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Intramuscular injection

An intramuscular injection (IM) is a parenteral technique for delivering medication into the depth of a specifically selected muscle, where the rich vascularity promotes rapid absorption into the bloodstream.^[1] This method is widely used in clinical settings for administering vaccines, antibiotics, hormones, and other therapeutics that require efficient delivery or avoidance of first-pass metabolism in the liver.^[2] The choice of injection site depends on factors such as the patient's age, body mass, medication volume (typically up to 5 mL in adults), and the need to avoid major nerves or blood vessels.^[2] Common sites include the deltoid muscle in the upper arm (suitable for volumes up to 2 mL and often used for vaccines in adolescents and adults), the vastus lateralis in the anterolateral thigh (preferred for infants and self-administration), and the ventrogluteal region in the hip (considered the safest for larger volumes due to minimal neurovascular structures).^[3]^[4]^[1] The dorsogluteal site in the buttocks is less favored owing to the risk of sciatic nerve injury.^[2] While effective, IM injections carry risks including localized pain, hematoma, infection, abscess formation, or rare nerve palsies if landmarks are misidentified.^[1] Proper training and anatomical knowledge are essential to ensure safety and efficacy, particularly in pediatric or obese patients where needle length adjustments may be needed.^[3]

Fundamentals

Definition and Mechanism

An intramuscular injection is a technique for delivering medication into the depth of specifically selected skeletal muscles using a hypodermic needle, penetrating beyond the subcutaneous fat and dermal layers to reach the muscular tissue directly.^[1] This method leverages the anatomical structure of muscles, which consist of layered fibers surrounded by connective tissue, allowing the needle to deposit the drug in a region with minimal interference from overlying adipose tissue.^[1] The primary mechanism of intramuscular injection involves the absorption of the injected substance through the extensive capillary network and rich vascularity of skeletal muscle, enabling rapid diffusion into the bloodstream for systemic distribution.^[1] Skeletal muscles possess a high density of blood vessels compared to subcutaneous tissue, which promotes efficient uptake of water-soluble drugs via passive diffusion across concentration gradients maintained by local blood flow.^[5] This vascular architecture results in faster and more uniform absorption than routes with lower perfusion, such as subcutaneous administration.^[5] Intramuscular injections are particularly suited for medications requiring quick onset or controlled release, including vaccines, antibiotics, hormones, and analgesics, as the muscle's blood supply supports both immediate systemic effects and potential depot formation for sustained delivery.^[1]

Pharmacokinetics and Rationale

Intramuscular injections facilitate drug absorption primarily through the rich vascular network of skeletal muscle, where the injected medication diffuses into surrounding capillaries for rapid uptake into the systemic circulation.^[1] This process typically involves an initial phase of quick absorption for aqueous solutions, often achieving significant plasma levels within minutes to hours, followed by a distribution phase influenced by the drug's physicochemical properties.^[1] For depot formulations, absorption is biphasic: an initial slow release from the injection site forms a reservoir in the muscle tissue, enabling prolonged systemic exposure over days to weeks.^[1] Bioavailability of intramuscularly administered drugs is generally high, ranging from 90% to 100% for most compounds, as the route bypasses gastrointestinal barriers and hepatic first-pass metabolism.^[6] ^[7] Key factors affecting this include the drug's solubility—aqueous formulations absorb faster than oil-based ones—muscle blood flow, which varies by site and physiological state, and the injected volume or dispersion within the tissue.^[8] For instance, reduced blood flow in certain muscles can delay absorption, while highly soluble drugs achieve near-complete bioavailability.^[8] The intramuscular route is clinically rationalized for scenarios requiring faster onset than oral or subcutaneous administration, particularly for emergency treatments or drugs prone to erratic gastrointestinal absorption.^[6] It avoids first-pass hepatic metabolism, preserving drug potency for compounds like certain antibiotics or hormones that undergo significant oral inactivation.^[6] Additionally, it suits poorly water-soluble agents by allowing larger volumes (up to 5 mL in adults) and providing a depot for sustained delivery, reducing dosing frequency.^[1] Pharmacokinetic parameters for intramuscular injections often include a time to peak plasma concentration (T_max) of 30 to 60 minutes for rapidly absorbed drugs, enabling quicker therapeutic effects compared to subcutaneous routes.^[9] ^[10] The elimination half-life remains drug-specific but informs dosing intervals; for example, standard formulations may require repeat injections every 4-12 hours, while depots extend this to weeks.^[11] Depot intramuscular injections, such as those using oil-based testosterone esters like enanthate or undecanoate, exemplify sustained-release formulations that form an intramuscular reservoir for gradual hydrolysis and absorption.^[12] These achieve peak testosterone levels within 1-3 days for enanthate (maintaining therapeutic concentrations for about 2 weeks) or around 7 days for undecanoate (with effects lasting 10-12 weeks), supporting less frequent dosing in hormone replacement therapy.^[13] ^[12]

Indications and Contraindications

Medical Indications

Intramuscular (IM) injections are primarily indicated for administering medications that require rapid absorption, reliable bioavailability, or when oral or intravenous routes are impractical or unavailable. This route is particularly suitable for patients who are noncompliant with oral medications, uncooperative, or intolerant to gastrointestinal administration.^[1] Additionally, IM injections are used in scenarios where intravenous access is not feasible, such as in emergency settings or outpatient care, leveraging the muscle's vascularity for quicker onset compared to subcutaneous routes.^[1] A key prophylactic application of IM injections is in immunizations, accounting for approximately 5% of their use, as recommended by health authorities for optimal immune response. Vaccines routinely administered via IM include influenza (inactivated influenza vaccine), hepatitis B, diphtheria-tetanus-pertussis (DTaP, Tdap), Haemophilus influenzae type b (Hib), human papillomavirus (HPV), pneumococcal conjugate (PCV13), and meningococcal conjugate (MenACWY) vaccines.^[14]^[1] The World Health Organization and Centers for Disease Control and Prevention endorse IM administration for these vaccines to ensure effective antigen delivery and minimize local reactions.^[14]^[15] For therapeutic purposes, which comprise over 95% of IM injections, common categories include antimicrobial agents for treating infections where sustained release is beneficial. Examples are penicillin G benzathine for syphilis or streptococcal infections and streptomycin for tuberculosis.^[1] Analgesics such as ketorolac are indicated IM for moderate to severe pain, including acute migraine attacks in emergency settings, providing rapid relief when oral intake is limited.^[16] Antiemetics like metoclopramide are used IM for nausea and vomiting, particularly in postoperative or migraine-related cases, to facilitate faster symptom control.^[16]^[17] Hormone therapies also frequently employ the IM route for depot formulations that enable prolonged action. Medroxyprogesterone acetate (Depo-Provera) is administered IM as a long-acting contraceptive, while testosterone esters are used IM for hypogonadism replacement therapy.^[1] In emergencies, IM epinephrine is the first-line treatment for anaphylaxis, injected into the anterolateral thigh for swift systemic absorption to reverse life-threatening allergic reactions.^[18] Biologicals such as immunoglobulins and toxoids are likewise delivered IM for passive immunity or booster protection.^[1]

