5

Injections

INJECTIONS

CORE CONCEPTS

• Select an appropriate needle and syringe for an injection.

• Assemble a needle and syringe for an injection using sterile technique.
• Select medication for injection using physicians’ orders.
• Draw medication from a vial and an ampule.
• Reconstitute medication with a diluent.
• Prepare an intradermal, subcutaneous, and intramuscular injection.
• Provide treatment for an allergic reaction and anaphylactic shock.

INTRODUCTION A basic knowledge of which medication is being

prescribed, and why, can also help prevent medica-
Combat medics are required to administer injec- tion injection errors. Many medications have very
tions. Injection is a method of delivering liquid medi- similar spellings or similar words, but have very dif-
cations into the body. The term parenteral can be used ferent indications and usages. Extreme caution must
for any method of getting medication into the body be taken when comparing the prescription and the
other than through the gastrointestinal tract (enteral). actual medication to be given. After administering
The parenteral routes include intramuscular (IM), the medication, monitor the patient for the prescribed
subcutaneous (SQ), and intradermal (ID) injections. amount of time (defined by either a drug reference or
Enteral routes include oral, mucosal, intranasal, or per the medical officer [MO]). During this time, monitor
rectum. The administration routes affect the onset of for adverse reactions both locally at the site of injection
a medication’s action. and systemically. Systemic reactions affect the entire
body and include fevers, vomiting, sweating, redness,
INJECTIONS generalized swelling, and difficulty breathing. Adverse
reactions can lead to anaphylaxis, shock, or death if
Combat medics may give injections by various not recognized and treated. Report all reactions to the
routes. The following general principles apply for MO and add them to the patient’s medical records.
each method: Sterile techniques are paramount to preventing
the introduction of pathogens into the body during
• Before administering any medication, com- the administration of an injection. Pathogens in this
pare the drug name on the vial with the drug situation are usually bacteria that are normally found
name on the doctor’s order. on the skin surface. These bacteria can be resistant to
• Validate the medicine when taking it from various antibiotics and it is becoming more common
storage, while preparing and drawing up the to have patients with a history of skin infections, boils,
medication, and prior to administering the and abscesses. If the skin is not cleansed appropriately,
medication to the patient. bacteria will be pushed into the tissue by the needle.
• Check the patient’s chart (or dog tags) for al- Cleaning and proper preparation of the skin before an
lergies to medications. injection will help keep infection rates low.
• Ask the patient to verbally confirm any known
medication allergies prior to administration.

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PREPARING AND USING SUPPLIES FOR used to administer an injection. Filter needles contain
INJECTIONS a filter to prevent glass particles from being drawn up
into a syringe and accidentally injected into the patient.
Needles
Caution: All parts of the needle are sterile. Do not
All parts of the needle are sterile. Be careful not to touch the hub because contamination could cause
touch the hub. This would contaminate the needle patient infection. Only the outside of the needle cover
and possibly pass an infection to the patient. Only the may be touched.
outside of the needle cover may be touched. A needle
consists of the following parts (Figure 5-2): Syringes

• lumen—hollow cavity inside of needle, A syringe is an instrument that is attached to a nee-

