/

This booklet has been prepared by Wyeth

Laboratories vvith the hope that it vvill be
useful to students in various fields of medi-
cine vvhose responsibilities vvill ultimately
include the giving of intramuscular injections.
For those vvhose training is already an ac-
complished fact vve hope the booklet vvill
act as a refresher.

Everyone agrees that intramuscular injec-

tions should avoid major nerves and vessels,
but there is no universal agreement on speci-
fically preferred sites and procedures. This
booklet presents a selected cross section of
thinking on those sites and procedures most
generally accepted for adults and children.

Illustrations in this booklet are intended

primarily as an aid to general site orientation.
Specific procedures as described in the text
of the booklet are recommended in adminis-
tration of intramuscular injections.

We vvish to express our appreciation to

Daniel .J. Hanson, M.D., Department of Path-
ology and Research Institute, Mercy Hospital,
Toledo, Ohio, for permission to reprint a
portion of his article, "Intramuscular Injection
Injuries and Complications," to Philip S. Barba,
M.D., Adjunct Professor of Pediatrics, Temple
University School of Medicine, for his helpful
comments on pediatric intramuscular injec-
tions, and to Alice C. Cook, R.N., Senior In-
structor at The Memorial Hospital School of
Nursing, Wilmington, Delavvare, for her tech-
nical assistance and advice.
Intramuscular Injections

WYETH LABORATORIES Philadelphia, Pa. 19101

 Table of Contents

Injections in General .. 4

Intramuscular Injections. 5

Precautions and Recommendations for Intramuscular Injections . 6

Intramuscular Injection Sites

Mid-Deltoid Area . 8

Gluteus Medius 10

Ventrogluteal Area 12

Vastus Lateralis ... 14

Intramuscular Injections in Infants and Children .. 16

Pediatric Intramuscular Injection Sites

Gluteal Region .. 18

Vastus Lateralis. 20

Deltoid . 22

Preparing for the Injection. 24

Orders for Medication 25

Preparation Steps for Injection With Prefilled TUBEX Sterile

Cartridge-Needle Unit.......... . . 26

Preparation Steps for Injection With Reusable Syringe 27

Giving the Injection ..... 28

After the TUBEX Injection ... 30

After the Injection With a Reusable Syringe ... 31

Bibliography . 32

TUBEX in the Hospital . 34

TUBEX Closed Injection System Components . Inside back cover

 Injections in general

Giving injections is a serious and important part of medical

treatment. In a very real sense the same kind of preparation
and caution employed in an operating procedure must be
exercised in giving injections. Two foreign objects are be-
ing introduced into the body, a hypodermic needle and the
medication, and this should be done with as much precision
as a surgeon employs when using a scalpel. The accuracy of
the choice of injection site and the excellence of the tech-
nique of injection help control the effectiveness of the medi-
cation. A misdirected injection or improper technique in
administering the injection may prevent medication from
acting most efficiently or, more important, may cause irrep-
arable damage.

A physician orders an injection for a patient only when

it is absolutely necessary or the manner of treatment most
suited to the existing circumstances. Some of the reasons and
advantages for giving injections of medication (also referred
to as parenteral therapy) are:

1. To administer medication when the mental

or physical state of the patient may make
any other route difficult or impossible.

2. To achieve a quick response to the medica-

tion.

3. To guarantee the accuracy of the amount

of medication received.

4. To obtain a sure response from the patient.

5. To prevent irritation of the digestive system,

loss of medication through involuntary ejec-
tion or destruction by digestive acids.

6. To anesthetize a specific area of the body.

7. To concentrate medication at a specific lo-

cation in the body.

4
Intramuscular injections

Intramuscular injections are given when a quick but pro-

longed action is preferred to an immediate effect of short
duration. By injecting medication into the muscle a deposit
of medicine is formed which is gradually absorbed into the
blood stream. When given properly, the intramuscular injec-
tion is probably the easiest, safest, and best tolerated of the
several types of injections.

Generally speaking, large quantities of medication are sel-

dom injected into the muscles and a 2- or 2.5-cc. syringe will
be adequate for most treatments.

Medications for many intramuscular Injections are in an

aqueous solution or in a suspension, while a few are in an oil
solution or suspension. When an aqueous suspension or oil
solution or suspension is administered, it is generally neces-
sary to give the injection at a slower rate because of the
thicker liquid.

