Help: Worried and Concerned.

[brnxbomers]

i jus started doing HCG for the first time. i just did my second 250 i.u. today. Subq...the first one went great but today i went to the other side and it bled a drop or two after i took it out...and now later today it looks slightly red and bruised??

Should i be worried??? Or i hit a vessel. i was using slins btw

much advice needed

Thanks

[Atomini]

Is it hot to the touch? Any fever?

Unless those 2 extra signs come up, I think you're fine. Could be just a hit vessel.

[cherrydrpepper]

Make sure you are aspirating dude. All i shot today was vitamin c and b12 but i aspirated both shots. Just pull back a little and if a bubble comes into the syringe you are good; if blood comes in you have to start over. I don't like to take chances because if you inject air into a vein by accident it can cause an embolism and kill you.

[ottomaddox]

Have you heard of The "Air Bubble Technique of IM injecting?

I don't like to take chances because if you inject air into a vein by accident it can cause an embolism and kill you.

Originally posted on MuscleSci by 956Vette:

Introduction

Intramuscular (IM) injections, as the name implies, administer drugs directly into the muscle beneath the subcutaneous tissue. This route allows quicker absorption than subcutaneous injections.

In the UK the Z-track method is widely used, advocated by Beyea and Nicoll (1996) as it controls leakage into the surrounding tissues and is generally more comfortable for the patient.

However, a comparative study of depot intramuscular injection techniques has revealed that the air-bubble method widely used in Canada and USA is significantly more effective at controlling seepage than the Z-track (Quartermaine, 1995).


A further study compiled at the Bracton Centre, Specialist Mental Health Service, could provide no advantages to choosing either the air-bubble method or the Z-track method over each other.
Complications of IM injections

Complications can occur at the site of the injection following IM drug administration, such as seepage of the injection solution and/or bleeding from the injection site onto the skin, pain, irritation and even skin lesions. Such complications are widely recognised and have been investigated (Hay 1995, Murphy 1991). One cause of complications noted in these investigations is some degree of fault in the IM injection administration technique itself.

Injection sites

Taylor et al (1993) recommend the rotation of sites if a series of injections is to be administered, in order to reduce the risk of local reaction.

IM injections should be given into the upper outer quadrant of either the thigh or buttock, into the gluteal muscles.

Correctly identify the site

Place patient on their side with their top leg flexed to relax the muscle.
Mark out an imaginary cross thus dividing the area into four quarters.
By injecting into the upper outer quadrant of the buttock, the sciatic nerve will be missed.
Z-track technique

Place the ulnar side of your non-dominant hand on the chosen injection site and stretch the skin taut.
Hold the needle at 90 degrees to the skin.
Plunge the needle in quickly, penetrating the muscle and leaving about a third of the needle exposed.
Pull back on the plunger to observe for blood aspiration. If blood is aspirated the procedure should be discontinued.
If no blood is aspirated, slowly and continuously inject the drug.
After a couple of seconds withdraw the needle at the same angle at which it went in.
Release the skin. This has the effect of breaking the needle track as the skin and subcutaneous layers move back over the muscle. The drug is therefore locked within the muscle. (Belanger, 1985)
Air bubble technique

The procedure for the air bubble technique differs from the Z-track in only one way. When drawing up the medication, a small bubble of air is also drawn up. This is injected into the muscle with the drug, thus forming an air lock in the muscle depot preventing the medication from seeping out along the needle track into other subcutaneous tissue or onto the skin. (Pritchard and Mallett 1992, Taylor et al 1993)

Keen, (1986) suggests that the Z-track technique produces more pain at the injection site and this is further supported by MacGabhann (1996).

Does experience improve IM technique?

MacGabhann goes on to suggest that "The period of training for staff during the study highlighted disparate knowledge and practice of injection techniques. There was no working policy or procedure on administering injections to which staff could refer". This implies a potential discrepancy between ongoing training and improving techniques.

Katsma and Smith (1997) suggest that the potential for pain experience in IM injections is due to the kinematics of injections, ie. the movement of the needle through muscle and tissue. He goes on to say "Minimizing of this effect is accomplished by controlling the needle trajectory during penetration along a linear path from point of contact to end point."

The study invloved 35 RGNs and 21 3rd year student nurses. Student nurse characteristics differed from experienced nurses primarily in syringe angular positioning. They tended to be closer to the "textbook" style (which they had been recently taught) with angle at contact closer to vertical. However, kinematic characteristics describing the non-linear characteristics during needle penetration were not significantly different from those of experienced nurses.


While it is fair to assume that the more experience a nurse has the more likely she will be to optimize a technique for IM administration, this study suggests the wide variability of the nurse kinematic characteristics argues against this optimization occurrence.

Conclusion

There are arguments for and against both the Z-track method and the air bubble method of IM injection techniques and currently in the UK the most commonly used is different variants of the Z-track method (MacGabhann, 1996). This said, nurses should not become complacent in their abilities to administer injections. As the study by Katsma and Smith showed, some experienced nurses have a much poorer technique than those less experienced than them. To understand the rationale, supported by effective research, behind good injection technique can only serve as a benefit to the profession as a whole, our patients and the nurses of the future.