• bevel—cutting edge of needle (slanted), dle and used for injecting fluids into cavities or vessels.
• hub—point of attachment to syringe, Hypodermic syringes are the most common type used
Figure 5-1. A combat medic using proper technique to ad-
• cannula (shaft)—elongated part of the needle, by combat medics. They are attached to hypodermic
minister an injection. and Figure 5-3. Different sizes of needles. From top to bottom, needles and are used to inject fluid through the skin.
• protective cover (not shown). needle gauge decreases as needle diameter increases. Syringes come in many different sizes depending
on the type of medication and amount of fluid to be
Needles are sharp and made of stainless steel. Stan- administered. Most syringes possess units of measure-
There are many advantages to administering a med- dard needle lengths are from 1/2 to 5 in. The length is It is important to select the appropriate needle when ment in milliliters. A cubic centimeter (cc) is equal to a
ication via injection. Advantages and benefits of injec- determined from the tip of the point to the junction of administering an injection. Choose one with the proper milliliter (mL); however, the cc unit of measurement is
tions that should be considered include the following: the shaft and hub. The gauge (diameter) of the needle length based on the following factors: no longer used. An example of syringes that measure
varies from 14 to 28; the larger the gauge number (G), in different units are those used by people with diabe-
• The majority of medications are most effective the smaller the diameter (Figure 5-3). For example, a • type of injection—SQ, IM, or ID; tes. These syringes are used to administer insulin, and
when given by injection. 14 G needle has a larger lumen in the bevel and can • the size of the patient—eg, thin or obese; and their measurements are not in milliliters, but in units.
• The medication cannot be provided in any administer larger amounts of fluid at a faster rate • the injection site—eg, 1 in. needle length for an Most syringes have similar parts, as shown in Figure
other form. than a 22 G needle, which has a smaller lumen and IM injection into the deltoid muscle versus 1.5 5-4. They include the following:
• The patient’s condition requires a quicker administers smaller amounts of fluid at a slower rate. in. length for an IM injection into the gluteus
onset of the desired action (through rapid maximus muscle. • Barrel—a clear plastic or glass tube marked
absorption) than is typically achieved with with calibrated scales. The inside of the barrel
enteral medications. Select the needle with the proper gauge (most is sterile.
• The entire dose of the medication must be commonly from 18 to 25 G). The larger the number, • Plunger—the movable portion inside the barrel.
obtained to achieve the desired effect. the smaller the bore (diameter). For example, a 25 G The rubber portion and the shaft are sterile.
• Due to nausea, vomiting, or other reasons like needle has a very small opening and may be used for • Needle adapter—the sterile portion of the
altered mental status or injury to the mouth, SQ or ID injections, whereas a 23 G needle has a larger syringe where the needle attaches.
the oral route is not available. bore and may be used for an IM injection. Also, small- • Calibrated scales—measurement markings on
• The drug cannot be absorbed through the gauge needles are indicated for watery medications, the barrel that vary depending on the overall
digestive system. and large-gauge needles are indicated for viscous size of the syringe.
(thick) medications.
Combat medics must know the locations of com- Blunt-tip needles and needleless systems are becom- Select an appropriate syringe by first checking
mon administration sites, the type of injection to be ing more common for administration of medications the drug manufacturer’s specifications. Determine
administered, and the mechanism of action of the med- through an intravenous (IV) port attached to IV tubing. whether a glass or plastic syringe should be used for
ication being injected. When providing an injection A blunt-tip needle is a rigid, unbeveled needle that sig- the medication since some medications deteriorate in
(Figure 5-1), follow procedures exactly to prevent an nificantly reduces accidental needlesticks because the a plastic syringe. Drug manufacturers’ specifications
adverse outcome. An accidental injection into a nerve point of the needle is not sharp like standard needles. provide guidance. Ensure that the total capacity of the
could result in injury and paralysis. An unintended Some IV tubing companies make tubing with integrated syringe is appropriate for the amount of medication to
injection directly into a blood vessel could cause the needleless and IV medication ports. This allows combat be administered. The syringe should be large enough
medication to be absorbed too rapidly, possibly result- medics to attach a syringe without a needle, for safer to hold the entire dose and small enough to draw up
ing in injury or death of a patient. Some medications, medication administration. an accurate dose. Check the intervals of the calibration
such as injectable steroids, must be injected into deep Another type of needle a combat medic may use is marks on the syringe to ensure they are appropriate
muscle tissue, and failure to do so could result in de- a “filter needle.” Filter needles are used only to draw for the dose of medication to be administered.
formity due to tissue atrophy. Figure 5-2. The parts of a needle. up medications from glass ampules, and are NEVER