Contraindications and Precautions

Absolute contraindications for intramuscular (IM) injection include known hypersensitivity or allergy to the medication or its excipients, as this can precipitate severe allergic reactions such as anaphylaxis.^[1] Active bleeding disorders or severe coagulopathy also constitute absolute contraindications due to the high risk of uncontrolled hemorrhage at the injection site.^[19] Relative contraindications encompass conditions where IM injection may proceed with heightened caution or alternative routes preferred. These include local infection, cellulitis, or dermatitis at the intended injection site, which could exacerbate the infection or lead to poor absorption.^[1] Muscle atrophy or emaciation in the target area is another relative contraindication, as atrophied muscles absorb medications inadequately and increase the risk of subcutaneous deposition.^[20] Neuromuscular disorders, such as myasthenia gravis, represent a relative contraindication particularly when the injected drug may worsen neuromuscular transmission, necessitating evaluation of the specific medication.^[21] Anticoagulation therapy is a relative contraindication, as it elevates the risk of hematoma formation, though IM injection may be performed if benefits outweigh risks and with additional hemostatic measures.^[22] Precautions prior to IM injection involve a thorough assessment of the patient's medical history for allergies or prior adverse reactions to ensure no hypersensitivity risks.^[23] Monitoring for potential compartment syndrome is essential, especially with large-volume injections or in patients with compromised tissue integrity, by selecting appropriate sites and volumes to avoid excessive pressure buildup.^[24] Dose adjustments are required in cases of renal or hepatic impairment, as these conditions can alter drug metabolism and clearance regardless of the administration route.^[1] Special alerts include avoiding IM injections in patients with thrombocytopenia or those on anticoagulation without prior reversal or consultation, to mitigate bleeding risks.^[25]

Technique

Preparation and Equipment

Intramuscular injections require meticulous preparation to ensure safety, efficacy, and minimization of infection risk, involving the assembly of sterile equipment, proper medication handling, patient readiness, and adherence to aseptic principles.^[26] Essential equipment includes a sterile syringe typically ranging from 1 to 5 mL in capacity, selected based on the volume of medication to be administered, and a needle of 22-25 gauge with a length of 5/8 to 1.5 inches for adults, chosen based on body weight, site, and muscle depth to ensure intramuscular placement.^[3] Additional items encompass alcohol swabs or alcohol-based antiseptic solutions for skin disinfection, nonsterile gloves to maintain barrier protection, and a sharps container for safe needle disposal after use.^[1] A filter needle may be used when drawing medication from vials or ampules containing potential particulates to prevent contamination of the syringe.^[1] Medication preparation begins with verifying the correct drug against the prescription, inspecting the vial or ampule for expiration date, cloudiness, discoloration, or visible particulates, and discarding any compromised product to avoid adverse effects.^[27] If the medication is in powder form, reconstitution is performed by adding the appropriate diluent, such as sterile water or saline, according to manufacturer instructions, followed by gentle mixing until fully dissolved without vigorous shaking to preserve integrity.^[26] The dose is then drawn into the syringe using aseptic handling, ensuring no air bubbles are introduced, and the needle is changed to a fresh one for injection if a filter needle was used initially.^[1] Patient preparation involves explaining the procedure to the individual, addressing any concerns to reduce anxiety and obtain informed consent, and positioning them comfortably to expose the injection site while promoting muscle relaxation, such as lying supine or on their side depending on the selected area.^[1] Site selection considers the patient's body habitus, age, and muscle mass to ensure proper intramuscular placement, briefly referencing anatomical landmarks like the deltoid or vastus lateralis for optimal access.^[28] Aseptic techniques are paramount throughout, starting with thorough hand hygiene using soap and water if visibly soiled or alcohol-based rub otherwise, performed immediately before handling equipment.^[26] Work surfaces must be disinfected with an appropriate agent, such as 70% isopropyl alcohol, and all manipulations conducted in a clean environment to prevent microbial introduction, including avoiding touch contamination of syringe tips, needle caps, and vial septa.^[29] Gloves are donned after hand hygiene and changed if torn or contaminated, reinforcing the barrier against pathogens.^[30]