5
Precautions and recommendations for Intramuscular Injections

Reprinted with the permission oj the author, Daniel J. of well-defined landmarks locating the vertical line.
Hanson, M. D., Department oj Pathology and Research H the vertical is drawn only slightly medial to the
Institute, Mercy Hospital, Toledo, Ohio jrom "I ntramus- proper location, the intersection with the horizontal
cular Injection Injuries and Complications" published will be located medial to the sciatic nerve. This will
in GP January, 1963. expose the nerve to injection although the injection
may be assumed to be given in the "upper outer
RecornluendatioJJs
quadrant."
A local lesion of greater or lesser extent, depending
upon the material injected, is produced in the tissues We recommend a minor modification for the loca-
each time an injection is given. The operator must be tion of the injection site, using definite anatomic
aware of the differences in tissue toleration when landmarks. A line drawn from the posterior superior
choosing the substance to be injected and he must iliac spine to the greater trochanter of the femur is
control the site of the resultant lesion by locating the lateral to and parallel with the course of the sciatic
needle tip in a relatively silent intramuscular area. nerve. Any injection lateral and superior to this line
will be removed from the course of the sciatic nerve
Many cases of 'generalized anaphylactic and related
and will be within the region of the greatest gluteal
reactions after intramuscular injection cannot be
mass, as recommended by Hochstetter and others.
predicted. However, most injection accidents are re-
lated to tissue damage at the injection sites. These The deltoid and posterior triceps area should be
accidents are preventable. When complications occur, avoided in adults when anything but the most non-
they usually can be attributed to faulty injection irritating substance is injected. The muscle masses
technique. available for injection in these areas are generally
With the previously described facts in mind, several not as large as those in the gluteal areas and an in-
points will be listed which are particularly important jection which is only slightly misplaced may involve
in avoiding injection complications. the radial nerve. In addition, pain and tenderness are
more noticeable to the patient in this area.
Select the Agent. When a choice is possible, select
the agent which demonstrates the greatest tissue Infants present a different problem. The gluteal area
toleration. is extremely small and is composed primarily of
fat. There is only a poorly developed, small muscle
In the case of antibiotic injections, it has been shown
mass. An y injection in this area is dangerously close
that procaine penicillin and oxytetracycline cause
to the sciatic nerve. A squirming, fighting child in-
the least extensive reactions at the injection sites.
creases the danger of injecting into or adjacent to the
Chloramphenicol succinate and tetracycline provoke
nerve. In such patients, the lateral or anterior thigh
the most severe necrotic lesions.
is recommended for intramuscular injections. These
Choose the Proper Site. In adults, the recommended muscles are better developed at birth and are far re-
site of intramuscular injection is the upper outer moved from any major nerves. Nathan, for similar
quadrant of the gluteal area. The gluteal area is not reasons, used the deltoid area in infants with good
synonymous with the buttocks. A review of the anat- results. The gluteal musculature develops with loco-
omy of the area will reveal that the term "buttocks" motion and, therefore, may be used for injection
includes a zone of fat tissue inferior to the gluteal when the child has been walking for a year or more
musculature adjacent to the posterior thigh. (usually at the age of 2 or 3). Individual evaluation
In determining the injection site in the gluteal zone of the musculature should be made and may indicate
... the classic method of intersecting perpendicular the use of the thigh at an even older age. This loca-
lines may be dangerous, especially in the hands of tion may also be used safely in adults although pain
nonprofessional personnel, because of the absence is more noticeable than in the gluteal area.

6
Intramuscular injection sites/the Mid-Deltoidarea

A site often chosen for its ease of access is the axilla or armpit on the bottom. The two side
deltoid area which can be employed when the pa- boundaries are lines parallel to the arm one-third
tient is in either a standing, sitting, orJprone posi- and two-thirds of the way around the outer lateral
tion. While the deltoid muscle forms a fairly large aspect of the arm.
triangle on the shoulder prominence, the actual Care should be taken to avoid not only the acro-
area available to a shoulder injection is limited, mion, clavicle and humerus, but also the brachial
since there are major bones, blood vessels and veins and arteries and the radial nerve. It is rec-
nerves to be avoided. The recommended bounda- ommended that the number and size of injections
ries of the injection area form a rectangle bounded made at this site be limited. The area is small and
by the lower edge of the acromion on the top to cannot tolerate repeated injections and large
a point on the lateral side of the arm opposite the quantities of medication.