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devices, the safety mechanism is built into the syringe. Check on Learning
The needle on a syringe-based safety device can be Note: The outside of the syringe barrel does not
detachable or permanently attached. Typically, the have to be kept sterile. 6. While preparing to administer an injection,
needle has a standard or conventional design. Safety the needle is removed from the flexible
syringes help prevent needlesticks. wrapper. Inadvertently, you drop the needle
4. Inspect the syringe.
on the floor. The protective cap was in place
a. Pull on the plunger. When pulling on the
Check on Learning when the needle touched the floor. Can the
plunger, a distinct “pop” should be felt;
needle still be used? Why or why not?
if it is not, the seal was previously broken
1. What parts of the needle are sterile? and the equipment must be discarded. Recapping a Needle
2. Put these needles in order from the largest to b. Grasp the flared end of the syringe and
smallest diameters: 25 G, 18 G, and 22 G. move the plunger back and forth to test Recapping needles is not recommended because it
3. What factors influence the length of the for smooth, easy movement. increases needlestick risk. Sometimes it may be nec-
needle that should be used for a particular c. Visually check the rubber stopper (inside essary to recap a needle, such as after withdrawing
injection? the syringe) to ensure that it is attached medication from a vial or ampule. If you must recap
4. What parts of the syringe are sterile? securely to the top end of the plunger, a needle, use the following scoop technique while
5. How do you know which syringe to select? forming a seal. If the plunger is stuck holding the assembled needle and syringe in your
or does not move smoothly, discard the dominant hand. Follow these steps:
Assembling the Needle and Syringe syringe.
d. Push the plunger fully into the barrel 1. Drape a blue chux pad over a hard, flat
During needle and syringe assembly, you are re- until you are ready to fill the syringe with surface that has been cleared of any other
sponsible for maintaining the sterility and security of medication. equipment. Place the protective cap on the
the equipment. First, inspect the needle and syringe chux pad.
packaging for defects, such as openings, holes, and 5. Unpack the needle.
water spotting. Discard the equipment into a sharps a. Peel the sides of the flexible wrapper 2. Insert the needle into the open end of the
container if any defect is found. apart to expose the needle hub. Do not protective cap and lift the protective cap,
Figure 5-4. The parts of a syringe. Use the following steps for assembling a needle touch the hub; only touch the outside of causing it to slide down on the needle.
and syringe: the needle cover.
b. If the needle is packaged in a hard plas- 3. Cover the needle with the protective cap,
The plunger fits inside the tube or barrel of the sy- 1. Don personal protective equipment (PPE). tic tube, twist the cap of the tube until ensuring that the cap is secured to the needle
ringe. It creates a tight seal inside the syringe, usually The minimum PPE for administering injec- a “pop” is felt and remove the cap to hub.
with the assistance of a small rubber or plastic gasket. tions is gloves and eye protection. expose the needle hub.
This prevents the contents from escaping out the rear
of the syringe, keeping dosages consistent. When WARNING: Never recap a dirty (used) needle.
2. Select and inspect equipment. 6. Assemble the syringe.
depressed, the plunger forces fluid or gas out of the Always use extreme caution when recapping a
a. Ensure that all necessary equipment is a. Join together the syringe and needle by
opening of the syringe. When pulled back, a vacuum clean needle. Never hold the sheath (the protective
retrieved. inserting the needle adapter of the sy-
is created inside the barrel that will suck up any fluids needle cover) in your nondominant hand and attempt
b. Select the appropriate size needle and ringe into the needle hub.
or gases in contact with the syringe. If the plunger is to recap the needle. Use the scoop method when
syringe for the type of injection being b. Tighten the needle and syringe by twist-
not the right size, or is defective, it can be difficult to recapping a clean needle.
performed. ing the needle clockwise one-quarter
pull back or push forward, which can interfere with c. Ensure that all packaging is properly turn to ensure that the needle is securely
medication administration. sealed and undamaged. Verify that noth- attached to the syringe. PREPARING MEDICATIONS FOR
ing is expired.
Caution: The needle adapter and the shaft of the ADMINISTRATION
7. Place the assembled needle and syringe on
plunger are sterile. Do not touch the adapter or 3. Unpack the syringe. the work surface; leave the protective cover Drawing and Administering Medication
the shaft of the plunger because contamination a. Peel the sides of the wrapper apart to on the needle. from a Vial
could cause patient infection. expose the rear end of the syringe barrel. a. Leave the plunger pushed fully into the
b. Grasp the syringe by the barrel. Be careful barrel. Liquid medications are packaged in different con-
not to touch the adapter or shaft of the b. Keep the assembled needle and syringe
Safety Syringes tainers such as vials, ampules, and prefilled syringes.
plunger. within sight to ensure safety and prevent A vial is a small glass bottle that contains a liquid
c. Pull the syringe from the packaging. contamination.
Most syringe and needle combinations comprise medication. It differs from an ampule by its distinct
some type of safety syringe. In syringe-based safety rubber stopper. The rubber stopper allows insertion

