Intramuscular Injection

of Emergency Medications

2 September 2019 PMS 1

 Overview
• Each injection route is unique
• The characteristics of the tissues influence the rate of
drug absorption and thus the onset of the drug
action
• Before injecting a drug you should know
– the volume of the drug to administer
– the intended route of administration
– the characteristics and viscosity of the preparation
– the appropriate sites for injection
– the location of anatomical structures relating to the proposed
injection site

2 September 2019 PMS 2

 Routes of Injection
• Intradermal, ID – effect in hours to days
• Subcutaneous, SC – effect in mins to hours
• Intramuscular, IM – effect in minutes

}
• Intravenous, IV – effect in seconds
• Intra-articular
• Intra-arterial
• Intra-lesional Highly specialised routes
• Intracardiac
• Intrathecal
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 Emergency Medications
• In emergency situations a healthcare professional may
be required to give the following treatments by
intramuscular injection:

– Acute diabetic hypoglycaemic coma – Glucagon

1 mg by GlucaGen® HypoKit

– Acute anaphylactic (allergic)reaction -

Adrenaline (epinephrine) 0.5 mg by syringe & needle
or 0.3 mg by EpiPen® auto-injector
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 Needle Sizes for IM Injection

• Use a blue (23G) hypodermic needle for small or

thin adults
• Use a green (21G) hypodermic needle for
medium to large adults

• EpiPens® and GlucaGen® HypoKits have the

correct needle ready-assembled

2 September 2019 PMS 5

 Skin Preparation
• If visibly clean, skin preparation is NOT
required for ID, SC, IM or IV injections
• If required, use ethyl alcohol swabs
• Swab with a circular motion from site of
proposed injection outwards
• Allow to dry before injection
• In an emergency skin cleansing may be
omitted

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 Basic Principles 1
• Ordinarily, any drug administration is checked against
its prescription. In an emergency the drug is checked
against standard protocols or patient group
directives. Ensure the drug to be administered is
correctly identified against the protocol for
• Drug
• Dose
• Date and time / indications
• Route / method

2 September 2019 PMS 7

 Basic Principles 2
• Ensure all equipment is to hand
• Place all items together in a tray
• Hygienic hand wash before procedure
• Wear gloves
• Draw up drug as prescribed
• Explain to patient the process
• Expose site
• Proceed as for particular technique to be used

2 September 2019 PMS 8

 Using a Glass Ampoule
e.g. Adrenaline 1:1000

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 Checking the Ampoule
• Inspect for cloudiness or particulate
matter
Break point • Check it is the required drug
Bulb marker
• Check the expiry date
Score mark • Check and record Lot/batch No. if
Neck
appropriate
1mg in 1ml Exp: 07/2018
Adrenaline 1:1000

• Calculate appropriate volume to draw

Body up
Label
Adrenaline 1:1000 contains 1mg in every 1ml

Therefore,

To give a 0.5mg dose, draw up 0.5 ml of the drug

2 September 2019 PMS 10

 Opening an Ampoule
• Wear Gloves

• Wipe the ampoule neck with an alcohol wipe and

allow to dry (30 seconds)
• Hold upright and tap ampoule to empty fluid out of
bulb
• Locate the neck score mark with the marker

• Using an ampoule snapper, apply pressure to the

bulb away from the score mark
• A sharp snapping motion will snap off the bulb

• Do not apply excess pressure to bulb of ampoule

• After opening check fluid for any glass particles -

dispose if any seen
• Throw top of ampoule into sharps bin

2 September 2019 PMS 11

 Drawing up from an Ampoule
• Use a blunt drawing-up needle

• If only a small amount of volume

required, the fluid can be drawn up

from the ampoule resting on a work

A surface (A)


• If most or all of the volume is required
C
the ampoule can gradually be tipped

from the vertical drawing the last part


of the volume from the shoulders (B)
B
• There is no need ever to invert the

ampoule completely (C) or to inject air

2 September 2019 PMS into it. 12

 Using a Vial
e.g. Glucagon 1mg

2 September 2019 PMS 13

 Checking the Vial
Central • For fluids, inspect for
rubber bung cloudiness or particulate
matter
• Check drug name
Metal • Check expiry date
cap • Check and record Lot/batch
powder for reconstitution
Glucagon hydrochloride

Lot: gluc/37549092/12

No. if appropriate
1mg

• Check concentration
Exp: 11/2019

Label
• Calculate dose for injection

2 September 2019 PMS 14

 Inserting the Needle
• The rubber bung should
be swabbed with alcohol
and allowed to dry
• To prevent coring of the
45-60° bung insert the needle at
45-60°
• Inject the water for
injection into the vial
• Allow air to return into
the syringe
2 September 2019 PMS 15
 Withdrawing the Fluid
• Shake the vial to dissolve the
drug
• Hold the vial & syringe
upside-down
• Inject the air back into the
vial
• Withdraw the volume
required
• Check no “cored” rubber
particles appear in the
syringe barrel

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 Preparing to Inject

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 Expelling any air
• Tap with finger on the barrel  Do not re-sheath the
of the syringe to remove any needle!
bubbles
 Remove needle and
• Expel any air by depressing dispose of in sharps bin
the plunger taking care not to
aerosol

