Question to the RN's about IM deltoid injections

[badasshairday]

Q to the RN's, LVN's, MA's, or anyone who regularly gives shots.

Had to give a deltoid IM injection of depo-provera today. The nurses don't give injections of depo because it is a catholic hospital and their contract states they cannot. Patient was thin, and I gave her 1.5cc IM deltoid shot. I've done numerous of these so far without any issues.

However this time, I did note significant resistance when depressing the plunger. After drawing up the medication, I removed excess air and squirted a little out. I accidently closed the needle cover, and had to replace it with a new needle. I did not squirt excess medication out of the new needle. After injecting and aspirating, I depressed hard on the plunger which had more resistance than usual. The pt winced with pain, and said it was a sharp pain, which has never happened before. The pain decreased after removing the needle. No complaints of parasthesias or weakness immediately after so I didn't think anything of it. But the resistance was weird, and I feel like I should not have forced it in since it caused her pain.

What caused this resistance? Could I have hit the bone? Or could it have been the very small amount of air in the new needle tip? I know the small amount of air isn't an issue because it is IM. I think 1.5cc IM to the deltoid is too much now that I think about it, especially since she was on the thinner side. Gluteal would probably been a better route. Thanks.

PS: I guess I am just a little paranoid that I may have caused her harm in hindsight.

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[chimichanga]

...Had to give a deltoid IM injection of depo-provera today. The nurses don't give injections of depo because it is a catholic hospital and their contract states they cannot.

I only give 1 cc or less in the deltoid...that's just me, but it is how we teach it at our program...

I recall the last office where I was a nursing sup, it was policy for all Depo shots to be given in the glut...Too many 'problems' in the deltoid...Can't remember specifics...Thought the manufacturer recommended glut also, but I could be wrong...

On a side note, I have never signed a 'contract' of any sorts, and I used to work for CHW...

Pts used to come in for the morning after pill to our ER, and some ER docs claimed they too had signed a 'contract' prohibiting the writing of the morning after pill script...I never believed them, but they all were a united front...So what happened: EMTALA violation for turning ER pts away...

personal views do not belong in health care...I question this contract on these nurses' parts, and cry foul...

sorry for the derail...

 

[badasshairday]

I think they have to sign it to be able to work there.

Anyways, what do you think of the resistance thing? Maybe I gave it too fast, or the 1.5cc was too much for her deltoid causing a tear/knot in between muscle strands? I dunno, but I definitely will note to give this pt the shot in the glut from now on.

I only give 1 cc or less in the deltoid...that's just me, but it is how we teach it at our program...

I recall the last office where I was a nursing sup, it was policy for all Depo shots to be given in the glut...Too many 'problems' in the deltoid...Can't remember specifics...Thought the manufacturer recommended glut also, but I could be wrong...

On a side note, I have never signed a 'contract' of any sorts, and I used to work for CHW...

Pts used to come in for the morning after pill to our ER, and some ER docs claimed they too had signed a 'contract' prohibiting the writing of the morning after pill script...I never believed them, but they all were a united front...So what happened: EMTALA violation for turning ER pts away...

personal views do not belong in health care...I question this contract on these nurses' parts, and cry foul...

sorry for the derail...

 

[chimichanga]

I have always given my IMs faster that we teach...never had a problem...Can't remember, is Depo viscous?

IMHO, the 1.5 was on the fence for 'too much' Definitely depends on the muscle size...You said she was thin...Probably was it...You would know if you hit the bone...You'll only do it once...Was it an inch needle?

 

[badasshairday]

I have always given my IMs faster that we teach...never had a problem...Can't remember, is Depo viscous?

IMHO, the 1.5 was on the fence for 'too much' Definitely depends on the muscle size...You said she was thin...Probably was it...You would know if you hit the bone...You'll only do it once...Was it an inch needle?

Depo ends up precipitating, so you have to shake well before drawing it up.

Yep, 1in-1.5in, I think 22gauge. She was thin, but not super thin. I'm worried I damaged her muscle by forcing it in causing a small muscle tear or strain. Contacted the resident, and will give the patient a call tomorrow. Argh, malpractice as a third year med student. Should I be worried? Prognosis?

 

[chimichanga]

Me thinks you have nothing to worry about...I only use 1 inch or smaller in the deltoid, though it's personal preference vs muscle mass...reread your first post...likely was the air in the new needle...shouldn't be an issue,as air will displace quickly...No worries...Some patients are way more sensitive than others...

 

[badasshairday]

Thanks. 🙂

 

[Dwindlin]

Relax. Like chim said you have little to worry about. My biggest fear when doing IMs was putting into a vessel, but you aspirated so that shouldn't be an issue. Also, as chim has already said, 1.5mL may be a bit much for a delt, I (again like chim) won't go over 1mL. If I need to give more I go to the glut.

 

[chimichanga]

...My biggest fear when doing IMs was putting into a vessel.

Interesting point...We teach to aspirate, but could you, from a physician standpoint, please explain why it's that big of a deal...

Certainly I get that if you do, it's like giving it IV...So then what's all the fuss about...

Vistaril, Haldol, Depo,and certain vaccines would be the only concerns (off the top of my head), as their respective manufacturers recommend not giving these IV...So I always aspirate when giving those...But the rest of the meds that we give IM are also given IV, at (usually) the same dose...

Anyone?

I haven't aspirated for years, and have had zero problems...
I think many things we teach nurses are outdated...
For example, our current curriculum also teach to push slowly (10 seconds per ml) for IMs...I've always thought that was BS, and refuse to personally teach it...

 

[Dwindlin]

Interesting point...We teach to aspirate, but could you, from a physician standpoint, please explain why it's that big of a deal...