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of a needle and withdrawal of medication from the and consistency by holding the vial up to
vial without spilling if the bottle is tilted or inverted Caution: Always check allergies before administer- light. If it is a dark, light-obscuring vial,
(Figure 5-5). The characteristic rubber stopper of a ing any medication. Have the patient describe the this check must be done when drawing
vial is protected from damage by a protective cap, reactions in their own words. Check with the MO to up the medication into the syringe.
typically made out of plastic or metal (Figure 5-6). see if the patient described an allergy that would f. If there is any evidence of medicine or
Once the protective cap is removed from the vial, it contraindicate use of the medication. package contamination or damage, or if
cannot be replaced. Vials come prepared as single- or the vial is outdated, discard the product
multi-dose bottles. 2. Don PPE. The minimum PPE for drawing IAW local SOPs and obtain a new vial.
Use the items listed below for drawing medication medication from a vial is gloves and eye g. Open the packaging on both the 18 G (or
from a vial: protection. blunt) and administration needles, as
well as the syringe. Connect the hub of
• blue chux pad 3. Check and assemble equipment. the 18 G (or blunt) needle to the needle
• syringe—appropriate size for the type of a. Select the correct medication from the adapter on the syringe.
medication being given storage area. h. Open the alcohol prep pad.
• 18 G or blunt needle used for drawing the i. Conduct the first verification by en-
medication from the vial suring that the medication and con- 4. Remove the cap from the medication vial and
• needle of the appropriate size for adminis- centration (if applicable) are exactly cleanse the vial with the alcohol prep pad.
tering the medication via the desired type of what was ordered by the MO.
injection ii. Verify that the medication was prop- 5. Remove the protective cap from the needle
• alcohol prep pad erly stored (eg, refrigerated). safely. Pull the needle cover straight off with-
• 2 in. × 2 in. (2 × 2) gauze pad iii. Premixed medications may have to out bending or touching the needle.
be shaken or rolled in your hands to
Use the following steps for drawing medication ensure that the medication is resus- 6. Pull back on the plunger to draw air into the
from a vial: pended in the solution; always check syringe for injection into the medication vial.
1. After receiving the MO’s order to administer the medication label for instructions. a. The amount of air to draw up equals the
Figure 5-5. A combat medic using proper technique to draw a drug from a vial, ask the patient if they have b. Obtain the required equipment. amount of fluid to be administered.
medication from a vial. The vial is inverted and the rubber known allergies, ask female patients if they c. Ensure that all packaging is properly b. Follow the directions on the medication
stopper prevents medicine from leaking out. could be pregnant (some medications can sealed and undamaged. Verify that noth- vial, if provided.
harm the fetus), and verify the 6 Rights for all ing is expired. Examine the container. If it c. Recheck to ensure that the medication
patients. Verifying the 6 Rights ensures that is a multi-dose vial that has been opened, being drawn up into the syringe is the
the combat medic has the correct: check the rubber stopper for defects, such correct medication and concentration (if
a. patient—confirm the patient’s identity us- as small holes or torn plugs. applicable) ordered by the MO. This is
ing two patient identifiers in accordance the second check for accuracy.
with (IAW) your local MTF standard Note: The protective cap should be in place on
operating procedures (SOP)—usually by single-dose vials. If the protective cap has been 7. Insert the 18 G (or blunt) needle into the
asking them to state their name and date removed, discard the vial and select a new one from medication vial on the table.
of birth (DOB), the medication storage area. a. Place the medication vial upright on a
b. medication, table. Insert the 18 G (or blunt) needled
c. dosage, d. Check the date the multi-dose vial was syringe through the rubber stopper, en-
d. route, opened and check the expiration date of suring the needle tip passes completely
e. time, and the medication. through. Ensure the hub of the needle
f. documentation. i. Multi-dose vials should have the fol- does not touch the rubber stopper.
lowing information written on the b. Pick up the syringe and vial and turn
Caution: If a female patient believes there is a label once opened—time, date, and them upside down.
chance she could be pregnant, contact your super- initials detailing first use. c. Elevate the syringe and vial to eye level.
visor or the prescribing MO. Do not administer the ii. Multi-dose vials are good for 28 days
injection without written authorization. from the date of first use, unless the 8. Push the plunger forward to inject air from
manufacturer specifies otherwise. the syringe into the vial. The amount of air
e. If possible, check the medication for injected should equal the amount of fluid that
Figure 5-6. Removal of the protective cap of a single-dose vial. floating particles and changes in color must be withdrawn.
The rubber stopper can be seen just below the protective cap.