Acromion

Brachial vessels

8
100-lb. female 130-lb. male

135-lb. female 180-lb. male

210-lb. female 240-lb. male

9
Intramuscular injection sites/the Gluteus Medius

Perhaps the most commonly considered site for The patient should be lying face down. A "toe-in"
injections is the posterior gluteal area. In defining position relaxes the muscles. The injection site
this site for injection purposes care should be should be clearly exposed. Under no circum-
given to restrict injections to that portion of the stances should there be any compromise with
gluteus medius which is above and outside of a correct technic. Do not hurry, do not let
diagonal line drawn from the greater trochanter modesty tempt you to give this injection to a per-
of the femur to the posterior superior iliac spine. son who is bending over a table or with his cloth-
Extreme caution should be observed to ensure ing only partially removed from the injection site.
that the boundary line is maintained, avoiding the The needle is inserted perpendicular to the flat
hazard of possibly injecting into either the sciatic surface on which the patient is lying-needle pene-
nerve or the superior gluteal artery. tration should be on a direct back-to-front course.

r
Greater trochanter of the femur
Superior gluteal artery
(not illustrated)

Sciatic nerves Gluteus rnaxirnus Gluteus medius

7/~ior superior iliac spine

10
100.lb. female 130-lb. male

135-lb. female 180-lb. male

210-lb. female 240-lb. male

11
Intramuscular injection sites / the Ventrogluteal area

The ventrogluteal area (von Hochstetter's site) Palpate to find the greater trochanter, the anterior
has been accorded growing recognition as a site superior iliac spine and the iliac cresLWhen inject-
removed from major nerves and vascular struc- ing into the left side of the patient, place the palm
tures. The subcutaneous fatty layer is relatively of the right hand on the greater trochanter and the
shallow and there is good gluteal muscle density. index finger on the anterior superior iliac spine.
Because anatomical landmarks are easily identi-
(Use the left hand to delineate the site when
fiable around the ventral area of the gluteal
injecting into the patient's right side.) Spread the
muscles, this site is also recommended for injec-
middle finger posteriorly away from the index
tions in children. Although especially suitable for
a patient lying on his back, this site is also acces- finger as far as possible along the iliac crest, as
sible with the patient lying prone, on his side, shown in the straight-line drawing below. A "V"
or standing. space or triangle between the index and middle
The patient should always be sufficiently exposed finger is formed. The injection is made in the
to enable adequate identification of anatomical center of the triangle with the needle directed
landmarks. slightly upward toward the crest of the ilium.

Ventrogluteal area
Iliac crest
(in triangle) (not illustrated)

Greater trochanter of the femur Posterior edge iliac crest

12
- J

100-lb. female 130-lb. male

135-lb. female 180-lb. male

210-lb. female 240-lb. male

13
Intramuscular injection sites / the Vastus Lateralis

Another site recommended for its relative safety Although it is easier to give an injection in the
and freedom from major nerves and blood vessels vastus lateralis when the patient is lying on his
is the vastus lateralis. This injection area is back, it is acceptable to use this site when he is in
bounded by the mid-anterior thigh on the front of a sitting position. The entire area should be
the leg, the mid-lateral thigh on the side, a hand's exposed to permit identification of anatomical
breadth below the greater trochanter at the proxi- landmarks pertinent to this site. This site may
mal end and another hand's breadth above the also be used for pediatric patients. See pages 20
knee at the distal end. and 21 for specific recommendation.

Mid-portion vastus latera lis

Greater trochanter (not illustrated)

14
100-lb. female 130-lb. male

135-lb. female 180-lb. male

210-lb. female 240-lb. male

15
 Intramuscular injections
in infants and children

Every precaution which applies when administering intra-

muscular injections to adults also applies for infants and
children-with one added precaution-the margin for error
is critically narrower!
Current medical literature abounds with recommendations
stressing correct technic and proper site selection.
Close examination of this literature permits inference of
these basic guidelines for pediatric intramuscular injections:

16
Some notes to underscore

1. No injection should ever be given with the attitude of

casual indifference or mechanical routine. Careful
attention to detail is mandatory for every injection-
no matter who gives it.

2. Proper injection technic requires a sound knowledge of

the anatomy involved. The terms used to describe the
injection site and pertinent landmarks must be under-
stood precisely.

3. Major nerves and blood vessels must be avoided and

injection sites should be selected accordingly. Rotate
among useable sites when repeated injections are
necessary.

4. The entire injection area should be fully exposed to per-

mit an unobstructed overall view of the injection site.

5. The target muscle should be large enough to accommo-

date the medication to be injected. Medication de-
posited into the belly of the muscle permits optimal
absorption. A relaxed muscle is highly desirable.

6. The needle length should be adequate to deposit the

medicament into the belly of the target muscle.

