Editing Intramuscular injection (section)

==Technique==
[[File:Intramuscular Injection.JPG|thumb|right|An intramuscular injection is performed perpendicular to the skin, close to a 90 degree angle.]]
[[File:Needle-insertion-angles-1.png|thumb|right|Comparison of angle of intramuscular injection with other injection types]]
An intramuscular injection can be administered in multiple different muscles of the body. Common sites for intramuscular injection include: [[Deltoid muscle|deltoid]], [[Gluteal muscles|dorsogluteal]], [[Rectus femoris muscle|rectus femoris]], [[Vastus lateralis muscle|vastus lateralis]] and [[ventrogluteal]] muscles.<ref name="JBI" /><ref>{{Citation|last=Bolger|first=Gordon T.|title=Routes of Drug Administration|date=2018-01-01|url=http://www.sciencedirect.com/science/article/pii/B9780128012383110992|work=Reference Module in Biomedical Sciences|publisher=Elsevier|language=en|doi=10.1016/b978-0-12-801238-3.11099-2|isbn=978-0-12-801238-3|access-date=2020-11-25|url-access=subscription}}</ref> Sites that are bruised, tender, red, swollen, inflamed or scarred are generally avoided.<ref name="Taylor">{{cite book |last1=Taylor |first1=Carol |title=Fundamentals of nursing: the art and science of nursing care |date=2011 |publisher=Wolters Kluwer Health and Lippincott Williams & Wilkins |isbn=978-0-7817-9383-4 |edition=7th |location=Philadelphia }}</ref> The specific medication and amount being administered will influence the decision of the specific muscle chosen for injection.

The injection site is first cleaned using an antimicrobial and allowed to dry. The injection is performed in a quick, darting motion perpendicular to the skin, at an angle between 72 and 90 degrees. The practitioner will stabilize the needle with one hand while using their other hand to depress the plunger to slowly inject the medication – a rapid injection causes more discomfort. The needle is withdrawn at the same angle inserted. Gentle pressure may be applied with gauze if bleeding occurs.<ref name=Lippincott>{{cite book |last1=Lynn |first1=Pamela |last2=Taylor |first2=Carol |title=Lippincott photo atlas of medication administration |date=2019 |publisher=Wolters Kluwer |location=Philadelphia, PA |isbn=978-1-9751-2136-5 |pages=39–40 |edition=Sixth}}</ref> Pressure or gentle massage of the muscle following injection may reduce the risk of pain.<ref name=JAN2019 />

=== Aspiration ===
Aspirating for blood to rule out injecting into a blood vessel is not recommended by the US [[Centers for Disease Control and Prevention|CDC]], [[Public Health Agency of Canada]], or [[Norwegian Institute of Public Health|Norway Institute of Public Health]], as the injection sites do not contain large blood vessels and aspiration results in greater pain.<ref name="CDCPink">{{cite book|url=https://www.cdc.gov/vaccines/pubs/pinkbook/vac-admin.html|title=The Pinkbook|date=25 September 2019|publisher=[[Centers for Disease Control and Prevention|CDC]]|language=en-us|chapter=Vaccine Administration|quote=Aspiration is not recommended before administering a vaccine.|access-date=12 September 2020|author1=JoEllen Wolicki |author2=Elaine Miller}}</ref><ref>{{cite web|date=2020-12-02|title=Vaccine administration practices: Canadian Immunization Guide|url=https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-1-key-immunization-information/page-8-vaccine-administration-practices.html |access-date=2021-05-25|website=Public Health Agency of Canada |quote=Aspiration before injection of vaccine is not recommended, as there are no large blood vessels at the recommended immunization sites and not aspirating before injection has been demonstrated to reduce pain.}}</ref><ref>{{cite web|title=Praktisk info om vaksinasjon|url=https://www.fhi.no/nettpub/vaksinasjonsveilederen-for-helsepersonell/vaksinasjon/praktisk-vaksinasjon/ |access-date=2021-05-25|website=Folkehelseinstituttet|date=9 April 2008 |language=no|quote=However, it is not recommended to aspirate before intramuscular and subcutaneous vaccine injection provided that the vaccine is placed in the appropriate place … does not involve the risk of injecting intravenously because there are no large blood vessels in these sites. Aspiration can cause the vaccination to be more painful because it takes longer to give the vaccine}}</ref> There is no evidence that aspiration is useful to increase safety of intramuscular injections when injecting in a site other than the dorsogluteal site.<ref name="Nurs2015" /> 

