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Drop Your Drawers and Bend Over
by Sara Lebouef
My friend Texson asked me to write this post for you guys. He felt that I should share my 23 years of IM glut injection experience and maybe prevent someone from seriously injurying or damaging themselves.
First a lesson in anatomy - or more info than you think you need:
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Finding the injection area
When the gluteal muscles are used, injections should be made on the upper, outer quadrant of the buttock to avoid damaging the sciatic nerve.
You can find and outline the injection area by creating an index with your hand to use as a pinning guide. This is done while facing the glute:
Using the femoral and pelvis bones (see illustration above), you can create an index with your hand by placing the thumb on the outer portion of the femoral bone (outer most part), and stretch your index finger to the highest point of the pelvic bone. The area above this index line made with your fingers is the safe injection area. Create the index on the left side using the right hand and vice versa.
The super lateral (upper outer) quadrant of the buttock is relatively free of nerves and vessels and is frequently used for intramuscular injections in order to avoid the sciatic nerve and other important structures. An alternative site is over the gluteus medius in a triangular area bounded by the anterior superior iliac spine, the tubercle of the iliac crest, and the greater trichinae (hip bone).
The Sciatic Nerve
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Note the white strands in the cut-a-way. These represent the sciatic nerves approximate location and are what you really want to avoid! The largest nerve in the body, the sciatic nerve consists of two parts, tibial and fibular, which are initially bound together and then separate at a variable level into two nerves
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Okay - now some things that are not in the books
1. If possible, do not do the injection yourself.
2. Relax. The idea of getting an injection can cause you to tense the glut muscle and make the shot painful .
3. The shot needs to be administered while standing and with your toes pointed inwards (heels apart and with big toes almost touching). It is not possible to tighten the gluteus in this position so the shot is less painful. Relaxed muscle is easier to go through than tightened muscle, and judging from some of the really nice tight butts Ive seen on here you need all the help you can get in that area. Hey Im a woman I looked lol
4. Clean the area with alcohol or Betadine. Really scrub the injection area well. Just a quick swipe is not good enough - scrub!
5. After the injection, massage the area for at least 15 seconds or more. You just injected some really thick, heavy stuff. Massaging helps with blood flow to the area and starts a faster absorption process.
6. Never reuse a needle! Theres a reason why they are disposable - they're cheap, dull easily, cause increased scar tissue and increase risk of infection. No - wiping it with alcohol is not good enough!
7. Inserting the needle slowly is not a good method to use for penetration. It is almost impossible to keep the syringe completely steady and rocking it causes even more tissue damage. Instead, push the needle in like a dart - fast. This method is less painful and less damaging.
8. Rotate the sites. Alternative sites include the vastus lateris (thigh muscle) or the deltoid (the arm muscle), pecs and others. Repeatidly injecting in the same sites causes increased scar tissue to form in the area.
Only want to shoot the glut? Then you have approx 4 square inches of 'safe' area on each side in which to rotate the shots.
9. Dont use an air bubble in the syringe. A carryover from the days of reusable syringes, air bubbles can affect the medication dosage by 5% to 100%. Modern disposable syringes are calibrated to administer the correct dose without an air bubble.
10. For single-dose or multidose vials: Reconstitute powdered drugs according to instructions. Make sure all crystals have dissolved in the solution. Warm the vial by rolling it between your palms to help the drug dissolve faster or heat it on the hot plate of and electric coffee maker.
11. Wipe the stopper of the medication vial with an alcohol sponge or wipe and then draw the prescribed amount of medication. Verify the correct dosage.
12. IM injections deposit medication deep into muscle tissue. This route of administration provides rapid systemic action and absorption of relatively large doses (up to 3 ml in appropriate sites).
13. Always aspirate (draw back on the plunger) to see if blood is withdrawn. If blood is withdrawn, the needle tip is in a vessel and the needle should be repositioned. Be aware that you can be inside a vien and still withdraw an air bubble if the needle is seated against the interior wall of the vien.
14. Injecting IM medications outside of the muscle could possibly result in a poor response to the medication or adverse effects. Medications given into the subcutaneous tissue could result in an alteration of the anticipated action.
15. Be aware of the relationship of muscle mass, subcutaneous tissue, and needle length used during an IM injection. In addition, Continually assess your knowledge and techniques by reading articles.
16. Utilizing the proper technique when giving an IM injection will help minimize the possibility of a complication. If a complication occurs, the true etiology (cause) of the injury must be made known so that appropriate treatment can be given. That means telling the Doctor the truth!!!! Treatment of the necrosis or infections proceeds along standard treatment lines. Be aware that the necrotic or infectious lesion on a buttock or thigh might not be an ulceration but a pretender.
17. The technique of injecting as the needle is advanced through the tissues is not recommended. This technique results in the medication being distributed along the needle track and in multiple tissues, which causes erratic absorption of the medication as well as injection into the subcutaneous tissues. Avoiding intravascular injection with this technique is impossible.