Certainly I get that if you do, it's like giving it IV...So then what's all the fuss about...

Vistaril, Haldol, Depo,and certain vaccines would be the only concerns (off the top of my head), as their respective manufacturers recommend not giving these IV...So I always aspirate when giving those...But the rest of the meds that we give IM are also given IV, at (usually) the same dose...

Anyone?

I haven't aspirated for years, and have had zero problems...
I think many things we teach nurses are outdated...
For example, our current curriculum also teach to push slowly (10 seconds per ml) for IMs...I've always thought that was BS, and refuse to personally teach it...

This is the issue. Most of the time I think you are right and it isn't a big deal. However there are some drugs (epi is the quickest that comes to mind) that either are a different dose or concentration when given IM. I really wouldn't want to accidentally give a 1:1000 dose of Epi into a vessel.

I think really what it comes down to is making it a habit so you don't forget on the few times where it actually may matter.

 

[The right Path]

Hitting the bone isn't that big a deal. If you think you have, just pull back a little.

Changing the needle after drawing up the medication isn't a bad thing either. The amount of air in it is negligible, and the new needle hasn't been dulled by the rubber stopper of the vial so it is potentially less painful. Furthermore, the fresh needle isn't coated with the medication drawn up so in theory, if you Z-track it, the medication isn't as likely to irritate the subcutaneous tissues.

Sometimes syringe plungers kind of "stick" and feel like they need more force.

For patient comfort, insert the needle quickly and smoothly, but inject slowly and steadily.

And lastly, shots generally kinda hurt. Some patients bitch about it more than others. Don't worry about it.

 

[chimichanga]

...I really wouldn't want to accidentally give a 1:1000 dose of Epi into a vessel...

agreed, but epi 1:1000 should be subcutaneous only, for anaphylaxis...you shouldn't be close to a vessel if given properly and with a 5/8" needle...i may be missing something, but i can't for the life of me come up with why we would give IM epi...without IV access, (old school ACLS reference upcoming) we can give it down the ET tube...

 

[clubcantholdme]

Ya gotta be kidding, after all the smack you talk about nurses you want an answer???!!!

 

[badasshairday]

Ya gotta be kidding, after all the smack you talk about nurses you want an answer???!!!

hmmm? Just because I think the DNP is silly?

I have nothing but respect for RN's, and have learned a great deal from them during my rotations as a 3rd year medical student.

Again, thanks for the responses. 👍

 

[medic25]

agreed, but epi 1:1000 should be subcutaneous only, for anaphylaxis...you shouldn't be close to a vessel if given properly and with a 5/8" needle...i may be missing something, but i can't for the life of me come up with why we would give IM epi...without IV access, (old school ACLS reference upcoming) we can give it down the ET tube...

We actually switched our EMS system over to IM epi from SC due to better systemic absorption. Take a look at the study below:

http://www.ncbi.nlm.nih.gov/pubmed/11692118

 

[chimichanga]

We actually switched our EMS system over to IM epi from SC due to better systemic absorption. Take a look at the study below:

http://www.ncbi.nlm.nih.gov/pubmed/11692118

nice...thanks for the link...gotta love progression!

still 0.01/kilo?

 

[medic25]

That's correct, still 0.01 mg/kg

 

[NYRN]

hmmm? Just because I think the DNP is silly?

I have nothing but respect for RN's, and have learned a great deal from them during my rotations as a 3rd year medical student.

Again, thanks for the responses. 👍

👍 The right thing is for us to learn from each other and help each other out. I always offer procedures to med students, if they want to learn it great, if not, its OK.

I think you may have hit bone, or if the solution is thick a 22g may have been too small. Some thick meds I can think of off the top of my head: lorazapam, valium, penicillin. I would use 18g needles for that one. Injections that burn: tetanus, ceftriaxone.

I don't like the glut route, but I will give larger volume injections in the thigh, up to 2 mL, and I only use the thigh for small children.

Don't be afraid to ask the nurses, I promise most of us love to teach. I have yet to (personally) have a bad experience with a med student 🙂

 

[fab4fan]

It's possible you hit a spot that had been previously injected a couple of times; that can give you resistance. It happened to me already with a patient who came in for monthly injections that needed to be in the deltoid.

 

[primadonna22274]

Agree with the experienced nurses here. I too don't give too many IM injections anymore but there are a few reasons why Depo-provera is best given in a larger muscle (glute, thigh): larger volume is a practical consideration. Also the pharmacokinetics must be considered--if the serum (not too viscous as I recall) ends up SC rather than IM the efficacy could theoretically be altered. I've always thought it was a stretch but you don't want the pregnant Depo patient blaming you for giving the injection in the wrong place...OK, don't panic, she'll be fine. 😉
As for the resistance you felt, not sure what to say about that--I've experienced that on occasion as well.
Add to the list of really miserable IM injections: Solu-Medrol. I try to give it IV whenever practical or PO dexamethasone. More of a consideration now that we have an injectable Decadron shortage....
Lisa ED PA-C

 

[NYRN]

agreed, but epi 1:1000 should be subcutaneous only, for anaphylaxis...you shouldn't be close to a vessel if given properly and with a 5/8" needle...i may be missing something, but i can't for the life of me come up with why we would give IM epi...without IV access, (old school ACLS reference upcoming) we can give it down the ET tube...

We used to give it SQ as well but there have been changes (not sure of the source) and we as well as EMS are giving it IM in both children and adults. I believe it's because of faster onset.

 

[Dwindlin]

We used to give it SQ as well but there have been changes (not sure of the source) and we as well as EMS are giving it IM in both children and adults. I believe it's because of faster onset.

In this region I still give it SQ for severe asthmatics, but anaphylaxis goes IM.