7. A slow rate of injection allows the relaxed muscle to

distend and accommodate the medication deposit. A
too-rapid rate of injection into a taut muscle can result
in expulsion of the medication from the muscle into
surrounding tissues, causing severe irritation and
needless patient discomfort.

8. Few children are completely cooperative. Since they

may struggle when least expected, it is important that
adequate measures be taken to keep the child still
during the actual injection. Restraining the uncoopera-
tive patient often requires two persons. Whenever
possible a trained physician or nurse should assist.
Office assistants or parents may be used when no one
else is available to help.

17
Pediatric intramuscular injection sites/Gluteal Region

The gluteal region and the buttock are not syn- the buttock and extends forward to the anterior
onymous. Each must be defined to establish the superior iliac spine. When the musculature is
proper injection sites. adequately developed and proper technic is used,
Buttock refers strictly to the gluteal prominence. the gluteal region is a very suitable area for
The buttocks are confined to one area of the injection.
gluteal region-the nates, clunes, "rump" or The gluteal region includes two distinct injection.
"seat." Injections should never be given into any sites: (1) the ventrogluteal area and (2) the pos-
quadrant of the buttock. terolateral aspect of the gluteal region.
The gluteal region is much more expansive than

Ventrogluteal or von Hochstetter's site This site has

been described in detail on pages 12 and 13. Those
same technics apply for pediatric injection pro-
cedures.

Posterolateral aspect of the gluteal region

1. The patient lies prone on a flat table surface.
A "toe in" position relaxes the muscle.

2. Palpate to locate the posterior superior iliac

spine and the head of the greater trochanter.
The injection site must be superior and Gluteal region Buttock
lateral to the imaginary line connecting
these two landmarks. The area above the
head of the trochanter and below the iliac
crest is most remote from major nerves
and vessels. Gluteus

3. The syringe is held perpendicular to the flat

table surface on which the patient is lying.
The needle is directed on a straight back-to-
front course.
Sciatic N.

18
Post. sup. iliac spine

Gluteus medius M.

Sup. gluteal A.

Gluteus maximus M.

Inf. gluteal A.

Greater trochanter
of femur

Sciatic N.

19
Pediatric intramuscular injection sites/ Vastus Lateralis

The quadriceps femoris is the largest muscle

group in the anterolateral thigh. The vastus
lateral is is the major muscle of this group and is
located on the most lateral aspect of the thigh
away from major nerves and vessels. The anterior
surface of the mid-lateral thigh is therefore a suit-
able site for intramuscular injections in this area.
Survey the overall size of the thigh and plan the
needle insertion depth accordingly. In very small
infants, needle insertion to just a one-inch depth
will penetrate into the muscle belly.
The infant lies on his back. Grasp the thigh and
compress the muscle tissue as shown. This helps
to stabilize the extremity and concentrates the
muscle mass. Using the position shown, the left
arm helps to restrain the struggling patient.
The needle penetrates the gathered muscle mass
on the lateral portion of the anterior thigh and is
Vastus lateralls M.
directed on a front-to-back course. This is re-
moved from the medial portion of the thigh where
major nerves and vessels are located among the
deeper layers of the muscle tissue.
An alternate injection site in this area is the
anterolateral surface of the upper thigh. When
this location is used, the needle is directed distally )
and inserted obliquely at an approximate 45° angle /
to the horizontal and long axes of the leg. The , '

needle should not penetrate deeper than one inch. /'-'--:"":,

Compressing the muscle tissues between the fingers I
I

amasses the musculature at the site of injection. I

I
Alternate site
, I

,
,, I
, I

, !
, ,
I ,

,, ,I
, ,
I ,

," ,'
:;.l~-\.)

20
 /

Deep femoral A.

Sciatic N.
Rectus femoris M.

Femoral A. & V.
Vastus lateralis M.

21
Pediatric intramuscular injection sites / Deltoid

The deltoid muscle in infants and young children

is shallow and can accommodate only a very small
volume of the more fluid medications. Another
limiting factor is that repeated injections in this
area are painful.
The patient can sit, stand or lie down and this site
is still accessible. Whatever position is used, the
entire shoulder and arm area should be exposed
to permit full view of all pertinent landmarks.
The injection should be given in the densest por-
tion of the deltoid muscle-above the armpit and
below the acromion in the posterolateral area,
mid-way between the posterior axillary line and
an imaginary line bisecting the lateral surface of
the upper arm. Grasp the muscle mass at the
injection site and compress between the thumb
and fingers. The needle is inserted pointing
slightly upward toward the shoulder.