Standard Procedure

The standard procedure for an intramuscular (IM) injection involves a series of evidence-based steps to ensure safe and effective administration of medication into the muscle tissue, promoting optimal absorption while minimizing discomfort and complications.^[1] This technique assumes that preparation and equipment, such as a sterile syringe, needle of appropriate length (5/8 to 1.5 inches for adults based on weight and site), and the medication, have already been assembled.^[3] To begin, perform hand hygiene using soap and water or an alcohol-based hand rub to maintain aseptic conditions.^[31] Select and expose the injection site, then clean the skin with an alcohol swab in a circular motion from the center outward, allowing it to air dry completely to reduce the risk of introducing contaminants.^[26] Next, stretch the skin taut at the site using your non-dominant hand to stabilize the area and facilitate needle insertion.^[23] Insert the needle swiftly and smoothly into the muscle at a 90-degree angle to the skin surface, using a dart-like motion to penetrate the muscle belly perpendicularly; this angle ensures the medication reaches the intended depth, which varies by site and patient but for the deltoid in adults is achieved with needles of 5/8 to 1.5 inches based on weight (e.g., 5/8-1 inch for <152 lbs, up to 1.5 inches for heavier individuals).^[28]^[1] Once inserted to the hub of the needle, inject the medication slowly at a rate of approximately 1 mL every 10 seconds to allow muscle fibers to stretch gradually, reducing pain and the risk of leakage.^[1]^[32] The maximum volume per injection varies by site and muscle mass (e.g., up to 1 mL for deltoid, 5 mL for vastus lateralis or ventrogluteal), to prevent overflow into subcutaneous tissue.^[33]^[34] After injection, withdraw the needle quickly and steadily at the same 90-degree angle, without recapping it, and immediately dispose of it in a sharps container.^[31] Apply gentle pressure to the site with a clean gauze or cotton ball for 10-30 seconds to promote hemostasis and absorption, but avoid massaging unless specified for the medication, as this can increase irritation.^[23] Monitor the patient for immediate adverse reactions, such as excessive bleeding or pain.^[1] Finally, document the procedure in the patient's medical record, including the medication name and dose, injection site, date and time, needle gauge and length used, patient tolerance, and any observations.^[26] This documentation ensures continuity of care and legal compliance with healthcare standards.^[31]

Aspiration and Z-Track Method

The aspiration technique in intramuscular injection involves inserting the needle fully into the muscle and then gently pulling back on the syringe plunger for 5 to 10 seconds to observe for the presence of blood, which would indicate inadvertent entry into a blood vessel.^[35]^[36] If no blood appears, the injection proceeds; otherwise, the needle is withdrawn and discarded to avoid intravenous administration. This step aims to enhance safety by preventing unintended vascular injection, though it is associated with increased patient discomfort and procedural time.^[37] Current guidelines reflect a debate on the necessity of aspiration, particularly for non-intravenous medications. The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) do not recommend routine aspiration for intramuscular vaccine administration, citing the low likelihood of puncturing major blood vessels at standard sites like the deltoid or vastus lateralis.^[3]^[38] For non-vaccine medications, some nursing protocols still advise aspiration in high-risk sites or with certain drugs to minimize complications, though evidence suggests it may not significantly reduce risks in most cases and can be omitted to improve efficiency and reduce pain.^[39]^[40] The Z-track method is an advanced intramuscular injection modification designed to seal the medication within the muscle and prevent leakage into subcutaneous tissue, which can cause irritation or staining. To perform it, the provider displaces the patient's skin laterally (about 1-2 inches) with the non-dominant hand, inserts the needle at a 90-degree angle into the muscle, injects the medication slowly, withdraws the needle while maintaining skin displacement, and then releases the skin to form a zigzag tract that closes over the injection path.^[1]^[23] This technique is particularly indicated for administering irritating, viscous, or oily medications, such as vitamin B12 or iron dextran, where leakage could lead to local reactions or reduced efficacy. It is commonly used in the ventrogluteal or deltoid sites to further minimize subcutaneous tracking and is supported by nursing guidelines for reducing post-injection complications in these scenarios.^[41]^[42]

Injection Sites and Anatomy

Intramuscular injections are administered into specific muscle groups to ensure effective absorption while minimizing risks to underlying structures such as nerves and blood vessels. The primary sites include the deltoid, vastus lateralis, ventrogluteal, and dorsogluteal muscles, each selected based on anatomical features that provide adequate muscle mass and relative safety.^[1] These sites are identified through palpation of bony landmarks to locate the thickest portion of the muscle, avoiding areas near major neurovascular bundles like the radial nerve in the deltoid or the sciatic nerve in gluteal regions.^[1] The deltoid muscle, located in the upper arm, is a common site for small-volume injections, particularly vaccines, due to its accessibility and moderate muscle bulk. To identify the site, palpate the acromion process of the scapula and extend the fingers 2–3 fingerbreadths (approximately 5 cm) downward toward the axilla; the injection is given in the center of this triangular area, which corresponds to the thickest part of the muscle.^[3] This site accommodates a maximum volume of 1 mL in most adults, as larger amounts may lead to discomfort or suboptimal absorption, and care must be taken to avoid the radial nerve and axillary vessels located inferomedially.^[23]^[1] The vastus lateralis muscle in the anterolateral thigh is preferred for infants, young children, and some adults requiring larger volumes, owing to its large size and low risk of damaging major nerves or vessels. Landmarks are determined by dividing the thigh into thirds from the greater trochanter to the lateral femoral condyle; the injection is administered in the middle third, approximately 7–13 cm below the greater trochanter, targeting the vastus lateralis without encroaching on the femoral artery or sciatic nerve.^[43] This site supports volumes up to 5 mL in adults and is particularly suitable for patients with limited arm mobility.^[33] The ventrogluteal site, situated in the lateral hip over the gluteus medius and minimus, is widely regarded as the safest for intramuscular injections because of its thick muscle layer, minimal subcutaneous fat, and distance from major nerves and vessels. To palpate, place the palm of the hand on the greater trochanter, extend the index finger along the anterior superior iliac spine, and position the middle finger posteriorly toward the iliac crest to form a V-shaped triangle; the injection is given in the center of this area, ensuring avoidance of the superior gluteal nerve.^[1]^[44] It accommodates volumes up to 4–5 mL and is recommended for adults and ambulatory children.^[43] Although historically used, the dorsogluteal site in the upper outer quadrant of the buttock is generally avoided due to its proximity to the sciatic nerve, which increases the risk of injury even with proper landmarking. The site is located by drawing an imaginary line from the posterior superior iliac spine to the greater trochanter and injecting 5–7.5 cm lateral and superior to this line in the gluteus maximus, but this area has variable fat thickness and potential overlap with the nerve in up to 10–20% of cases depending on body habitus.^[1]^[45] Site selection depends on patient-specific factors, including age (e.g., vastus lateralis for neonates and infants under 12 months), body mass index (deeper sites like ventrogluteal for obese individuals), mobility (deltoid for self-administration), and medication volume (deltoid limited to ≤1 mL, gluteal sites for >2 mL).^[46]^[33] Sites should be rotated across injections to prevent localized fibrosis, scar tissue formation, or lipohypertrophy, with the insertion angle typically at 90 degrees to reach the muscle belly.^[1]

