affects CO₂/O₂ exchange or acid-base balance
• After therapeutic hyperventilation therapy or CPR
• Ammonia levels, CO levels, or lactate levels
• Severe hypovolemia & venous sample can't be readily obtained

Contraindications for arterial puncture

• Absolutely contraindicated when arterial pulse is not palpable
• Neg modified Allen test for radial artery access
• No visible landmarks
• Patients with d/o such as coagulopathy, severe thrombocytopenia, anticoagulant therapy, end-stage renal dz with AV shunt
• Local skin infections
• Chronic skin rashes
• Skin previously burned or scarred

Complications of arterial puncture

Hemorrhage or hematoma (brachial/femoral > radial)

Thrombosis (radial > brachial)

Transient arterial spasm

Nerve damage

Infection

Radial artery for arterial puncture

• Most common site used
• Close to skin surface/readily accessible
• Lowest complication risk
• Palpate b/w styloid & flexor carpi radialis
• Pt of max pulse just proximal to transverse wrist crease
• Check collateral circ with Allen test
• Distal forearm & wrist slightly hyperextended & on firm surface

Brachial artery for arterial puncture

• Greater risk of complication
• Occlusive complications carry greater potential for tissue loss distal to artery
• Courses along median surface of antecubital fossa
• Access in antecubital fossa
• Arm fully extended & secured on firm surface, ulnar side up

Femoral artery for arterial puncture

• Angle of insertion: 90°
• Only use if radial or brachial artery access not possible or advisable
• NAVEL - inguinal crease (lateral to medial)
• Patient should be supine on a firm surface with hip extended & rotated externally

Needle size for arterial puncture

21-25G, 1/2 - 5/8 inch

Angle of insertion for arterial puncture

40-60° angle

60-90° for femoral puncture

Indications for MDI & Nebulizer use

Treat bronchospasm (kids & adults)

MDIs used to deliver steroids, mucolytics, and ergotamine tartate for migraines

Aerosolized racemic epinephrine for treatment of croup

Aerosolized pentamidine to treat Pneumocystis carinii pneumonia

Spacers are beneficial with MDIs for young kids & older adults, and help decrease incidence of candidiasis

Common side effects with MDI/nebulizer meds

Nervousness

Dizziness

Palpitations

Tachycardia

HTN

Diaphoresis

Tachypnea

Throat irritation

Common nebulized meds

B2 agonists Albuterol

Levalbuterol (Xopenex®)

Corticosteroids Budesonide (Pulmicort®)

Anticholinergics Ipratropium (Atrovent®)

Other: Cromolyn (Intal®)

Combination meds: Albuterol/Ipratropium (Duoneb®)

Peak Expiratory Flow Rate

Quickest expulsion of air forced out after a maximum inspiratory effort

Used when spirometry is not an option

Best obtained when patient awakens in the morning

Pulse oximetry

Allows for continuous measurement of O₂ saturation

Use of incentive spirometer

Smokers

Patients with lung disease

Before or after head, neck, chest, or abdominal surgery

(Prevents atelectasis in post-op)

People who are active or cannot move

DO NOT USE in asthmatic with exacerbation