22
 Brachial plexus

Deltoid M. ~...:;..

Axillary N.

Median & Ulnar N.

Deep brachial A.
)
Radial N.

Brachial A.

23
Preparing for the injection

THE NURSE Cartridge-Needle Unit or where a reusable syringe

Before preparing and gIVIng an injection the is used, additional preparation is necessary. First,
nurse should be thoroughly familiar with the writ- the empty syringe must be assembled. After the
ten medication order and any special instructions vial of medication has been selected and the seal
or precautions necessary. As in any other medical sterilized with alcohol, the needle is then inserted
procedure, washing of hands before preparing a through the seal, the plunger of the syringe de-
medication and the use of sterilized equipment pressed to expel the air into the vial, and the cor-
are "musts". rect amount of medication withdrawn into the syr-
THE INSTRUMENTS AND MEDICATION inge. The needle is then withdrawn from the vial
When giving an injection with a prefilled TUBEX@ and, in the case of an empty TUBEX Sterile
Sterile Cartridge-Needle Unit, the only equip- Cartridge-Needle Unit, the rubber needle-sheath
ment preparation required is as follows: Select is replaced in order to maintain sterility.
THE PATIENT
the correct premeasured, prefilled cartridge-
needle unit. Mark the patient's name and room When preparing the patient for the injection, an
on the medication envelope before enclosing the attitude of confidence and quiet efficiency in what
TUBEX.Place envelope, the TUBEX@Hypodermic you are doing will generally help to set patients
Syringe and a disposable TUBEX@Isopropyl Alco- at ease and instill a greater degree of cooperation.
hol Sponge on a tray to take to the patient's room. Screening and keeping the patient covered as
much as possible will prevent both uneasiness and
In instances where an empty TUBEX Sterile possible chills.

24
Orders for medications

DOSAGE AND APPLICATION:

Abbreviation Derivation English

aa . ana . of each
ad lib . ad libitum . freely as desi red
c . cum . with
ce . cubic centimeter . cubic centimeter
Gm. (use capital G) . Gram . Gram
gr . g ra n u m . grain
gtt . gutta . drop
m . minim . minim
q.s . quantum sufficit . a sufficient amount
a . rec ipe . take
s . sine . without
3.. . drach ma . dram
:3 ..•...•.........•....•....•.....•.....•...•...........................•....•...•..•. uncia . ounce

TIME OF ADMINISTRATION:

Abbreviation Derivation English

a.c . ante ci bum . before meals

b.i.d . bis in die . twice a day
H . hora . hour
h.S . h 0 ra 5 om ni . bed time
o.d . omni d ie ~ . daily or once daily
D.n. om ni nocte . every night
p.c . post cibum . after meals
p.r.n . pro re nata . whenever necessary (dose
may be repeated)
qh (q3h, q4h, etc.) . quaque hora . every hour (3, 4, etc.)
q.i.d. (or 4i.d.) . quater in die . fou r ti mes a day
si op. sit . si opus sit . if necessa ry
stat . stati m . immediately
t.i.d . te r in die . three times a day

HOURS:

Abbreviation Usual Times

a.c . one-half hour before a meal

b.i.d . 10 A.M. and 4 P.M.
o.d . 10 A.M.
D.n. 8 P.M.
p.c . one hour after a meal
q.i.d . 8 A.M. ,12 noon, 4 P.M., 8 P.M.
q.2.h . 6 A.M. and on even hours day and night
q.3.h . 6- 9. 12- 3, etc., day and night
qA.h . 8. 12- 4- 8, etc., day and night
t.i.d . usually keyed to meals or specifically designated

25
 Prefilled TUBEX@
Preparation steps for injection with St en.1e C ar t.d
n ge- N ee dl e U n .t
I

1. Read the medication order.

2. Select the TUBEX unit required.

3. Write patient's name and room number on envelope and enclose TUBEX cartridge.

4. Place TUBEX Sterile Cartridge-Needle Unit, TUBEX@Hypodermic Syringe and TUBEX@Isopropyl

Alcohol Sponge on tray to take to patient.

TO LOAD THE TUBEX HYPODERMIC SYRINGE

5. Grasp barrel of syringe in one hand. With the

other hand, pull back firmly on plunger and
swing the entire handle-section downward so that
it locks at right angle to the barrel.

6. Insert TUBEX Sterile Cartridge-Needle Unit,

needle end first, into the barrel. Engage needle
ferrule by rotating it clockwise in the threads at
front end of syringe.

