vaccination that did not go well

[Lisochka]

I hate flu shots! But I need my job....So, I have been giving flu shots to people for over a year. I have never had a situation like I ad a couple of days ago. Young guy, is getting a flu shot. All of a sudden, the blood comes out in a projectile manner... It just squirts out right at me! I finished the shot and pressed on his arm with a cotton ball for about 30 seconds. when I looked at the cotton ball, that side of the cotton ball was fully covered in blood. But no blood leaking from his arm. so I put a bandaid and he went home. I tried calling him the next day to see how he was doing but he has not answered his phone.


Have you ever had anything like that?
How to prevent it? In old people I could see the veins and avoid them. But in young guys its hard because they have muscles and I cant see much...I did make sure I did it into is deltoid...

 

[sosoo]

what needle size did you use? was he skinny? i heard a similar story because wrong needle size was used.

 

[jawnly211]

that actually happened to me one time

this guy was yoked! nohomo.....easy to find his deltoid.....when i pulled the needle out, bloodsteam literally squirted out, projectile-style, and plopped onto the floor......it even made a "squirt" sound

i was running out of cotton balls.....dude was really releasing blood

eventually calmed that sucker down but had quite a mess to clean afterwards

quite an experience to say the least

 

[owlegrad]

Am I the only person who read this as "vacation that did not go well"?

 

[cellardoor6]

I've given at least 1000 shots by now, and I haven't had anything like this happen. I had a couple people who had what looked like a bruise or swollen vein directly after giving the shot which freaked me out or a bit of bleeding instantly dripping down the arm. Are you saying that the blood actually squirted on you or the floor??

 

[Eichhoernchen]

Am I the only person who read this as "vacation that did not go well"?

Haha,totally thought the same thing! I was confused when I read the first sentence.

I haven't had anything worse than a drop of blood happen while giving a shot and I've given quite a few this season. I would freak out though!!

 

[group_theory]

It looks like you hit a superficial artery. Hopefully you did not inject the content of the vaccine directly into the artery (interarterial injection). I doubt you hit the axillary or brachial artery unless you were way off on your landmark.

If you did hit a superficial artery, then just apply direct pressure for at least 5 minutes, preferably 10 minutes. If the patient is on plavix, therapeutic coumadin, lmwh, etc., then 15 to 30 minutes of direct pressure.

30 seconds is not enough for either vein or arterial puncture. Most likely that patient developed a hematoma over the injection site that is sore. A bandaid by itself is not sufficient, you need to apply direct compressive pressure (remember, arterial circulation is a high pressure system)

It is no big deal ... Just don't inject into the vessel, and apply direct pressure for at least 5-19 minutes. Do enough injections, or IVs, and everyone will eventually hit an artery. The key is recognizing it and knowing what to do.

*I surmise that it was arterial bases on your description.

 

[Lisochka]

It looks like you hit a superficial artery. Hopefully you did not inject the content of the vaccine directly into the artery (interarterial injection). I doubt you hit the axillary or brachial artery unless you were way off on your landmark.

If you did hit a superficial artery, then just apply direct pressure for at least 5 minutes, preferably 10 minutes. If the patient is on plavix, therapeutic coumadin, lmwh, etc., then 15 to 30 minutes of direct pressure.

30 seconds is not enough for either vein or arterial puncture. Most likely that patient developed a hematoma over the injection site that is sore. A bandaid by itself is not sufficient, you need to apply direct compressive pressure (remember, arterial circulation is a high pressure system)

It is no big deal ... Just don't inject into the vessel, and apply direct pressure for at least 5-19 minutes. Do enough injections, or IVs, and everyone will eventually hit an artery. The key is recognizing it and knowing what to do.

*I surmise that it was arterial bases on your description.

shoot! I did not apply the pressure for 5 minutes. What do I do now? I am so afraid!
What if the person had lots of bleeding, etc...
Do you think I should call him again?
God, I hate vacinations!

 

[Lisochka]

IJust don't inject into the vessel, and apply direct pressure for at least 5-19 minutes. .

How deep it lies? I stuck the whole needle in, like I usually do for an IM shot....
How do I know if I am injecting into an artery?
The needle was on a retractable syrenge, that we always use for the flu shots and vaccines..