References

Belanger MC (1985) Long acting neuroleptics: technique for intramuscular injection. Canadian Nurse. 81, 8, 41-44.

Beyea, S., Nicoll, L.M. (1996) Back to basics. Administering Intramuscular Injections the right way. American Journal of Nursing 96:1, 34-35

Hay J (1995) Complications at site of injection of depot neuroleptics. British Medical Journal. 311, 421.

Katsma, D., Smith, G. Intramuscular injection mechanics: Does experience improve technique?Nursing Research, 46, 288-292, 1997.


Mac Gabhann L (1996) A comparison of two depot injection techniques. Nursing Standard. 12, 37, 39-41

Murphy JI (1991) Reducing the pain of intramuscular (IM) injections. Clinical Care. July/August, 35.

Quartermaine S (1995) A comparative study of depot injection techniques. Nursing Times. 91, 30, 36-39.

Pritchard AP, Mallett J (1992) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Third edition. London, Blackwell Scientific.


Taylor C, Lillis C, Le Mone P (1993) Fundamentals of Nursing: The Art and Science of Nursing Care. Second edition. Philadelphia PA, JB Lippincott.

I thought this would be worthwhile as I often see questions about how much air it will take to cause death...and many people are convinced it is only a couple of mL's. This also describes simply and briefly the anatomy of the vessels and flow of circulation to make death by air (air embolism) possible.

SCIENCE IN CRIME DETECTION
DEATH BY AIR INJECTION
Dr. Anil Aggrawal


Technically known as cases of "air embolism". The word embolism comes from Greek en, "in," and ballein, "to throw or cast". Henceforth we will be using the term "air embolism".

Before telling anything further about death by air embolism, let us first understand a little bit about the way our blood circulates in our body. This is very essential to understand how a person is killed by injection of air. Our heart is comprised of 4 chambers. There are two chambers on the right and two on the left side. The chambers on the right side are known as right atrium and right ventricle, while the chambers on the left side are known as left atrium and left ventricle. Bad blood (deoxygenated) from legs, head, arms and in fact from every part of the body returns to the upper right chamber called the right atrium.

With each contraction of the heart the right atrium sends this bad blood to the right ventricle. The right ventricle, in turn, sends this blood to the lungs via pulmonary arteries. Do not let the complicated names baffle you. Just remember that atrium and ventricles are fancy sounding names of some chambers of the heart. Ventricle is a larger chamber than atrium. Also keep in mind that "artery" is the name of a conduit which takes the blood away from the heart while vein is the name of a conduit which brings blood to the heart. The word pulmonary comes from Latin pulmo, "the lung". Thus "pulmonary artery" refers to a conduit which takes the blood away from the heart towards the lung.

In the lung, the bad blood is purified (oxygenated). This is done by the help of the air which we breathe all the time. The pure blood is returned to the heart via pulmonary veins. The blood comes in the third chamber of the heart known as left atrium. Left atrium sends this blood to the left ventricle, which in turn, pumps this pure blood to the whole body via a very big conduit known as the aorta. The body organs use this pure blood, and when this blood becomes impure, it is once again returned to the right atrium. And thus the circulation goes on.
Now we are ready to understand how air embolism works. First of all we must appreciate that nature has made this whole system of circulation air-proof. This means that there is no way, air could enter this system of conduits and pipes. If somehow air could enter the system (such as by injection of plain air through a syringe), the air will form an "air lock" within the system. This "air lock" is quite familiar to plumbers and owners of diesel engines, where the normal flow of liquid through tubes is wholly or partially blocked by air. Quite in the same manner this air lock blocks the flow of blood through the arteries and veins, thus bringing the circulation to a halt. Let us make this a little more clear.

Air could be made to enter the circulation either through the arteries or through the veins. When an injection of air is given, the air bubbles start travelling towards the right atrium. From right atrium they keep travelling onwards till they come to the lung. Here the capillaries are too narrow to allow the big bubbles to pass. The result is that these bubbles get entangled in the blood vessels of the lung. The whole blood traffic stops and the person dies very quickly. In fact this bad blood can not be purified by the lungs, because the traffic of blood towards the lungs has been stopped. The body can not imagine that such a sinister thing has happened. It "thinks" that the blood is not getting purified because of lack of air. So it quickens the respiration. The person starts gasping. But nothing helps because the cause lies somewhere else and the person dies.

Now this is where discrepancies lie…in how much is needed. This article cited 200 mL (cc’s), which I think is an exaggeration. Other articles I have come across state wide ranges…anything from 20 mL to the above mentioned 200. I say about 20 mL, as an educated guess…and I read that in some nursing journal during schooling as well. 20 mL is approximately the length of an IV line…so those who’ve been in hospital can now envision how much is needed.

Search it's the ultimate tool!

[DocBman]

No worries brother. Your fine, bruising could be from too much movement once inside or maybe you did hit a vessel on way out. If so, it clots very quick and the bruising is just residual from what bled out before coagulation.

I agree with everyone else MAKE SURE YOU'RE ASPIRATING!!! Also, someone mentioned before redness, fever and warm to the touch. If you have these symptoms, keep a close eye on the sight eg. red streaks under the skin from the injection site.

Give it three days. If symptom get worse see a doc, other than that I wouldn't worry too much.