Notes:
Injection Fibrosi is a complication that may occur if the injections are delivered with great frequency or with improper technique.
Alternating the injection site can prevent complications from tissue necrosis (dead/ dieing tissue). Repeated injection of any medication into the same area will increase the size of the necrotic lesion.( looks like black thick scar- it's dead tissue)
Don't like rules! Think all of this is bull shit!
THIS COULD HAPPEN TO YOU!
Table 1. Complications of IM injections
Seeping of injected solution
Bleeding from the injection site
Hematoma
Intravascular injection
Nerve injury
Pain
Abscess
Necrosis of tissue
Scar formation
Contracture of joints
Malignancy
Today, the incidence of developing a complication from IM injections ranges from 0.4 percent to 19.3 percent of people receiving the IM injection of a medication. The complications that can occur following this procedure are numerous, and some are surprising . It has been suggested that most of the problems stemming from the procedure are related to local trauma of the injection itself or the irritating properties of the drug. Others suggest that inadequate training in the proper injection technique is responsible for many of the complications. In some cases, the true etiology of the problem is not immediately apparent.
Abscess Formation
Abscess formation at the site of an IM injection was the first recorded complication. The bacteria can be carried to the tissues because of poor site preparation. Inadequately sterilized equipment and medications also can be responsible for inoculation of the area. The majority of these complications present with red, hot masses surrounding the previous injection sites. Occasionally, an abscess will rupture, and the site will be draining pus and liquid fat. Incision and drainage of the area will result in marked improvement in the discomfort and will allow for cultures to be obtained to direct antibiotic therapy. The majority of these cases are seen within a few days to a few weeks following the injection; however, in some cases, an abscess clinically may not be apparent for years after the injection.
More commonly, the abscesses that are seen at IM injection sites are sterile abscesses. These are nodules of liquefied fat and muscle resulting from necrosis of the involved tissues. Their development has been blamed on a hypersensitivity to the injected medication, but more detailed research has shown that the problem develops when a caustic medication is injected in an inappropriate location. When the medication is injected into the subcutaneous tissues rather than the muscle, absorption is delayed, which allows for a greater tissue reaction to the medication. This reaction is manifested by local tissue necrosis and liquefaction with a surrounding area of intense inflammation. Thus, a painful nodule filled with sterile, liquefied tissue remains at the site. Many times this problem is caused by not using a needle of sufficient length to reach the muscle.
Nerve injury
Nerve injury is another serious complication of IM injections and occurs more frequently than originally thought. The site of injection is the crucial factor in determining the degree of nerve fiber injury. The degree of injury varies significantly, depending upon the specific agent injected. The most severe injuries have been associated with widespread axonal and myelin degeneration
Pathological alterations in the nerve were evident as early as 30 minutes following injection injury. The postulated mechanisms of injury include direct needle trauma, secondary constriction by scar, and direct nerve fiber damage, due to both axon and Schwann cell, with a breakdown in the blood-nerve barrier by neurotoxic chemicals in the injected agent
Neurological sequelae can range from minor transient sensory disturbance to severe sensory disturbance and paralysis, with chances of recovery were small.
Sciatic nerve injury following injection is commonly manifested by paresis in the sciatic distribution followed by a causalgia or burning pain in the extremity several hours or days later. Damage to motor function can be more severe, and recovery may be less complete or not at all. There is no specific medication that is neurotoxic when injected close to a nerve, but all will result in complete transverse necrosis of the nerve with extension of the necrosis to the exit of the nerve from the spinal cord if injected directly into any nerve.
Foot Drop
Foot drop indicative of a sciatic nerve injury following gluteal intramuscular. The course of the sciatic nerve in the gluteal region places it at risk for injury from IM injections. Proper technique minimizes the risk of injury. Symptoms painful, swollen left leg that improved during several weeks. leg "started to shrink." No history of polio infection and did not have any weakness in other limbs or associated sensory disturbance. lower leg revealed marked muscle wasting. Power was markedly reduced to grade I out of 5 for dorsiflexion, inversion, and eversion. An absent ankle jerk, although sensory examination are normal. Typical high-steppage gait indicating left foot drop. Findings were consistent with a partial sciatic nerve injury, most likely secondary to the injections. The prognosis for improvement was poor.
Pain
Pain during an IM injection generally is to be expected. Persistent pain, however, at the injection site is not an expected event. Reports that persistent pain may occur in 23 percent of the patients who have complications. The prolonged pain is usually due to irritation or chemical neuritis of a nerve; however, local muscle spasm due to the presence of the irritating medication has been faulted. Continued pain at an IM injection site must be investigated to ensure it is not a symptom of an underlying abscess or other local problem. Many times this requires an MRI. Needle size nor needle length influence the degree of pain experienced at the time of the injection or the incidence of post-injection persistent pain.
