Intramuscular route

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Route of delivery for pharmaceuticals involving injection of agent into substance of the muscle.

Commonly sites deltoid, gluteus maximus and quadriceps.

Contents

How to do it

LogoWarningBox4.pngAspirating does not make it impossible to inject intravenously. It helps though.

Usual precautions: correct setting, correct patient, correct prescription, correct drug, correct dose, correct equipment. Avoid injection where the skin is infected or inflamed. Draw the drug up and exclude air.

Deltoid

Ask patient to put hand on hip. This relaxes the deltoid muscle, making the injection less painful. Some clean site with alcohol swab.

Identify main muscle bulk, usually located above axilla, but below acromion (see diagram in [1]). Identify intended injection site.

Hold skin taut and pierce skin perpendicularly with a quick, sharp jab. Ideally, a single action should penetrate skin and muscle, resulting in the end of the needle in the main muscle bulk. If not advance needle quickly into muscle. Some aspirate as a precaution, but there should be no large blood vessels if you are in the right place. Inject drug. Some rub the are afterwards to increase dispersion/absorption.

As with gluteal injections, patients with thick subcutaneous fat may require longer needles.[2]

Gluteal

The large bulk of the gluteus maximum is ideal for intra-muscular injection. The injection should be given in the upper outer quadrant of the buttock. Confusion arises because anatomically the buttocks is a much larger area than the lay view of it, extending from the gluteal creases inferiorly to as far laterally as the greater trochanters and as far superiorly as the anterior superior iliac spine. Furthermore, many diagrams draw four quadrants on the buttocks as if it were 2-dimensional, whereas in real life the upper outer quadrant is quite lateral. Injecting in the upper outer quadrant of the lay perception of what the buttocks are risks damage to the sciatic nerve.

the gluteal injection site

Note that the needle may have to be inserted to the hilt in order to go through the excess subcutaneous tissues that some patients have.[3][4]

Thigh

Specifically vastus lateralis. Mid-thigh (middle-third), between mid-anterior and mid-lateral. One study suggests that systemic absorption is faster from the thigh compared to the arm and is therefore the preferred route in giving adrenaline in anaphylaxis.[5]

Advantages

  • Simple and accessible, cf. EpiPen.
  • No indwelling medical devices required, although devices exist for intra-muscular cannulation.
  • Required for certain types of drugs, e.g. immunoglobulins, vaccines

Disadvantages

  • Absorption dependent on blood flow. May be danger of sudden absorption of drugs, e.g. if large amounts of opioids administered to a 'shut-down' patient, sudden overdose may result when perfusion to muscle improves.
  • Slower absorption than intravenous, i.e. not good for immediate analgesia. This may be an advantage, e.g. when adrenaline is used in anaphylaxis as administration of 0.5mg of adrenaline intravenously could be result in tachyarrhythmias.
  • Painful.
  • Limited volume.
  • Nerve damage, if incorrectly performed (often confusion over meaning of upper, outer quadrant).
  • Potential for subcutaneous injection, especially in overweight patients.[6][7]
  • Sterile or infected abscesses reported. May be related to inadvertent subcutaneous injection. Rare, but disastrous.[8][9][10]

References

  1. Immunization Action Coalition leaflet
  2. Poland GA, Borrud A, Jacobson RM, McDermott K, Wollan PC, Brakke D, Charboneau JW. Determination of deltoid fat pad thickness. Implications for needle length in adult immunization. JAMA : the journal of the American Medical Association. 1997 Jun 4; 277(21):1709-11.
  3. Chan VO, Colville J, Persaud T, Buckley O, Hamilton S, Torreggiani WC. Intramuscular injections into the buttocks: are they truly intramuscular? European journal of radiology 2006;58:480-4. (Direct link – subscription may be required.)
  4. Nisbet AC. Intramuscular gluteal injections in the increasingly obese population: retrospective study. BMJ (Clinical research ed.) 2006;332:637-8. (Direct link – subscription may be required.)
  5. Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. The Journal of allergy and clinical immunology. 2001 Nov; 108(5):871-3.(Link to article – subscription may be required.)
  6. Chan VO, Colville J, Persaud T, Buckley O, Hamilton S, Torreggiani WC. Intramuscular injections into the buttocks: are they truly intramuscular? European journal of radiology 2006;58:480-4. (Direct link – subscription may be required.)
  7. Nisbet AC. Intramuscular gluteal injections in the increasingly obese population: retrospective study. BMJ (Clinical research ed.) 2006;332:637-8. (Direct link – subscription may be required.)
  8. Pillans PI, O'Connor N. Tissue necrosis and necrotizing fasciitis after intramuscular administration of diclofenac. The Annals of pharmacotherapy 1995;29:264-6.
  9. Lie C, Leung F, Chow SP. Nicolau syndrome following intramuscular diclofenac administration: a case report. Journal of orthopaedic surgery (Hong Kong) 2006;14:104-7.
  10. Mutalik S, Belgaumkar V. Nicolau syndrome: a report of 2 cases. Journal of drugs in dermatology 2006;5:377-8.
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