Risks and Complications

General Complications

Intramuscular injections commonly cause pain at the site of administration, with studies reporting incidences ranging from 21% to 80% depending on the medication and technique used.^[47]^[33] This discomfort typically peaks immediately after injection and resolves within 1-2 days, often described as moderate in severity.^[47] Infections, such as abscesses or cellulitis, represent a significant but infrequent risk, occurring in less than 2% of cases when proper aseptic technique is followed.^[48] These complications arise from bacterial contamination during the procedure and can lead to localized swelling, redness, and fever if untreated.^[1] Allergic reactions to the injected medication or excipients may manifest as urticaria, itching, or more severe responses, though they are uncommon in routine administrations.^[1] In rare instances, anaphylaxis can occur, with reported rates as low as 11 per million doses for certain vaccines administered intramuscularly.^[49] Hematoma formation results from inadvertent puncture of blood vessels, leading to localized bleeding and bruising; this complication is generally rare, with an incidence of approximately 0.06%.^[50] Systemic issues can arise from procedural errors or medication properties, including inadvertent intravenous administration, which accelerates drug absorption and may cause toxicity or overdose effects such as cardiovascular instability.^[1] Anaphylaxis, as a systemic allergic response, can also progress to hypotension, bronchospasm, and shock if not promptly managed.^[51] Prevention of these general complications emphasizes strict asepsis, including hand hygiene, skin disinfection with alcohol or chlorhexidine, and use of sterile equipment to minimize infection risk.^[28] Accurate dosing and verification of the injection path help avoid overdose or vascular puncture, while post-injection monitoring of vital signs enables early detection of systemic reactions.^[1]

Site-Specific Complications

Intramuscular injections carry risks that vary by anatomical site due to differences in underlying structures such as nerves, blood vessels, and bones. Complications arising from improper site selection or technique can lead to localized injuries, with the deltoid, gluteal, and thigh regions presenting distinct vulnerabilities based on their proximity to critical tissues.^[1] In the deltoid muscle of the upper arm, shoulder injury related to vaccine administration (SIRVA) is a recognized complication, typically resulting from injections placed too high or too deep, causing inflammation of the subacromial bursa, rotator cuff tendons, or surrounding soft tissues. This leads to persistent shoulder pain, reduced range of motion, and potential long-term dysfunction, often requiring conservative management like physical therapy or corticosteroid injections. Additionally, the axillary nerve, which innervates the deltoid and lies beneath the muscle, is susceptible to direct trauma from needles inserted too low or posteriorly, resulting in axillary neuropathy with symptoms such as deltoid weakness, sensory loss over the shoulder, and muscle atrophy in severe cases.^[52]^[53]^[54] Gluteal site injections, particularly in the dorsogluteal region, pose significant risks to the sciatic nerve due to its superficial course through the lower buttock, rare, with an overall incidence of nerve injuries from IM injections estimated at 3.38 per 1,000,000 injections, though higher risk at the dorsogluteal site due to sciatic nerve proximity. leading to acute pain, foot drop, sensory deficits in the lower leg, and possible chronic neuropathy. In the same area, the proximity of the injection site to the ilium or sacrum increases the rare but serious risk of osteomyelitis, where bacterial contamination from the injection spreads to adjacent bone, causing localized bone destruction, abscess formation, and systemic infection that may necessitate surgical debridement and prolonged antibiotics.^[55]^[56]^[54] For thigh sites like the vastus lateralis, femoral nerve irritation can occur if the needle deviates medially toward the nerve's path along the quadriceps, resulting in transient or persistent quadriceps weakness, knee buckling, and paresthesia down the anterior thigh. Bruising is also more prevalent in this mobile region due to the site's exposure to mechanical stress from leg movement, which can exacerbate hematoma formation or vessel trauma, leading to visible ecchymosis and discomfort that resolves slowly over days to weeks.^[1]^[39] To mitigate these site-specific risks, modern clinical guidelines recommend the ventrogluteal site over the dorsogluteal for gluteal injections, as it avoids the sciatic nerve and major vessels while providing adequate muscle mass, thereby reducing nerve injury incidence by up to several fold compared to traditional approaches. Proper landmarking and technique training remain essential across all sites to minimize anatomical vulnerabilities.^[23]^[57]

Special Populations and Considerations

Pediatric and Geriatric Use

In pediatric patients, intramuscular injections require careful site selection due to smaller muscle mass and developmental variations. The vastus lateralis muscle in the anterolateral thigh is the preferred site for infants and young children because of its larger size and lower risk of nerve or vascular injury compared to other areas.^[4] For older children, the deltoid muscle may be used, but volumes should be appropriate to the medication and patient size to avoid overflow into subcutaneous tissue.^[14] These guidelines align with childhood vaccine schedules, where many immunizations, such as those for hepatitis B and DTaP, are given intramuscularly to ensure optimal immune response.^[58] Pain management is essential in pediatrics to improve cooperation and reduce distress during injections. Techniques such as distraction—using toys, videos, or verbal engagement—have been shown to significantly lower perceived pain scores in children undergoing vaccinations.^[59] Topical anesthetics, like eutectic mixture of local anesthetics (EMLA) cream applied 60 minutes prior, provide effective numbing for needle insertion, particularly in infants and toddlers, though application time must be balanced against procedural delays.^[60] Challenges include securing cooperation from fearful children, which may necessitate parental involvement or positioning aids to minimize movement. In geriatric patients, age-related changes such as reduced muscle tone and mass increase the risk of inadvertent subcutaneous deposition rather than true intramuscular delivery.^[39] To mitigate this, the bunching technique—squeezing the muscle tissue before injection—is recommended for the deltoid site, as studies in cadavers demonstrate it achieves proper depth in over 75% of cases, compared to less than 15% with the flattening method.^[61] Frailty in older adults elevates the potential for complications like infection at the injection site due to thinner skin and slower healing.^[62] Site rotation is advised for repeated injections to prevent localized muscle atrophy.^[20] Pharmacokinetic adjustments are often necessary in geriatrics, as intramuscular absorption can be delayed, leading to slower peak concentrations; for example, tobramycin peaks occur later in elderly patients, potentially requiring dose modifications to avoid under- or overdosing.^[63] Skin fragility further complicates procedures, increasing bruising risks, while overall reduced lean mass may alter drug distribution and necessitate lower volumes or alternative routes in frail individuals.^[64] These considerations emphasize tailored approaches to enhance safety and efficacy.