Necrosis
Necrosis of the surrounding tissue following IM installation of a medication was not thought to occur unless the you were allergic to the medication. It has been found that necrosis of the muscle will occur after any IM injection no matter what medication is injected. The only variable is the size of the necrotic lesion and the severity of it. Forceful placement of a volume of fluid into a closed space will cause damage. In other words, the surrounding muscle and tissues in the immediate area of the needle tip are subjected to the pressure of the mass of fluid that has been instilled into the area, which causes pressure necrosis. The toxicity of the medication, the volume injected, and even the speed at which the injection is given also will influence the size of the necrotic lesion.
Scar Formation
The significance of the necrosis may be negligible when few injections are given, but if multiple injections are given, especially in the same area over a protracted period of time, the areas of necrosis may become quite large and result in large areas of fibrosis of the tissues. This may be manifested by hard nodules felt deep in the tissues and even sunken areas of scar tissue seen on the surface of the skin. Dystrophic calcification of the scar tissue can occur with time resulting in even more painful areas
Muscle Fibrosis
Muscle Fibrosis from IM injections is a significant problem. Numerous reports have shown that in humans fibrosis of the extremity muscles following IM injections can result in contracture of joints. The local damage caused by the injected medication plus the local pressure necrosis causes the muscles to scar and shorten. This causes the extremity to be held in an abnormal position, prevents normal range of motion, and can dislocate an extremity. This problem has been reported in the shoulder due to deltoid fibrosis, the hip due to gluteal fibrosis, and the knee due to quadriceps fibrosis. In a thorough review of the subject of muscle fibrosis, Brodersen concludes that the majority of the muscle fibrotic complications and contractures were not apparent until the advent and widespread use of IM injections. Repeated IM injections causes damage to the muscle with development of the fibrosis. Treatment of these problems requires operative release of the fibrotic contractures and intensive postoperative physical therapy. Treatment with physical therapy, use of nonsteroidal agents, and stretching are not effective.
Malignancy
Despite the severity of the previously discussed problems, a far more disturbing complication has been reported following IM injectionsthe development of malignancies at injection sites. The reported tumors have all been forms of sarcoma. There has not been a common medication injected in patients who developed the malignancies. Even though the incidences must be extremely low, any patient who has had an IM injection and continues to complain of a painful nodule at the injection site well after the injection should be thoroughly examined.
Bleeding
Bleeding from the injection site is not uncommon. Significant bleeding and hematoma formation can occur if blood vessels are injured. The person administering the IM injection should be adequately familiar with the anatomy of the region into which the medication is being given to avoid damage to blood vessels and subsequent bleeding complications.
Leakage
Leakage or seeping of the injected solution from the injection site after the needle is removed seems to be an insignificant problem but can result in erratic absorption of the medication and loss of the expected dose of the medication. This usually occurs in patients who have significant scarring at the injection site, which makes the tissue hard and less receptive to accepting the volume of fluid injected. Large amounts of simple edema fluid or lymphedema fluid at the injection site can result in erratic absorption of the medication and in medication loss since the injection tract cannot seal easily.
Treatment
The treatment of each of these complications should be individualized to the particular complication. The problems that appear as open wounds should be treated as any wound would be treated. Debridement ( cutting out dead tissue, seen as black/ brown hard scab like appearance with soft purulent soft, green / white tissue under it) is needed for necrotic open wounds followed by good moist wound care. Painful nodules occurring soon after injection should be treated expectantly to see if they will resolve with time. Infectious complications will require treatment with incision and drainage and appropriate antibiotic medication. For the other complications, prompt specialty referral will be the best approach.
Since all IM injections cause necrosis (death) of the tissues and some type of reaction, avoiding the technique completely if possible would be best. If an IM injection must be done, the appropriate technique for carrying out the procedure must be observed.
Table 2. Avoidance of IM injection site complications
Determine landmarks
Clean skin thoroughly before inserting needle
Use disposable syringes
Use single unit dose medications
Use needle of adequate length
Inject medication only into muscle, not fat
Avoid injecting during needle insertion
Aspirate syringe prior to injecting
Avoid repeated injections into the same site
Stain showing Fat Abscess
white areas are the infected areas
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This is an abscess from an injection in painful stage 4 ulceration of the right ileal area that was full of necrotic (dead) tissue. Examination showed an area of induration (dent) of the right buttock at the site of the previous skin disruption. The hardness was at least 2cm below the surface of the skin. There was no overlying skin defect. No redness of the skin or other problems were noted. Magnetic resonance imaging (MRI) scan was interpreted as showing an abscess in the subcutaneous tissues of the right buttock just to the right of the midline.
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Bacteria liquefies the fat tissue and allows the bacteria to spread through the body.
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Small Abscess
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Large Abscess
that has tunneled down from original injection site to the lower buttocks, destroying tissue from the injection site down through the buttock and exiting on the lower buttock.
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Attached Files
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