 

[group_theory]

shoot! I did not apply the pressure for 5 minutes. What do I do now? I am so afraid!
What if the person had lots of bleeding, etc...
Do you think I should call him again?
God, I hate vacinations!

How deep it lies? I stuck the whole needle in, like I usually do for an IM shot....
How do I know if I am injecting into an artery?
The needle was on a retractable syrenge, that we always use for the flu shots and vaccines..

Most likely he developed a hematoma around the injection site, is feeling bruised and sore, and with time will slowly decrease in size ... And change in color as blood starts to break down. That is why you apply direct compressive pressure, to allow a clot to form mire quickly at the vessle puncture. For high pressure arterial system, the muscle and soft tissue are not enough by themselves to tamponade the arterial bleed until enough blood bleeds to increase the pressure and tamponade the bleed. That is why u hold direct pressure for 5 minutes after I do an ABG, and why you hold pressure over the femorial artery after a cath. The concern, although rare, is continued bleed into a close compartment, leading to compartment syndrome, but that is an extremely rare complication of arterial puncture. Persistent exsanguination is also rare unless the patient has an underlying coagulopathy, or in DIC.

If your patient was young, muscular, healthy without a bleeding disorder, then most likely he developed a hematoma, is sore for a few days, and otherwise gone on with his life.

I never insert the needle all the way to the hub ... If the needle breaks, then you have nothing to latch onto. And I always pull back on the plunger before injecting to make sure you are not in a vein or artery. If you get blood when toy pull back on the plunger, then pull out immediately and apply pressure. I do not know what length needle or gauge needle you use, but the smaller the needle, the less damage to muscle and vessel wall. Hitting an artery with a 25g needle is different than hitting it with a 18g or 16g needle.



*typing reply on my phone, so typo, mispelling, weird grammar can be blamed on my poor texting skills and autocorrect.

 

[Farmercyst]

Most likely he developed a hematoma around the injection site, is feeling bruised and sore, and with time will slowly decrease in size ... And change in color as blood starts to break down. That is why you apply direct compressive pressure, to allow a clot to form mire quickly at the vessle puncture. For high pressure arterial system, the muscle and soft tissue are not enough by themselves to tamponade the arterial bleed until enough blood bleeds to increase the pressure and tamponade the bleed. That is why u hold direct pressure for 5 minutes after I do an ABG, and why you hold pressure over the femorial artery after a cath. The concern, although rare, is continued bleed into a close compartment, leading to compartment syndrome, but that is an extremely rare complication of arterial puncture. Persistent exsanguination is also rare unless the patient has an underlying coagulopathy, or in DIC.

If your patient was young, muscular, healthy without a bleeding disorder, then most likely he developed a hematoma, is sore for a few days, and otherwise gone on with his life.

I never insert the needle all the way to the hub ... If the needle breaks, then you have nothing to latch onto. And I always pull back on the plunger before injecting to make sure you are not in a vein or artery. If you get blood when toy pull back on the plunger, then pull out immediately and apply pressure. I do not know what length needle or gauge needle you use, but the smaller the needle, the less damage to muscle and vessel wall. Hitting an artery with a 25g needle is different than hitting it with a 18g or 16g needle.



*typing reply on my phone, so typo, mispelling, weird grammar can be blamed on my poor texting skills and autocorrect.

Of the 4 places I've done immunizations for, I normally see BD Integra 3mL 25 G 1 inch needles. I haven't had a high pressure release. Only twice have I gotten more than a drop of blood big enough to need cotton. I have hit a nerve once, though.

 

[MountainPharmD]

I hate flu shots! But I need my job....So, I have been giving flu shots to people for over a year. I have never had a situation like I ad a couple of days ago. Young guy, is getting a flu shot. All of a sudden, the blood comes out in a projectile manner... It just squirts out right at me! I finished the shot and pressed on his arm with a cotton ball for about 30 seconds. when I looked at the cotton ball, that side of the cotton ball was fully covered in blood. But no blood leaking from his arm. so I put a bandaid and he went home. I tried calling him the next day to see how he was doing but he has not answered his phone.


Have you ever had anything like that?
How to prevent it? In old people I could see the veins and avoid them. But in young guys its hard because they have muscles and I cant see much...I did make sure I did it into is deltoid...

I have given thousands of flu shots and had all kinds of crazy things happen!