Patient Education and Aftercare

Patients should be informed that intramuscular injections commonly cause mild pain, soreness, or swelling at the injection site, which typically resolves within 1-2 days.^[65] These effects occur due to the needle insertion and medication delivery into the muscle tissue.^[1] Education materials should explain that over-the-counter pain relievers like acetaminophen can help manage discomfort if needed, but patients should follow dosage instructions from their healthcare provider.^[66] Key education topics include recognizing signs of potential complications, such as increasing redness, warmth, or swelling at the site, persistent pain beyond 48 hours, fever, or pus drainage, which may indicate infection or abscess formation.^[1] Other serious indicators include severe localized pain, numbness, or difficulty moving the affected limb, possibly signaling nerve injury or tissue damage.^[45] Patients must be advised to seek immediate medical attention if these symptoms appear or if systemic signs like high fever or chills develop, as delays can lead to more severe issues like sepsis.^[67] Aftercare instructions emphasize monitoring the injection site for 24-48 hours and applying a cold compress or ice pack wrapped in cloth for 10-20 minutes several times a day to reduce pain and swelling.^[66] Patients should avoid rubbing or massaging the area to prevent medication leakage or irritation, and refrain from strenuous exercise or heavy lifting involving the injected limb for at least 24 hours.^[68] Any adverse effects, even mild ones, should be reported to the healthcare provider promptly to ensure proper follow-up. For patients on chronic therapies requiring self-administration, such as certain hormone treatments, emphasis should be placed on strict hygiene practices: washing hands thoroughly with soap and water before preparation, cleaning the vial top and injection site with an alcohol swab, and using a new needle and syringe for each dose to minimize infection risk.^[69] Medications must be stored according to manufacturer guidelines, typically at room temperature away from direct sunlight and out of reach of children, with refrigeration specified for some formulations.^[62] Rotation of injection sites is crucial to avoid tissue damage from repeated use.^[1] To enhance accessibility, patient education should use clear, simple language free of medical jargon, with materials available in multiple languages where possible to accommodate diverse populations.^[62] Resources like illustrated guides or videos from reputable health organizations can support home care, ensuring understanding across cultural and literacy levels.^[70]

Historical and Veterinary Aspects

Historical Development

The development of intramuscular (IM) injection traces its origins to the mid-19th century, coinciding with the invention of the hypodermic syringe. In 1853, Scottish physician Alexander Wood independently developed a practical hypodermic syringe, inspired by the stinger of a bee, which he used to administer morphine subcutaneously for pain relief, marking a pivotal advancement in parenteral drug delivery.^[71] ^[72] Concurrently, French surgeon Charles Gabriel Pravaz created a similar piston syringe that year, initially designed for injecting coagulants into aneurysms, further enabling precise subcutaneous and emerging deeper tissue injections.^[73] These innovations laid the groundwork for IM administration, as early uses of morphine and other agents like quinine for malaria treatment in the 1850s and 1860s began to explore muscle layers for faster absorption and sustained effects.^[72] By the early 20th century, IM injections gained prominence in military medicine during World War I, where they facilitated mass vaccinations against diseases such as typhoid and tetanus. Tetanus antitoxin, derived from horse serum, was routinely administered via IM route to prevent wound infections among soldiers, significantly reducing mortality rates despite logistical challenges in battlefield settings.^[74] This era highlighted IM's utility for rapid, large-scale immunization, with millions of doses of tetanus prophylaxis distributed by Allied forces.^[75] Post-World War I, the 1930s saw advancements in sustained-release formulations, including protamine-zinc-insulin suspensions for subcutaneous diabetes management, alongside the development of IM depot preparations for hormones like progesterone, allowing prolonged therapeutic effects without frequent dosing.^[76] Influential figures shaped subsequent standardization efforts. Alexander Wood's work not only popularized hypodermic delivery but also influenced global adoption of injection therapies. Following World War II, the World Health Organization (WHO) played a key role in establishing uniform protocols for IM injections in vaccination campaigns, emphasizing safe sites and techniques to combat infectious diseases in developing regions.^[77] In the mid-20th century, anatomist Hochstetter first described the ventrogluteal site in the 1950s as a safer alternative to the dorsogluteal area, citing reduced risk of sciatic nerve injury; this recommendation gained traction in the 1970s through nursing and pharmacology literature advocating the shift for adult injections.^[78] Safety practices evolved significantly in the late 20th century, particularly regarding aspiration—the technique of pulling back the syringe plunger to check for blood, once routine to avoid intravascular injection. Studies from the 1980s and 1990s found no instances of blood return in most IM injections, concluding aspiration unnecessary and potentially increasing patient pain without benefit. This led to guideline changes by organizations like the WHO and CDC in the 1990s and 2000s that deemed it obsolete for most IM sites except dorsogluteal. These evidence-based shifts prioritized patient comfort and efficiency in modern protocols.^[3]

