Subcutaneous and Intramuscular Injections Learning Outcomes By the

Subcutaneous and Intramuscular Injections

Learning Outcomes By the end of the session you will be able to: • Understand the principles of ANTT • Relate ANTT to the skills of Subcutaneous (SC) and Intra Muscular injection (IM) • Understand theory and technique of IM and SC injections • Gain an understanding of anaphylaxis and its significance • Understand inoculation injuries and methods of reducing and treating

Protocols and Competency • Guides and protects practice • Supports update of knowledge • Act within your limitations • Practice must be supervised and documented until graduation • Supervision proximity should be negotiated with your supervisor • Keep your skills passport as evidence of training and competency

Aseptic Non Touch Technique (ANTT) ANTT is a framework which maintains Asepsis in order to protect patients from potentially harmful organisms. “Key Parts must only come into contact with other aseptic Key parts or Key Sites” (www. antt. co. uk) Asepsis is achieved by: • Hand decontamination • Non touch technique • Sterile equipment • Cleaning equipment/site until aseptic

Preparing the Patient • Confirm patient identity and allergies • Confirm indication • Explain procedure and gain consent • Check for a suitable site

Subcutaneous Injection Sites (slow and steady release)

Subcutaneous (SC) Injections • No skin prep required, but wash with soap and water if visibly dirty • Pinch skin into fold • 25 Gauge (Orange needle) insert at a 45° angle • If using a Pre-filled syringe Do NOT remove air bubble - insert at a (90°angle) • No need to aspirate • No need to massage • Rotate sites • 2 mls maximum volume

Intramuscular Sites (more rapid systemic absorption) Ventro-gluteal site Primary site, less risk of injury, small site (not for repeated injections) Volume 1 -5 mls

Deltoid Site Easily accessible, small area, least painful, rapid onset (greatest blood flow) Volume 0. 5 – 2 mls

Vastus Lateralis Easily accessible, will take repeated injections, reduced risk of injury, but painful for patient. Slower absorption. Volume 1 -5 mls maximum

Intramuscular (IM) Injections • Inspect for the most appropriate and clean the site for at least 30 seconds • Complete the Z-Track Technique • Assess the patients body size and select the appropriate gauge needle. Then insert at a 90° angle • Aspirate to ensure not in a vein • No need to massage • Rotate sites

Z-Track Technique 1. Prior to injection layers lie above one another 2. Pull top layer of skin, separating the layers

3. Insert needle at 90° into muscle layer, gently aspirate then inject medication 4. Release skin, remove needle, no medication leaks out

Potential problems • Discomfort – post sub-cut some stinging is often reported but should wear off after a short time • Pain – some patients have marked discomfort • Post administration anaphylaxis – rare, but should be always be considered

What is Anaphylaxis? Anaphylaxis is: • A severe life threatening, generalised or systemic hypersensitivity reaction – (Resuscitation Council, 2015) Anaphylaxis is categorised by: • Rapidly developing, life threatening Airway and/or Breathing and/or Circulation problems, usually with skin and/or mucosal changes

What Causes Anaphylaxis? Resus Council UK

Time to Fatality in Anaphylaxis Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000; 30(8): 1144 -50.

Patient Assessment • A – E assessment is the recognised method of assessing an acutely unwell patient • At each point of the assessment, treat any symptoms before moving onto the next step • Once completed, return to the beginning of the assessment and repeat • A thorough A – E assessment can be completed in just a few minutes

Airway • Airway Swelling; throat and tongue (pharyngeal/laryngeal oedema). • The patient has difficulty in breathing and swallowing and feel their throat is closing up. • Stridor (high Pitch inspiratory noise caused by an upper airway obstruction) • Hoarse Voice

Breathing • • • Shortness of Breath Wheeze Cyanosis (appears blue – usually a late sign) Confusion (caused by hypoxia) Fatigue Respiratory arrest

Circulation • • • Signs of shock; Pale/clammy Tachycardia (Increased pulse rate) Hypotension (low blood pressure) Feeling Faint Reduced consciousness Cardiac Arrest Do not stand the patient up!

Disability • Sense of impending doom • Anxiety/Panic • Decreased conscious level caused by ABC problems. Assess – • AVPU/GCS • Pupils • Blood Glucose

Exposure • • • Look for Skin Changes Skin changes are often the first response Urticaria (rash/hives) Angioedema (swelling of eyelids, lips, mouth) Check temperature

Treatment Resus Council UK

Inoculation Injuries What is an Inoculation Injury? Definition: • Any incident where somebody’s blood or body fluids could contaminate your blood or mucous membranes

How Can Inoculation Injuries Occur? • Sharps Injury • Splashes • Bites • Scratches

Reducing the Risk • Wear clean non-sterile gloves and apron – Risk assess for other PPE • Do not re-sheathe needles • Dispose of sharps at the point of care • Dispose of syringes and needles as a single unit • Do not overfill sharps containers • Use temporary closure device on sharp bins • Dispose of your own clinical waste

First Aid Treatment for Inoculation Injury • Bleed, wash with warm water, cover – Splash to eye, irrigate with water • Report incident to Manager / person in charge • Seek treatment: – Accident and Emergency Unit (A & E) – Occupational Health • Complete incident form

Control Of Substances Hazardous to Health (COSHH) Hierarchy Eliminate sharps Most effective control measure Needlesafe devices Sharps containers Safe practice Training and Information Personal Protective Equipment (PPE) Least effective control measure, requiring increasing participation and supervision

Learning Outcomes You are now able to: • Understand the principles of ANTT • Relate ANTT to the skills of Subcutaneous (SC) and Intra Muscular injection (IM) • Understand theory and technique of IM and SC injections • Gain an understanding of anaphylaxis and its significance • Understand inoculation injuries and methods of reducing them