My first year giving shots I was breaking everything down at the end of a clinic when someone came up and wanted a shot. I had a couple predrawn syringes left and didn't want to waste them so I did it. I had already taken the bandaids and gauze pads back to the pharmacy. I did not have a problem all day but this girl blead like I shot the vaccine in her with a rifle. I was holding my hand under the injection site with my glove as the blood was pooling up and dripping on the floor. I was yelling at my tech to get the guaze and bandaids. All in all pretty terrible.

 

[UMBgrad12]

wow, I did a lot of shot but nothing more than a tiny drop of blood, if I see too much blood, I think patient have to call 911 for me.

 

[Eichhoernchen]

So... today I was giving a Zostavax injection to a 98 year old lady and I think I hit an capillary for a first time. She slowly started bleeding underneath the skin, I was REALLY worried because it kept spreading internally but my pharmacist just said the woman was fragile. And right after that, I had to give the poor lady a flu shot.

 

[pinipig523]

You hit a superficial artery - no way you hit the brachial artery since that is in the medial aspect of the arm.

Pressure pressure pressure for 1-5 minutes, longer if the guy is on coumadin/pradaxa/etc.

No harm done.

 

[WVUPharm2007]

I like it when you hit bone for the first time. Nails on chalkboard feeling.

 

[bw6]

I hate flu shots! But I need my job....So, I have been giving flu shots to people for over a year. I have never had a situation like I ad a couple of days ago. Young guy, is getting a flu shot. All of a sudden, the blood comes out in a projectile manner... It just squirts out right at me! I finished the shot and pressed on his arm with a cotton ball for about 30 seconds. when I looked at the cotton ball, that side of the cotton ball was fully covered in blood. But no blood leaking from his arm. so I put a bandaid and he went home. I tried calling him the next day to see how he was doing but he has not answered his phone.


Have you ever had anything like that?
How to prevent it? In old people I could see the veins and avoid them. But in young guys its hard because they have muscles and I cant see much...I did make sure I did it into is deltoid...

Hmmm.. I read this and seriously had to check my phone for missed calls because I swear to god I thought this was about me. A pharmacy student working retail gave me my flu shot and the same thing happened. She probably just hit a small artery and I was fine, though my arm is still a little sore - feels like a mild bruise.

I am still not entirely convinced this thread is not about me considering this happened 3 days ago.

 

[npage148]

The worst about hitting a bone is that they never/can't feel it. You just hope they don't notice the look of terror on your face as you bounce the needle off the bone. My first practice injection in school I drilled the bone on my friend, good way to start out your vaccination career.

Luckily, I've never had any issues with blood, syncope, etc when vaccinating people. I'd like to keep it that way

 

[MindOverMatter]

I've hit a few vessels before that bled out after the shot. Sometimes you just get unlucky. Fortunately no major issues yet.

Does anyone else have a more difficult time giving the Zostavax injections? It just seems like a more painful spot, and for some reason I tend to give it a little slower. It also seems a little harder to puncture the skin on some of these older patients. Maybe it's just me, or the leathery skinned people living here in south FL.

 

[All4MyDaughter]

I've hit a few vessels before that bled out after the shot. Sometimes you just get unlucky. Fortunately no major issues yet.

Does anyone else have a more difficult time giving the Zostavax injections? It just seems like a more painful spot, and for some reason I tend to give it a little slower. It also seems a little harder to puncture the skin on some of these older patients. Maybe it's just me, or the leathery skinned people living here in south FL.

I had my first major bleeder yesterday after a flu shot. It didn't spurt, but it ran down her arm. She didn't seem troubled at all. But I worried that she bled all of the vaccine out.

I also gave her a Zostavax (my first ever) without incident!

 

[rxlea]

I hope I can minimize the amount of vaccines I give wherever I go.

 

[All4MyDaughter]

I hope I can minimize the amount of vaccines I give wherever I go.

I hope you have to give 100/day!

 

[MindOverMatter]

Haha, I used to be timid about giving vaccines, but then once you give a few hundred it becomes easy. I actually kind of like giving them now (as long as I have time to do it) because it's something different and gives you a few minutes to actually talk with patients and not be super stressed.

Besides, this is the one time you can actually inflict pain on your problem patients and not get in trouble for it.