Veterinary Applications

Intramuscular (IM) injections are widely used in veterinary medicine to administer vaccines, antibiotics, and sedatives to both companion animals and livestock, providing rapid absorption due to the vascularity of muscle tissue.^[79] For example, penicillin G is commonly given IM to cattle for treating bacterial infections such as pneumonia, with doses up to 20,000 units per kilogram of body weight.^[80] In pets like dogs and cats, IM injections of sedatives such as dexmedetomidine are routine for pre-anesthetic procedures, achieving onset within 5-15 minutes.^[81] Euthanasia agents, including barbiturates like pentobarbital, are also frequently administered IM in small animals when intravenous access is challenging, as recommended by the American Veterinary Medical Association (AVMA).^[82] Techniques in veterinary practice adapt to animal size and behavior, often involving restraint methods like halters for horses or squeeze chutes for cattle to ensure safety.^[83] Site selection varies by species to minimize tissue damage and maximize efficacy; in horses, the semimembranosus muscle in the hindquarter or cervical muscles in the neck are preferred for volumes up to 10 mL, using 1.5-inch, 18- to 20-gauge needles. For dogs, the cervical epaxial muscles or quadriceps are common sites, limited to 2 mL per site to avoid discomfort.^[84] Larger volumes, such as 15 mL in adult cattle, are feasible in neck muscles to prevent carcass blemishes in valuable cuts, with injections spaced at least 4 inches apart.^[85] Species-specific challenges arise in exotic animals, where IM sites must account for unique anatomy; in reptiles like snakes, epaxial muscles along the spine are used for antibiotics or fluids, with volumes under 0.5 mL to prevent organ compression.^[86] Lizards receive IM injections in forelimb muscles, while chelonians (turtles) use hindlimb sites, often requiring sedation due to stress responses.^[87] In livestock farming, mass IM administration of vaccines, such as clostridial toxoids in sheep, occurs via handling systems for efficiency, emphasizing needle hygiene to reduce infection risk.^[88] Regulatory frameworks differ from human medicine, with the FDA's Center for Veterinary Medicine approving drugs for IM use based on target animal safety and efficacy studies, unlike the human-focused Center for Drug Evaluation and Research. AVMA guidelines stress proper site selection and volume limits to avoid residues in food animals, aligning with Beef Quality Assurance programs that prohibit IM injections in high-value muscle areas like the hindquarter. Animal pharmacokinetics vary from humans, often showing faster absorption in species like horses due to greater muscle blood flow.^[79]