7. Swing plunger back into place and attach end

to the threaded shaft of the piston. Hold the metal
syringe barrel-not the glass cartridge-with one
hand and rotate plunger until both ends of TUBEX
Sterile Cartridge-Needle Unit are fully, but lightly,
engaged. To maintain sterility, leave the rubber
sheath in place until just before use.

TO ADAPT 2.CC. SYRINGE TO I.CC. TUBEX

The 2-cc. syringe can be used for a l-cc. TUBEX.

Engage both ends of TUBEX and push the slide
through so the number "1" appears. After use,
the syringe automatically resets itself for 2-cc.
TUBEX.

26
 . steps
Prepara tIon f or InJee
.. t.Ion WI'th/ S'Reusable
.ynnge

I. Read the medication order.

2. Obtain multiple-dose vial of medication.

3. Using forceps remove the syringe barrel and plunger from the sterile boats.

4. Insert plunger into the syringe barrel.

5. Using forceps remove needle from the sterile tray and attach securely to the syringe.

6. Using alcohol-saturated swab, clean the seal of the multiple-dose vial of medication.

7. Pull syringe plunger out to the graduation which corresponds to the amount of
medication ordered.

8. Penetrate the vial seal with needle and invert syringe and vial so that the vial is on top,
taking care that the needle tip is still in the medication.

9. Depress the plunger on syringe all the way in order to expel the air into the vial.

10. Pull out on syringe plunger until the desired amount of medication has been withdrawn.

II. Withdraw the needle from the vial.

12. Return multiple-dose vial to cabinet.

13. Write patient's name and room number on card.

14. Place card, reusable syringe, and alcohol swab on a sterile tray to take to the patient's room.

IS. Cover tray to maintain sterility.

NOTE:

When empty TUBEX@ Sterile Cartridge-Needle Units are used with multiple-dose vials, the
steps of preparation are similar to those for reusable syringes. Assembly is not as time con-
suming or complicated, since the TUBEX cartridge is merely secured into the TUBEX syringe
and the rubber sheath removed. Sterility is maintained after the cartridge-needle unit has been
filled by replacing the rubber needle-sheath until about to give the injection.

27
 Giving the intramuscular injection

Giving medication by means of the TUBEX@

Closed
Injection System or a reusable syringe is basically
the same. These illustrations show the technic
of injection with the draped ventrogluteal site
used as an example.
3. Holding the barrel of the syringe in the right
hand in a dart or pencil grip, introduce the needle
into the skin with a quick thrust.

1. Using an alcohol sponge or swab, cleanse an

4. Once the surface of the skin has been punc-
area approximately two inches square around the
tured by the needle, the remainder of the pene-
proposed injection site.
tration of the needle through the skin and into
the muscle should be with a firm and steady pres-
sureo In the case of average or heavy patients it
is preferable to retain the pressure on the skin
around the injection site with the thumb and
index fingers of the left hand for the entire time
2. With the index and thumb of the left hand the needle is being inserted. In thin patients, on
spread or tense the skin in the injection area. the other hand, it is often preferable to release
the pressure of the left hand once the puncture
has been made, and change to a slight pinching
grip in order to firm the injection site and avoid
the possibility of going too deep and striking a
28 bone, nerve or blood vessel.
5. Once the desired depth of insertion has been
reached, steady the syringe tip with the left hand
and with the right hand pull back or out on the
plunger approximately one-quarter inch for a few
seconds, to see if any blood can be aspirated
back into the syringe. Should blood appear in the 7. After the medication has been injected, apply

syringe, the needle should be withdrawn and a pressure against the injection site with the

new injection site selected. alcohol sponge in the left hand as the needle is
withdrawn by the right hand; this reduces the
risk of medication leaking into the subcutaneous
tissues and possibly forming abscesses.

9. After the injection has been given, it is im-

portant that all the information be recorded on
the patient's chart. This should include: the hour
of injection, name of the medication, amount and
6. If no blood appears, the position of the fingers
strength, method of administration, specific site
on the right hand can be shifted so that the
including which side of the body, any unusual
thumb covers the head of the plunger and the
reaction and your signature. No injection is com-
index and middle fingers are hooked under the
plete until this has been done.
side grips on the syringe barrel. With a firm pres-
sure on the thumb move the plunger downward 8. Then proceed to cleanse the injection site,
into the syringe as far as it will go. (The small air by massaging the area with the sponge to remove
bubble that is last to disappear is an important any blood or medication that might be present.
part of the injection, since it helps to spread the If rapid absorption is desired, the massaging
medication, clear the medicine from the needle, should be continued for about two minutes.
seal the injection site and prevent tracking of the
medication as the needle is withdrawn.) 29
 After the injection with/ TUBEX