 

[All4MyDaughter]

Haha, I used to be timid about giving vaccines, but then once you give a few hundred it becomes easy. I actually kind of like giving them now (as long as I have time to do it) because it's something different and gives you a few minutes to actually talk with patients and not be super stressed.

Besides, this is the one time you can actually inflict pain on your problem patients and not get in trouble for it.

I don't mind it much either, but it always seems to happen when a lot of other stuff is going on. At least I have great techs to direct traffic!

 

[group_theory]

The worst about hitting a bone is that they never/can't feel it. You just hope they don't notice the look of terror on your face as you bounce the needle off the bone. My first practice injection in school I drilled the bone on my friend, good way to start out your vaccination career.

Luckily, I've never had any issues with blood, syncope, etc when vaccinating people. I'd like to keep it that way

Are you guys really taught to bury the needle all the way in, to the hub? If you do that consistently, I can see you hitting bone on a regular basis. It should be an intramuscular injection, so as long as you are in the belly of a large muscle - you're good. I can see a 25g 1/2 inch needle having trouble on a morbidly obese patient (will probably be more subQ injection than IM) but for your average patient, you don't need to go all the way down. I would be careful how deep you go in if it is an elderly patient with not a lot of subcutaneous fat and muscles. You are not trying to do a bone marrow biopsy here (and if your patient is osteopenic or has osteoporosis, and you go in forceful enough, you may well be sampling a small amount of bone marrow). In addition, the periosteum has nociceptive nerve endings, so it can be painful at times if you hit it.


Certain injections are more painful (to the patient) than others. The influenza vaccine is a relatively benign one. Gardasil has generated complaints about pain by patients who have tolerated other vaccines in the past without issues. I've been told that Pen G benzathine is particularly painful. Lidocaine burns as you inject - I sometimes buffer it with a little bit of sodium bicarb and it seems to not burn as much.

 

[All4MyDaughter]

Are you guys really taught to bury the needle all the way in, to the hub? If you do that consistently, I can see you hitting bone on a regular basis. It should be an intramuscular injection, so as long as you are in the belly of a large muscle - you're good. I can see a 25g 1/2 inch needle having trouble on a morbidly obese patient (will probably be more subQ injection than IM) but for your average patient, you don't need to go all the way down. I would be careful how deep you go in if it is an elderly patient with not a lot of subcutaneous fat and muscles. You are not trying to do a bone marrow biopsy here (and if your patient is osteopenic or has osteoporosis, and you go in forceful enough, you may well be sampling a small amount of bone marrow). In addition, the periosteum has nociceptive nerve endings, so it can be painful at times if you hit it.


Certain injections are more painful (to the patient) than others. The influenza vaccine is a relatively benign one. Gardasil has generated complaints about pain by patients who have tolerated other vaccines in the past without issues. I've been told that Pen G benzathine is particularly painful. Lidocaine burns as you inject - I sometimes buffer it with a little bit of sodium bicarb and it seems to not burn as much.

What do you mean by "you guys"? There is no one "pharmacist" method of giving injections that we're all taught. I'm sure everyone's immunization course is a little bit different.

I use a shorter needle on smaller patients or old people with skinny/saggy arms. For most other patients, our pharmacy uses a 1 inch needle for IM injections. I've never hit bone.

 

[group_theory]

What do you mean by "you guys"? There is no one "pharmacist" method of giving injections that we're all taught. I'm sure everyone's immunization course is a little bit different.

I use a shorter needle on smaller patients or old people with skinny/saggy arms. For most other patients, our pharmacy uses a 1 inch needle for IM injections. I've never hit bone.

Sorry, "you guys" is my generic all-encompassing "anyone who does vaccination" ... and even though it says "you guys", should also be gender neutral. It's better than "you pharmacists" or "you nurses" or "you doctors" since I wasn't trying to pin anything on a specific group, more of a "how were you taught on giving IM injections"

anyway, the burying needle to the hub question came from this earlier post so I don't know if it is just one person's technique, or if that is how it was taught. This post, along with a few follow-ups that talks about hitting bone, made me curious in terms of how deep the injections are happening.

How deep it lies? I stuck the whole needle in, like I usually do for an IM shot....
How do I know if I am injecting into an artery?
The needle was on a retractable syrenge, that we always use for the flu shots and vaccines..

 

[MindOverMatter]

What do you mean, "you pharmacists"???