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Dec 12, 2022 · The results revealed that IM injection results in more rapid absorption during the first 8 minutes after injection, but SC injection results in ...
[11]
Pharmacodynamics and pharmacokinetics of intramuscular ...
Pharmacokinetic calculations revealed a time to maximum concentration from 1.6 to 1.7 hours, an elimination half-life of 1.6 to 2.4 hours, an apparent total ...
[12]
Pharmacokinetics of testosterone therapies in relation to diurnal ...
Serum T levels peaked approximately 7 days after each injection, with a mean C max of 30.9 ± 11.9 nmol/L (890.6 ng/dl) after the third IM TU injection. Serum T ...
[13]
Pharmacokinetics of Testosterone Enanthate After Intramuscular ...
Aug 18, 2020 · Then, the level decreased and reached <3.0 ng/mL at day 21. Mean time to maximum level of FT was 3.4 days, but in three cases it was at day 7.
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Vaccine Administration: During Vaccination - CDC
Jun 24, 2025 · Most adolescents and adults will require a 1- to 1.5-inch (25–38 mm) needle to ensure intramuscular administration. Site and Route Selection.
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Safety and acceptability of multiple injections
Information on acceptability and safety of administering multiple injections in one visit, as well as strategies to reduce pain and distress at the time of ...
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Migraine Medications - StatPearls - NCBI Bookshelf
Metoclopramide has the greatest evidence for efficacy in migraine and is associated with a less likelihood of extrapyramidal side effects than prochlorperazine, ...Missing: intramuscular | Show results with:intramuscular
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Metoclopramide is an effective treatment for migraine headache and may be effective when combined with other treatments.Missing: indications | Show results with:indications
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Epinephrine - StatPearls - NCBI Bookshelf - NIH
For the treatment of anaphylaxis, epinephrine is preferably injected intramuscularly into the anterolateral aspect of the thigh for rapid absorption, although ...Continuing Education Activity · Indications · Administration · Adverse Effects
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Special Situations | Vaccines & Immunizations - CDC
Jul 15, 2024 · Providers often avoid giving intramuscular injections or choose alternative routes for persons with bleeding disorders because of the risk for ...Breastfeeding And... · Persons Vaccinated Outside... · Dtap Vaccine
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18.6 Administering Intramuscular Medications – Nursing Skills – 2e
The intramuscular (IM) injection route is used to place medication in muscle tissue. Muscle has an abundant blood supply that allows medications to be absorbed ...Missing: authoritative | Show results with:authoritative<|control11|><|separator|>
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Drugs That Induce or Cause Deterioration of Myasthenia Gravis
Apr 6, 2021 · This review summarizes the drugs which can cause de novo MG, MG exacerbation or MG-like symptoms in nonmyasthenic patients.
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Using intramuscular injections in people on oral anticoagulants
Sep 20, 2023 · Giving IM injections to people on oral anticoagulants may increase risk of bleeding or bruising at the injection site.
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Nursing guidelines : Intramuscular Injections
A medication administered into a muscle is known as an intramuscular (IM) injection. The IM route allows for rapid absorption of specific medications. Choosing ...Missing: authoritative | Show results with:authoritative
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Acute compartment syndrome occurs when there is increased pressure within a closed osteofascial compartment, resulting in impaired local circulation.Missing: precautions | Show results with:precautions
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Vaccination for people with bleeding disorders
Jun 9, 2018 · Defer intramuscular injections if the INR is >3.0 (warfarin) or the anti-Xa (LMWH) level 4 hours post-dose is >0.5 units/mL. The National ...
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Best practices for injection - NCBI
Mar 2, 2010 · Avoid giving injections if your skin integrity is compromised by local infection or other skin conditions (e.g. weeping dermatitis, skin lesions ...Missing: complications | Show results with:complications
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Vaccine Administration - CDC
Jun 18, 2024 · Intramuscular injections are administered at a 90-degree angle to the skin, preferably into the anterolateral aspect of the thigh or the deltoid ...
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Chapter 18 Administration of Parenteral Medications - Nursing Skills
ADMINISTERING INTRAMUSCULAR MEDICATIONS. The intramuscular (IM) injection route is used to place medication in muscle tissue. Muscle has an abundant blood ...
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CDC's Core Infection Prevention and Control Practices for Safe ...
Apr 12, 2024 · Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled. ... Use aseptic technique when preparing ...Missing: IM | Show results with:IM
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Chapter 4 Aseptic Technique - Nursing Skills - NCBI Bookshelf
When performed properly, aseptic technique prevents contamination and transfer of pathogens to the patient from caregiver hands, surfaces, and equipment during ...
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Preventing Unsafe Injection Practices | Injection Safety - CDC
Mar 26, 2024 · Safe injection practices include one-time use of needles and syringes and limiting the sharing of medication vials.Missing: indications | Show results with:indications<|control11|><|separator|>
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Best practice guidelines for the administration of intramuscular ...
Aug 4, 2006 · ... rate of administration of the medication would ... 11, If no blood is aspirated, inject the medication slowly (approximately 1 mL per 10 s).Abstract · REVIEW OF CURRENT... · RESULTS OF THE REVIEW... · DISCUSSION
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Large-volume IM injections: A review of best practices
Feb 21, 2013 · Intramuscular injections offer improved treatment adherence, ease in monitoring of adverse effects, and multiple administration sites.Missing: contraindications precautions
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Intramuscular injection: An integrative research review and ...
Use of this guideline can assist the clinician to maximize the therapeutic effects of administered medication while minimizing or eliminating patient injury and ...Missing: slow rate
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Administering Intramuscular Injections - College of Nursing | ECU
Administer injection using Z track method, by positioning ulnar side of nondominant hand just below site and pull skin laterally approximately 1-1.5 inches and ...
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Intramuscular Injection Technique - Clinical Skills
Allowing at least 5 seconds for aspiration will show whether there is a back-flow of blood even if the needle is in a small blood vessel (Taylor & Lillis, 1997) ...<|control11|><|separator|>
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Aspirating during the intramuscular injection procedure - PubMed
The majority of health professionals do not aspirate for the recommended 5-10 seconds. Administering an injection faster without aspiration is less painful.
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Aspiration before intramuscular vaccines injection, should the ...
Although aspiration prior to intramuscular injection was standard practice until a few years ago, it is no longer recommended by the World Health Organisation.Missing: medical indications
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Medication Administration: Intramuscular Injections - Acute care
Intramuscular (IM) injections have been associated with adverse effects and pain, and this route of medication injection should be used as a last resort.
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[PDF] Aspirating for Blood When Administering Intramuscular (IM) Injections
A strong recommendation is made that when giving a vaccine IM, aspiration is not required (Cattaneo, Engert, Gray, & Vineyard, 2016; ACIP,. 2019). The certainty ...
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Administering medication by the Z-track method - Nursing - Lippincott
YOU SHOULD USE the Z-track method for all I.M. injections in adults. By leaving a zigzag path that seals the needle track, this technique prevents drug ...
[42]
Z-Track Method of Injection: Procedure and Side Effects
Dec 29, 2022 · The Z-track method is an intramuscular injection (IM) technique used to ensure the medication stays in the muscle instead of leaking into the surrounding ...
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Anatomically safe sites for intramuscular injections - NIH
Intramuscular (IM) injections are a technique used to deliver vaccines, hormonal agents, antibiotics, and high viscosity medication deep into the muscles of ...Missing: complications | Show results with:complications<|separator|>
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Revisiting IM Injections - AJN The American Journal of Nursing
The ventrogluteal site is located in the center of the triangle indicated by the red dots. Deltoid, dorsogluteal, rectus femoris, vastus lateralis, or ...
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Iatrogenic Injury to the Sciatic Nerve due to Intramuscular Injection
Iatrogenic injury to the sciatic nerve resulting from a misplaced gluteal IM injection is a persistent problem worldwide affecting patients in economically rich ...
[46]
Vaccine Administration Route and Site - CDC
Sep 8, 2021 · Intramuscular injections are administered into the muscle through the skin and subcutaneous tissue. The recommended site is based on age. Use ...
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Factors influencing time course of pain after depot oil intramuscular ...
Pain was reported by 80% of men, peaking immediately after injection, reaching only moderate severity, lasting 1–2 days and returning to baseline by day 4.