Aspiration was recommended by the [[Danish Health Authority]] for [[COVID-19 vaccine|COVID-19 vaccines]] for a time to investigate the potential rare risk of blood clotting and bleeding, but it is no longer a recommendation.<ref>{{cite web|date=2021-03-20|title=Covid-19 vacciner skal gives med aspiration før injektion|url=https://dsr.dk/politik-og-nyheder/nyhed/covid-19-vacciner-skal-gives-med-aspiration-foer-injektion|access-date=2021-05-25|website=Politik og nyheder, DSR|language=da|quote=The Danish Health and Medicines Authority's guidelines have long recommended this, and now the Statens Serum Institut is following suit.|archive-date=2021-03-22|archive-url=https://web.archive.org/web/20210322170314/https://dsr.dk/politik-og-nyheder/nyhed/covid-19-vacciner-skal-gives-med-aspiration-foer-injektion|url-status=dead}}</ref><ref>{{cite web|last=name|title=Intramuskulær injektion på børn og voksne|url=https://www.ssi.dk/vaccinationer/injektionsteknik/intramuskulaer-injektion-beorn-og-voksne |access-date=2023-10-04|website=Statens Serum Institut |language=da|quote=It has previously been recommended to aspirate before injection with Covid-19 vaccines in relation to investigation of a possible connection between injection with Vaxzevria® and the occurrence of rare and serious side effects. However, this is no longer a recommendation and Covid-19 vaccines can be injected without prior aspiration.}}</ref>

=== Z-track method ===
The Z-track method is a method of administering an IM injection that prevents the medication being tracked through the subcutaneous tissue, sealing the medication in the muscle, and minimizing irritation from the medication. Using the Z-track technique, the skin is pulled laterally, away from the injection site, before the injection; then the medication is injected, the needle is withdrawn, and the skin is released. This method can be used if the overlying tissue can be displaced.<ref>{{cite book |last1=Doyle|first1=Glynda Rees|last2=McCutcheon|first2=Jodie Anita|date=2015 |chapter=7.4 Intramuscular Injections |chapter-url=https://opentextbc.ca/clinicalskills/chapter/6-8-iv-push-medications-and-saline-lock-flush/ |title=Clinical Procedures for Safer Patient Care |publisher=BCcampus |language=en}}</ref>

===Injection sites===
The deltoid muscle in the outer portion of the upper arm is used for injections of small volume, usually equal to or less than 1&nbsp;mL. This includes most intramuscular vaccinations.<ref name="JBI" /> It is not recommended to use the deltoid for repeated injections due to its small area, which makes it difficult to space out injections from each other.<ref name="JBI">The Joanna Briggs Institute. Recommended Practice. Injection: Intramuscular. The Joanna Briggs Institute EBP Database, from the JBI@Ovid database, published 2019; JBI2138. Accessed on 12 September 2020.</ref> The deltoid site is located by locating the lower edge of the [[acromion process]], and injecting in the area which forms an upside down triangle with its base at the acromion process and its midpoint in line with the [[axilla|armpit]].<ref name="Taylor" /> An injection into the deltoid muscle is commonly administered using a 1-inch long needle, but may use a {{frac|5|8}}-inch long needle for younger people or very frail elderly people.<ref name=Vaccine2017 />

The ventrogluteal site on the hip is used for injections which require a larger volume to be administered, greater than 1&nbsp;mL, and for medications which are known to be irritating, viscous, or oily. It is also used to administer [[narcotic]] medications, [[Antibiotics|antibiotic]]s, [[sedative]]s and [[Antiemetic|anti-emetic]]s.<ref name="JBI" /> The ventrogluteal site is located in a triangle formed by the [[anterior superior iliac spine]] and the [[iliac crest]], and may be located using a hand as a guide.<ref name="Taylor" /> The ventrogluteal site is less painful for injection than other sites such as the deltoid site.<ref name="JAN2019">{{cite journal |last1=Şanlialp Zeyrek |first1=Arife |last2=Takmak |first2=Şenay |last3=Kurban |first3=Nevin Kuzu |last4=Arslan |first4=Sümeyye |title=Systematic review and meta-analysis: Physical-procedural interventions used to reduce pain during intramuscular injections in adults |journal=Journal of Advanced Nursing |date=December 2019 |volume=75 |issue=12 |pages=3346–3361 |doi=10.1111/jan.14183|pmid=31452229 |s2cid=201786789 }}</ref>

The [[vastus lateralis]] site is used for infants less than 7 months old and people who are unable to walk or who have loss of muscular tone.<ref name="JBI" /> The site is located by dividing the front [[thigh]] into thirds vertically and horizontally to form nine squares; the injection is administered in the outer middle square.<ref name=Taylor/> This site is also the usual site of administration for [[epinephrine autoinjector]]s, which are used in the outer thigh, corresponding to the location of the vastus lateralis muscle.<ref>{{cite web|url=https://medlineplus.gov/druginfo/meds/a603002.html|title=Epinephrine Injection|website=[[MedlinePlus]]}} Last revised 03/15/2017</ref>