 

[All4MyDaughter]

Sorry, "you guys" is my generic all-encompassing "anyone who does vaccination" ... and even though it says "you guys", should also be gender neutral. It's better than "you pharmacists" or "you nurses" or "you doctors" since I wasn't trying to pin anything on a specific group, more of a "how were you taught on giving IM injections"

anyway, the burying needle to the hub question came from this earlier post so I don't know if it is just one person's technique, or if that is how it was taught. This post, along with a few follow-ups that talks about hitting bone, made me curious in terms of how deep the injections are happening.

Like I said, we all received training at different times and locations... I had mine at school. At my school, we were taught to insert the needle completely but not to let the hub touch the patient. Other pharmacists were trained at their place of business or went to APHA training, etc. There's no one "pharmacist injection technique."

 

[group_theory]

What do you mean, "you pharmacists"???

you are seeing malevolent intent when there is none. I should have rephrase my question to "Are you really taught to bury the needle all the way in, to the hub?" instead of "Are you guys really taught to bury the needle all the way in, to the hub?" I tend to add "you guys" to mean that I wasn't singling out a single person when I was asking this question. My above post was also trying to convey that I wasn't trying to say "you pharmacist" or "you nurses" or "you doctors" or any single group ... more of a generic question

 

[MindOverMatter]

I'm just messing with you. I know there was no malevolent intent.

I don't remember exactly what they said back when I was trained (school), but I just go in deep enough to make sure I'm in the muscle, but not the entire way to the hub. I've hit bone one time, and I just backed it out a bit and proceeded.

Administering an IM injection is an incredibly easy process.

 

[All4MyDaughter]

you are seeing malevolent intent when there is none. I should have rephrase my question to "Are you really taught to bury the needle all the way in, to the hub?" instead of "Are you guys really taught to bury the needle all the way in, to the hub?" I tend to add "you guys" to mean that I wasn't singling out a single person when I was asking this question. My above post was also trying to convey that I wasn't trying to say "you pharmacist" or "you nurses" or "you doctors" or any single group ... more of a generic question

I think my issue with the question was it can't really be asked of us as a group. We all weren't taught to give injections at "Pharmacist Immunization Bootcamp." Our training on this is no more standardized than that of physicians, nurses, MAs or anyone else who gives injections.

 

[Ackj]

you are seeing malevolent intent when there is none. I should have rephrase my question to "Are you really taught to bury the needle all the way in, to the hub?" instead of "Are you guys really taught to bury the needle all the way in, to the hub?" I tend to add "you guys" to mean that I wasn't singling out a single person when I was asking this question. My above post was also trying to convey that I wasn't trying to say "you pharmacist" or "you nurses" or "you doctors" or any single group ... more of a generic question

Try "y'all" even if you aren't from the South. I don't say it aloud (for fear of ridicule, mainly) but it works well in text form. It is odd that English doesn't have a better plural form of "you."

 

[Ackj]

I've hit a few vessels before that bled out after the shot. Sometimes you just get unlucky. Fortunately no major issues yet.

Does anyone else have a more difficult time giving the Zostavax injections? It just seems like a more painful spot, and for some reason I tend to give it a little slower. It also seems a little harder to puncture the skin on some of these older patients. Maybe it's just me, or the leathery skinned people living here in south FL.

I find that the technique for SQ is harder than IM, although I've only done 2 of each, and they were on classmates rather than patients. NY doesn't let students vaccinate yet, and rph are only allowed to give Zosta as of last week, so maybe it'll be easier with practice. Even so, most will have much more practice with flu than zoster.

 

[npage148]

Are you guys really taught to bury the needle all the way in, to the hub? If you do that consistently, I can see you hitting bone on a regular basis. It should be an intramuscular injection, so as long as you are in the belly of a large muscle - you're good. I can see a 25g 1/2 inch needle having trouble on a morbidly obese patient (will probably be more subQ injection than IM) but for your average patient, you don't need to go all the way down. I would be careful how deep you go in if it is an elderly patient with not a lot of subcutaneous fat and muscles. You are not trying to do a bone marrow biopsy here (and if your patient is osteopenic or has osteoporosis, and you go in forceful enough, you may well be sampling a small amount of bone marrow). In addition, the periosteum has nociceptive nerve endings, so it can be painful at times if you hit it.