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Multipl MRSA Absesses Following Intramuscular Injection a Case ...
Complications such as abscess formation and sepsis after intramuscular injection were reported to be extremely rare, with a rate of 1.9% in a study5. For the ...Missing: incidence | Show results with:incidence
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Jan 15, 2021 · Twenty-one cases were determined to be anaphylaxis (a rate of 11.1 per million doses administered), including 17 in persons with a documented ...
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Bleeding complications following intramuscular injections among ...
Oct 28, 2024 · Bleeding complications following intramuscular (IM) injections are generally considered rare with reported incidence of 0.06%.
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Evidence update for the treatment of anaphylaxis - PMC - NIH
The estimated incidence for anaphylaxis in Europe is 1.5 to 7.9 per 100,000 person-years, with a lifetime prevalence of 1 in 300. International guidelines ...
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Shoulder Injury Related to Vaccine Administration: Diagnosis and ...
Mild shoulder discomfort is a common and well-recognized side effect of intramuscular deltoid injection associated with vaccination administration. Most cases ...
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Iatrogenic axillary neuropathy after intramuscular injection ... - PubMed
We hypothesize that direct mechanical trauma to the anterior branch of the axillary nerve resulted in axillary mononeuropathy with axonal loss, although ...
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[PDF] Upper limb nerve injuries caused by intramuscular injection or ...
Apr 25, 2017 · However, another study of blood donation-related nerve injury reported that 21.6% of patients suffered pain/sensory change more than 1 year and ...
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[PDF] Preventing Sciatic Nerve Injury due to Intramuscular Injection
Mar 4, 2016 · used sites for intramuscular (IM) injection are dorsogluteal. (DG) ... SNN resulting from an injection occurs at a 2.7% rate (28).
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Iliac Osteomyelitis and Gluteal Abscess Following an Intramuscula
Gluteal abscess following intramuscular injections are more common, often due to non-sterile injection techniques. We present a case of iliac osteomyelitis.Missing: risk proximity
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Adverse effects of dorsogluteal intramuscular injection versus ...
Jul 14, 2023 · Potential adverse effects: potential nerve injury (distance from real or theoretical site of injection to sciatic nerve), potential vascular ...
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[PDF] Vaccine Administration: Intramuscular (IM) Injection Children ... - CDC
Nov 16, 2020 · Administer vaccine using either a 1-mL or 3-mL syringe. ▫ Use a 22- to 25-gauge needle. ▫ Use the correct needle length (5/8- to 1.5-inch ...
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Vaccine Administration | Red Book - AAP Publications
The use of a 22- to 25-gauge needle is generally recommended for IM injections. Suggested needle lengths are described in Table 1.8. Note that the upper, outer ...Vaccine Preparation · Patient Care Before, During... · Sites and Routes of Vaccine...
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Reducing the pain of childhood vaccination: an evidence-based ...
Consistent with the pediatric study, adult studies showed that either rubbing or applying pressure to the injection site before injection reduced pain during ...
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Minimizing pain during childhood vaccination injections
Sep 30, 2014 · Lidocaine-prilocaine cream is proven to be effective in the reduction of vaccination pain in children 4–6 years of age as well as infants 12 ...<|control11|><|separator|>
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[PDF] Best practice for deltoid intramuscular injections in older adults
Jun 20, 2019 · This study tested the injection techniques of bunching (squeezing) or flattening (stretching) the deltoid muscle before administering IMI using ...
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[PDF] Intramuscular Injections – Best Practices for Safe Vaccine ... - AHRQ
A 22-25 gauge needle is recommended for vaccine intramuscular (IM) injections. Use the appropriate needle length based on the resident's weight (Table 1), ...
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This review examines the primary age-related physiological changes in geriatrics and their impact on the pharmacokinetics and pharmacodynamics of medications.
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Dec 1, 1982 · The appropriate site of injection depends upon the age and size of the child. Multiple injection sites may be preferable in some cases.
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Chapter 6: Vaccine Administration | Pink Book - CDC
Apr 8, 2024 · IM injections are administered into the muscle through the skin and subcutaneous tissue. There are only two recommended sites for administering ...
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Preventing and Managing Adverse Reactions - CDC
Jul 25, 2024 · Modern vaccines are safe and effective; however, adverse events have been reported after administration of all vaccines. ... IM: intramuscular; ...Vaccines And Persons With A... · National Vaccine Injury... · Table 5-1: Rapid Overview...
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Intramuscular injections can rarely result in serious infectious complications such as abscesses which may progress to bacteraemia and generalized sepsis.
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How to Give an Intramuscular Shot: Care Instructions
Gather your equipment. · Wash your hands with soap and running water. · Choose a spot on your outer thigh or the side of your hip for the shot. · Use alcohol to ...Missing: aftercare | Show results with:aftercare
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How to Give Yourself Intramuscular (IM) Injections - UW Health
Preparing the Injection: Wash your hands well with soap and water. Gather the supplies you need and place them on a clean, dry surface. Note: If your syringe ...Missing: hygiene | Show results with:hygiene
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Alexander Wood • LITFL • Medical Eponym Library
Jun 2, 2024 · Alexander Wood (1817-1884) was a Scottish physician. Inventor of the first hypodermic needle (1853), taking the 'sting of the bee' as his ...
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The history of the syringe - Exchange Supplies
The Fergusson syringe of 1853 became the forerunner of the modern syringe when Alexander Wood used it for the subcutaneous injection of opiates for the relief ...
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Brief History of Opioids in Perioperative and Periprocedural ...
French physician Charles-Gabriel Pravaz introduced the piston syringe in 1853. Pravaz's syringe was designed for injecting coagulant into aneurysms, but it was ...
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The Use of the Hypodermic Syringe in the Civil War
Jun 7, 2023 · ... syringe to accompany the needle were independently invented by scientists in 1853. Charles Gabriel Pravaz invented a silver tube syringe ...
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Treatment of War Wounds: A Historical Review - PMC
By the end of World War II, the toxin and its administration were improved to a point that of more than 2.7 million hospital admissions for patients with ...
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Solid State Chemistry of Long-Acting Injectable Suspensions
Sep 25, 2025 · [1] A major leap occurred in the 1930s with the development of protamine-zinc-insulin suspections for diabetes management.
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Injection safety - World Health Organization (WHO)
These policies, guidelines and best practice documents are available for download by a range of target audiences. WHO has also published the WHO guideline on ...
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[PDF] Comparison of the G and V methods for ventrogluteal site identification
The ventrogluteal site and the V method of its iden- tification were first described by Hochstetter in the. 1950s (Hochstetter 1954). The palm or heel of the.
[81]
Routes of Administration and Dosage Forms of Drugs - Pharmacology
A diverse range of drug dosage forms and delivery systems have been developed for the care and welfare of animals.Oral Route Of Administration... · Parenteral Route Of... · Topical Route Of...
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Onset and quality of sedation after intramuscular ... - AVMA Journals
Dec 1, 2013 · Objective—To compare onset time and quality of sedation achieved by IM injection of hydromorphone and dexmedetomidine into either the ...
[83]
[PDF] AVMA 2007 Guidelines on Euthanasia - OLAW
Intravenous injection of a barbituric acid derivative is the preferred method for euthanasia of dogs, cats, other small animals, and horses. Intraperitoneal ...
[84]
[PDF] SOP: Bovine Intramuscular Injection Table of Contents
Dec 12, 2017 · Typically, a 16- or. 18-gauge needle that is 1 ½ inches long is used for IM injections in cattle weighing over 500 pounds. Injection needles ...Missing: AVMA guidelines
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[PDF] SOP: Injections in Dogs and Cats - Virginia Tech
Dec 12, 2017 · SOP: INJECTIONS IN DOGS AND CATS. 3 c. Intramuscular injections can result in temporary or permanent nerve damage and muscle irritation. d ...Missing: AVMA | Show results with:AVMA
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[PDF] Injection Techniques Locations and Needle Choice
Injections should be in the neck's injection triangle, using sharp needles, changed for each syringe fill, and at least four inches apart.
[87]
Clinical Procedures for Reptiles - Exotic and Laboratory Animals
For IM injections in lizards and chelonians, the forelimb muscles are preferred, whereas for snakes, the epaxial muscles are used.
[88]
https://www.canr.msu.edu/uploads/236/65684/4H1669_AnimalScienceAnywhere-LivestockInjections.pdf
[89]
[PDF] Livestock Injection Methods and Placement
Intramuscular injection on fruit – If you placed the IM injection correctly, when you carefully peel back the skin you should be able to see the injection site ...