1. Return used TUBEx and tray to nursing station.

TO REMOVE EMPTY TUBEX@

2. Replace sheath, using a twisting motion to

avoid snagging. To disengage plunger from piston
hold the glass cartridge and rotate the plunger
counterclockwise. When plunger is disengaged,
pull back firmly on plunger and swing the entire
handle section downward. Do not pull plunger back
before disengaging or syringe will jam. Rotate
TUBEx Cartridge-Needle Unit counterclockwise to
disengage at front end of syringe and remove from
synnge.

3. Before discarding, the sheath-covered needle

should be bent to seal the lumen in order to dis-
courage pilferage or reuse. The syringe, never
having come in contact with patient or medication,
is returned to storage.

NOTE: Used TUBEx Cartridge-Needle Units should

not be employed for successive injections or as
multiple-dose containers. They are intended to be
used only once and discarded.

30
 After the injection witya Reusable Syringe

I. Return used syringe and tray to nursing station.

2. Fill, eject and rinse syringe with tap water.

3. Disassemble needle from syringe.

4. Fill syringe with detergent or blood solvent and let stand for at least 30 minutes.

5. Place needle in sterilizer for 30 minutes at 250 degrees Fahrenheit to decontaminate and
render safe for handling.

6. Brush syringe barrel interior, plunger and tip with low-sudsing, nonetching detergent.

7. Rinse syringe parts twice in tap water and once in a tray of distilled water.

8. Clean inside of needle hub with a water-saturated cotton swab containing blood solvent or detergent.
J

9. Pass a stylet through the interior of the needle to remove any skin tissue, rubber vial
stopper cores, blood or foreign matter.

10. Check needle for sharpness and, if needed, resharpen properly and repeat cleaning process.

II. Rinse entire needle with tap water, including ejecting through the needle with a syringe.

12. Repeat the flushing of the needle with a syringe filled with distilled water.

13. Place syringe and needle in individual paper wrappers and then into a tray ready for sterilizing.

14. Put tray into steam sterilizer, close sterilizer door and set the temperature at 250 degrees
Fahrenheit for 30 minutes.

15. At the end of 30 minutes open the sterilizer door slightly and allow the needle and syringe
to cool and dry for 15 minutes before removing.

16. Store sterile injection equipment in sterile tray or "boats" until required for use.

31
 BIBLIOGRAPHY

1. American Academy of Pediatrics: Report of the Committee on the

Control of Infectious Diseases 1966 (Red Book), Ed. 15,
Evanston, Ill., p. 4.
2. Broadbent, T. R.; Odom, G. L., and Woodhall, B.: Peripheral
nerve injuries from administration of penicillin; report of four
clinical cases, 1. Am. Med. Assoc. 140:1008 (July 23) 1949.
3. Brown, L. B., and Nelson, A. R.: Postinfectious intravascular
thrombosis with gangrene, Arch. Surg. 94:652 (May) 1967.

4. Butters, A. G.: Intramuscular injections (Correspondence), Brit.

Med. J. 2:1362 (Nov. 18) 1961.
5. Cates, H. A.: Primary Anatomy (Basmajian, J. V., [ed.]), Ed. 4,
Baltimore, Williams and Wilkins Co., 1960.
6. Combes, M. A.; Clark, W. K.; Gregory, C. F., and James, lA.:
Sciatic nerve injury in infants; recognition and prevention of
impairment resulting from intragluteal injections, J. Am. Med.
Assoc. 173:1336 (July 23) 1960.
7. Curtiss, P. H., Jr., and Tucker, H. l: Sciatic palsy in premature
infants; a report and follow-up study of ten cases, J. Am. Med.
Assoc. 174:1586 (Nov. 19) 1960.
8. Gellis, S. S. (ed.): Year Book of Pediatrics, 1965-66, Chicago,
Year Book Medical Publishers, pp. 374, 375; 433-435.

9. Gilles, F. H., and French, J. H.: Postinjection sciatic nerve pal-

sies in infants and children, J. Pediat. 58:195 (Feb.) 1961.
10. Gray, H.: Anatomy of the Human Body (Goss, C.M. [ed.]), Ed.
27, Philadelphia, Lea and Febiger, 1959.
11. Hanson, D. l: Intramuscular injection injuries and complica-
tions, GP 27:109 (Jan.) 1963.
12. Hanson, D. 1.: Acute and chronic lesions from intramuscular
injections, Hosp. Formulary Management 1:31 (Sept.) 1966.