Certain injections are more painful (to the patient) than others. The influenza vaccine is a relatively benign one. Gardasil has generated complaints about pain by patients who have tolerated other vaccines in the past without issues. I've been told that Pen G benzathine is particularly painful. Lidocaine burns as you inject - I sometimes buffer it with a little bit of sodium bicarb and it seems to not burn as much.

Since you're quoting me. No, I was not taught to bury the needle and that we would not have to go in all the way to the hub for most people. Though you get overly eager sometimes and go a little too deep and hit the bone (especially the couple you do).

 

[rxlea]

I hope you have to give 100/day!

I screwed up a subQ injection once. The person jerked as I inserted the needle abs then the fluid came out and she said it burned and then cried. I was traumatized. That was the last one I did.

We were taught that you don't have to go all the way to the hub but I find that on men, it's easier to just jam it in fast..in out done.

 

[All4MyDaughter]

I screwed up a subQ injection once. The person jerked as I inserted the needle abs then the fluid came out and she said it burned and then cried. I was traumatized. That was the last one I did.

We were taught that you don't have to go all the way to the hub but I find that on men, it's easier to just jam it in fast..in out done.

Bwhahahahahaaha.

Yes, I am 12.

 

[rxlea]

Bwhahahahahaaha.

Yes, I am 12.

Lulz hey, it doesn't take much for men. They're happy with what they get

 

[All4MyDaughter]

Lulz hey, it doesn't take much for men. They're happy with what they get

So true!

 

[Corpseman]

I never insert the needle all the way to the hub ... If the needle breaks, then you have nothing to latch onto. And I always pull back on the plunger before injecting to make sure you are not in a vein or artery. If you get blood when toy pull back on the plunger, then pull out immediately and apply pressure.

Do they not teach this anymore? I dont know how many times I have worked with pharmacists or nurses that had no idea to pull back before you inject.

I have done probably close to 75000 immunizations (everything from smallpox, anthrax, flu, JEV, you name it lol) in my life.....^^^ was the first thing I learned.

 

[bw6]

you are seeing malevolent intent when there is none. I should have rephrase my question to "Are you really taught to bury the needle all the way in, to the hub?" instead of "Are you guys really taught to bury the needle all the way in, to the hub?" I tend to add "you guys" to mean that I wasn't singling out a single person when I was asking this question. My above post was also trying to convey that I wasn't trying to say "you pharmacist" or "you nurses" or "you doctors" or any single group ... more of a generic question

You are not seeing sarcasm where there is some

 

[BidingMyTime]

Do they not teach this anymore? I dont know how many times I have worked with pharmacists or nurses that had no idea to pull back before you inject.

This is how I was taught. Although honestly, in all the years of giving myself insulin shots, I've hit an artery or something twice, and the syringe immediately pushed up filling with blood, no pull-back needed. It was immediately obvious.

 

[brianuseruser]

Not necessary according to the CDC.

"Aspiration before injection of vaccines or toxoids (i.e., pulling back on the syringe plunger after needle insertion but before injection) is not necessary because no large blood vessels are present at the recommended injection sites, and a process that includes aspiration might be more painful for infants (98)."

http://www.cdc.gov/flu/professionals/acip/dosage.htm

 

[Lisochka]

Thank you guys!

 

[clachan3]

I like it when you hit bone for the first time. Nails on chalkboard feeling.

I know, and it's always the unexpected ones too. They didn't look that skinny at all. It only happened to me twice out of may be 100+ flu shots. One older gentleman, and one young skinny girl.

 

[bumpercar]

bump

 

[Dred Pirate]

I hope I can minimize the amount of vaccines I give wherever I go.

I love the fact my total is 0

 

[trailerpark]

Walmart doesn't force their pharmacists to immunize yet so you have less workload if you simply don't do the APhA course. And interesting enough I got a letter in the mail asking get if I wanted to join a class action lawsuit for non exempt pharmacists that weren't compensated for the at home part of the IMZ course or the test.

 

[wagrxm2000]

Ah flu shots my favorite time of the year. I get more tech hours and get to sit and talk to people more.

 

[owlegrad]

Ah flu shots my favorite time of the year. I get more tech hours and get to sit and talk to people more.

lol yes flu shots are awesome, really balances the pharmacist's workload.