The dorsogluteal site of the buttock site is not routinely used due to its location near major [[blood vessel]]s and [[nerve]]s, as well as having inconsistent depth of [[adipose tissue]].<ref>{{cite journal |last1=Zimmermann |first1=Polly Gerber |title=Revisiting IM Injections |journal=American Journal of Nursing |date=February 2010 |volume=110 |issue=2 |pages=60–61 |doi=10.1097/01.NAJ.0000368058.72729.c6|pmid=20107407 }}</ref> Many injections in this site do not penetrate deep enough under the skin to be correctly administered in the muscle.<ref name="JBI" /><ref>{{cite journal |last1=Farley |first1=HF |last2=Joyce |first2=N |last3=Long |first3=B |last4=Roberts |first4=R |title=Will that IM needle reach the muscle? |journal=The American Journal of Nursing |date=December 1986 |volume=86 |issue=12 |pages=1327, 1331 |pmid=3641525}}</ref> While current [[evidence-based practice]] recommends against using this site, many healthcare providers still use this site, often due to a lack of knowledge about alternative sites for injection.<ref>{{cite journal |last1=Cocoman |first1=Angela |last2=Murray |first2=John |title=Recognizing the evidence and changing practice on injection sites |journal=British Journal of Nursing |date=October 2010 |volume=19 |issue=18 |pages=1170–1174 |doi=10.12968/bjon.2010.19.18.79050|pmid=20948472 }}</ref> 
This site is located by dividing the buttock into four using a cross shape, and administering the injection in the upper outer quadrant. This is the only intramuscular injection site for which aspiration is recommended of the syringe before injection, due to higher likelihood of accidental [[Intravenous therapy|intravenous administration]] in this area.<ref name="JBI" /> However, aspiration is not recommended by the [[US CDC|Centers for Disease Control and Prevention]], which considers it outdated for any intramuscular injection.<ref name="Lippincott" />

{{multiple image
|header=Sites for administration of intramuscular injections
|direction=horizontal | align=center | total_width = 1000px
|image1=Im-deltoid (cropped).png
|alt1=Deltoid site
|caption1=Diagram showing the [[deltoid muscle|deltoid]] site for intramuscular injection
|image2=Im-ventrogluteal-300x244.png
|alt2=Ventrogluteal site
|caption2=Ventrogluteal and rectus femoris sites for intramuscular injection
|image3=Injection Sites Intramuscular Thigh Adult.png
|alt3=Vastus lateralis site in adult
|caption3=Vastus lateralis site of administration in an adult
|image4=Injection Sites Intramuscular Thigh Child.png
|alt4=Vastus lateralis site in child
|caption4=Vastus lateralis site of administration in an infant or young child
}}

===Special populations===
Some populations require a different injection site, needle length, or technique. In very young or weak elderly patients, a normal-length needle may be too long to inject properly. In these patients, a shorter needle is indicated to avoid injecting too deeply.<ref name="Needles">{{cite journal |last1=Beirne |first1=Paul V |last2=Hennessy |first2=Sarah |last3=Cadogan |first3=Sharon L |last4=Shiely |first4=Frances |last5=Fitzgerald |first5=Tony |last6=MacLeod |first6=Fiona |title=Needle size for vaccination procedures in children and adolescents |journal=Cochrane Database of Systematic Reviews |date=9 August 2018 |volume=2018 |issue=8 |pages=CD010720 |doi=10.1002/14651858.CD010720.pub3|pmid=30091147 |pmc=6513245 }}</ref> It is also recommended to consider using the anterolateral thigh as an injection site in infants under one year old.<ref name=Needles />

To help infants and children cooperate with injection administration, the [[Advisory Committee on Immunization Practices]] in the United States recommends using distractions, giving something sweet, and rocking the baby side to side. In people who are overweight, a 1.5-inch needle may be used to ensure the injection is given below the [[subcutaneous tissue|subcutaneous]] layer of skin, while a {{frac|5|8}}-inch needle may be used for people who weigh under {{convert|60|kg|lb}}. In any case, the skin does not need to be pinched up before injecting when the appropriate length needle is used.<ref name="ACIP">{{cite web |title=ACIP Vaccine Administration Guidelines for Immunization {{!}} Recommendations {{!}} CDC |url=https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html |website=www.cdc.gov |publisher=[[Centers for Disease Control]] |access-date=12 September 2020 |language=en-us |date=21 June 2019}}</ref>