• Expel any excess fluid

–into ampoule or vial
–do not create an aerosol in the
air

2 September 2019 PMS 18

 Change the Needle
• If using a syringe and needle, change the needle for
an appropriate size for the patient; green or blue
• Reduces risk of infection
• Avoids tracking of medication (contaminating outer
shaft of drawing up needle) through superficial
tissues
• With EpiPens® and GlucaGen® HypoKits this is not
possible

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 Intramuscular Injection

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 Intramuscular (IM) Injection 1
• Fast absorption rate
• Low risk of tissue damage
• Higher risk of inadvertent injection into blood
vessels or damaging underlying structures
• Use green needle (or blue in thin individuals)
and insert at a 90°
• Up to 3ml of medication can be tolerated in a
person of normal build

2 September 2019 PMS 21

 Intramuscular Injection 2 (sites)
• Lateral Aspect of thigh
– safest of all IM sites (preferred)
– lacks major nerves and vessels
– allows rapid drug absorption
• Upper Outer Quadrant of Buttock
– risk of injecting sciatic nerve, greater
trochanter or major blood vessels.
• Deltoid area of the Arm
– poorly developed muscle
– used for small volumes only
– risk of injecting axillary nerve
– least comfortable site

2 September 2019 PMS 22

 Intramuscular Injection 3
• Swab skin if necessary
• Stretch skin around site
• Hold needle at 90º and quickly
plunge into skin
• Leaving approximately 1/3 of the
needle shaft exposed
• Pull back plunger
• If no blood, depress plunger
slowly
• If blood appears, withdraw
needle completely, replace
needle and repeat

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 The GlucaGen HypoKit ®

• Close relatives of Type 1 diabetics

• The GlucaGen® HypoKit is a self
are often trained to administer
contained kit for the
glucagon
administration of 1mg of glucagon
by IM injection in the case of • The GlucaGen® HypoKit should be
acute diabetic hypoglycaemic stored in a fridge
coma - when the patient cannot
take glucose by mouth due to the
risk to their airway
• Glucagon is a polypeptide
hormone produced by the alpha
cells of the Islets of Langerhans. It
increases plasma glucose
concentration by mobilising
glycogen stored in the liver.

2 September 2019 PMS 24

 Using the GlucaGen HypoKit (1) ®

• Call for an ambulance first!

• Remove the sheath from the pre-
filled syringe
• Remove the cover from the
glucagon vial
• Insert the needle through the
rubber stopper on top of the vial
and inject all of the water (1)
• Holding the two together, gently
shake the vial to dissolve the white
powder (2)

2 September 2019 PMS 25

 Using the GlucaGen HypoKit (2) ®

• When the solution is clear,

push the plunger all the way
into the syringe then invert
the assembly and slowly
withdraw all the solution (3)
• Expel any excess air from
the syringe and inject into
the patient’s thigh at a 90°
angle (4)

2 September 2019 PMS 26

 Hypoglycaemia follow-up actions
• Stay with the patient
• Record the time and dose of glucagon administered
• Nurse the patient in the recovery position
• Ensure an ambulance has been called
• Check that their airway remains patent and observe their breathing and
circulation (ABCs)
• Recovery to consciousness should occur within a few minutes but they
will require further medical attention
• Check their capillary blood glucose measurements at 10 minute intervals
• Do NOT give a second dose of glucagon. Further treatments may be
necessary but should be administered by the ambulance or a doctor only

2 September 2019 PMS 27

 The EpiPen Auto-injector ®

 The patient should be encouraged to

• The EpiPen is a single use device administer it themselves. If they
which can deliver a 0.3 mg dose of cannot a healthcare professional
adrenaline (epinephrine) by may be required to do it for them
intramuscular injection in the case of
severe anaphylactic (allergic) reaction
• Adrenaline has a rapid onset of
action after IM injection which makes
this the preferred route of
administration
• The full adult dose is 0.5 mg IM but
an EpiPen delivers a safer 0.3 mg
dose
• Many patients who suffer from
severe allergies carry their own
EpiPen for emergencies

2 September 2019 PMS 28

 Using the EpiPen ®

• Grasp the EpiPen in your dominant hand with

thumb closest to the grey safety cap
• Pull off the grey safety cap (Fig.1)
• Hold EpiPen 10 cm from the patient’s outer thigh,
black tip pointing towards the thigh (Fig.2)
• Jab firmly into the thigh so that the EpiPen is at
right angles to the skin. This may be done
through clothing if necessary
• Hold in place for 10 seconds (Fig.3)
• Massage injection area for a further 10 seconds
• Call for an ambulance!

2 September 2019 PMS 29

 Anaphylaxis follow-up actions
• Ensure an ambulance has been called
• Stay with the patient
• Record the time and dose of adrenaline administered
• Nurse the patient in the recovery position if necessary
• Ensure their airway remains patent and observe their
breathing and circulation (ABCs)
• Recovery should occur within a few minutes but they will
need hospital attention
• Further treatment may be necessary and the dose can be
repeated at 5 minute intervals but should preferably be
administered by the ambulance or a doctor

2 September 2019 PMS 30