13. Hill, L. F.: Sites for intramuscular injections (Editor's Column),

1. Pediat. 70:158 (Jan.) 1967.
14. Hill, L. F.: Complication resulting from an intramuscular injec-
tion (Letters to the Editor [reply]), 1. Pediat. 70:1012 (June)
1967.
15. Hughes, W.: Pediatric Procedures, Philadelphia, W. B. Saunders
Co., 1964, pp. 87-98.

32
16. Hughes, W. T.: Complication resulting from an intramuscular
injection (Letters to the Editor), J. Pediat. 70:1011 (June) 1967.
17. Intramuscular injections (Editorial), Brit. Med. J. 2:758 (Sept.
16) 1961.

18. Knowles, J. A.: Accidental intra.arterial injection of penicillin,

Am. J. Diseases Children 111 :552 (May) 1966.

19. Kolb, L. C., and Gray, S. J.: Peripheral neuritis as complication

of penicillin therapy, J. Am. Med. Assoc. 132:323 (Oct. 12)
1946.

20. Lachman, E.: Applied anatomy of intragluteal injections, Am.

Surgeon 29:236 (March) 1963.

21. Lloyd.Roberts, G. C., and Thomas, T. G.: The etiology of

quadriceps contracture in children, J. Bone and Joint Surg.
46B:498 (Aug.) 1964.

22. Matson, D.: Early neurolysis in treatment of injury of peripheral

nerves due to faulty injection of antibiotics, New Eng!. J. Med.
242:973 (June 22) 1950.

23. Morris, H.: Human Anatomy (Schaeffer, J.P. [ed.]) , Ed. 11, New
York, Blakiston Div. McGraw-Hill, 1953.

24. Scheinberg, L., and Allensworth, M.: Sciatic neuropathy in

infants related to antibiotic injections, Pediatrics 19:261
(Feb.) 1957.

25. Shaw, E. B.: Transverse myelitis from injection of penicillin,

Am. J. Diseases Children, 111 :548 (May) 1966.

26. Spinal cord damage from injection of penicillin (Editorials), J.

Am. Med. Assoc. 196:730 (May 23) 1966.

27. Talbert, J. L.; Haslam, R. H. A., and Haller, J. A., Jr.: Gangrene
of the foot following intramuscular injection in the lateral
thigh: a case report with recommendations for prevention, J.
Pediat. 70:110 (Jan.) 1967.

28. Turner, G. G.: The site for intramuscular injection, Brit. Med.
J. 2:56 (July 8) 1944.

29. Wolf, 1. J.: A two-stage "controlled" intramuscular injection

technic, Clin. Pediat. 7:230 (April) 1968.

30. Zelman, S.: Notes on techniques of intramuscular injection; the

avoidance of needless pain and morbidity, Am. J. Med. Sci.
241 :563 (May) 1961.

33
 Closed Injection System, Wyeth

TUBEX., Sterile Cartridge-Needle Unit, Wyeth

TUBEX., Hypoderrnlc Syringe, Wyeth
NON-REACTING GLASS CARTRIDGE
STURDY, STAINLESS, UNBREAKABLE SYRINGE

CONTAMINATION-PREVENTING

NEEDLE SHEATH

SUPER-SHARP, SILICONIZED,
Disposable Alcohol Sponge, Wyeth
STAINLESS STEEL NEEDLE
 Wyeth Laboratories • Philadelphia, Pa. 19101

PRINTED IN U.S.A.~COOE5923R5 CTO~MAY,j1969

This pamphlet on the intramuscular injection of medicines was what was
called a “detail” pamphlet. Its main purpose in life was to promote the
use and sale of a particular product. These had useful information in
them, In fact I cannot remember if I was given these for a particular
class while in school, while on rotation in a hospital so I wouldn’t be a
complete klutz, while on internship, or because I was lowest in seniority
and was therefore delegated to deal with the sales people. The
information in this pamphlet, once one ignores the product specific
verbiage, is useful and worth having. One never knows when one
might just have to give an injection in an emergency situation, refer to
earlier comment about not looking like a complete klutz. Also, with the
advent of just about any partially trained person giving injections for
allergies, Flu vaccinations and the like, maybe it would just be a good
idea to know if it is being done right.

These particular documents are not seen much anymore, they were well
made, high quality, and durable, pretty much pricing them out of
existence, particularly since they were handed out free. The cynical
might say also because they were useful.