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9. Pull the plunger back to the desired milliliter Use the items listed below for reconstituting medi- i. Conduct the first verification by en-
mark, withdrawing the prescribed medica- cine: suring that the medication and con-
tion into the syringe. centration (if applicable) are exactly
• two 3 to 5 mL syringes what was ordered by the MO.
10. Remove the needle from the vial and recap • 18 G or blunt needle used for reconstituting ii. Normally, powdered medication is
the needle using the scoop method. the medication packaged with its diluent in the same
• appropriate size needle for desired type of in- box. If no diluent is included, check
11. Attach the appropriate needle to the syringe jection, used for administering the medication the powdered medication label for
and administer the medication. • two alcohol prep pads instructions on what diluent should
a. After the medication has been drawn up Figure 5-7. A multi-dose vial properly labeled with the date • diluent and medication vials be used.
and is ready to be administered, conduct and time of opening. b. Obtain the required equipment.
a final recheck to ensure that the medica- Use the following steps for reconstituting a medi- c. Ensure that all packaging is properly
tion and concentration (if applicable) are cation: sealed and undamaged. Verify that noth-
exactly what was ordered by the MO. ing is expired.
This is the third and final check prior to 1. After receiving the MO’s order to administer d. If possible, check the diluent vial for
administration. a drug that requires reconstitution, ask the floating particles and changes in color
b. Pull back on the plunger slightly to with- patient if they have known allergies, ask and consistency by holding the vial up
draw any fluid that may be in the 18 G female patients if they could be pregnant to light.
(or blunt) withdraw needle. This moves (some medications can harm the fetus), and e. If there is any evidence of medicine or
all fluid into the syringe. verify the 6 Rights for all patients. Verifying package contamination or damage, or if
c. Detach the 18 G (or blunt) withdraw the 6 Rights ensures that the combat medic the vial is outdated, discard the product
needle by twisting counter clockwise and has the correct: into the sharps container and obtain a
discard it into a sharps container. a. patient—confirm the patient’s identity new vial.
d. Attach the administration needle. using two patient identifiers IAW your f. Open the packaging on both the 18 G (or
e. Slowly advance the plunger of the syringe local MTF SOP—usually by asking them blunt) and administration (depending on
to expel the air bubble from the top of to state their name and DOB, type of injection) needles, as well as both
the syringe and the new administration b. medication, syringes. Connect the hub of the needles
needle. Place the syringe at eye level and c. dosage, to the needle adapters on the syringes.
ensure the plunger is positioned exactly Figure 5-8. Glucagon is an emergency reconstituted medi- d. route, g. Open the alcohol prep pads.
on the prescribed milliliter mark once cation used to release sugar stores in the liver during a e. time, and
the air bubble has been expelled from the hypoglycemic event. The Bedford Laboratories (Bedford, f. documentation. 4. Remove the cap from the diluent and medi-
syringe and administration needle. OH) glucagon product shown here has two vials; the diluent cation vials and cleanse both with an alcohol
f. Administer the injection. is on the left and the powdered medication is on the right. prep pad.
Caution: If a female patient believes there is a
12. Discard the needle and syringe into the Reconstituting Medicines chance she could be pregnant, contact your super- 5. Safely remove the protective cap from the
sharps container. visor or the prescribing MO. Do not administer the 18 G (or blunt) needle and syringe unit by
Some medications come in a powdered form that injection without written authorization. pulling it straight off without bending or
Once the medication has been administered, return must be turned into a solution prior to administration. touching the needle.
the vial to the proper storage area. If it is a multi-dose Normally, the powdered medication is packaged in a Caution: Always check allergies before administer-
vial, verify that the date and the time the vial was vial, and another vial that contains a liquid diluent is 6. Pull back on the plunger to draw air into the
ing any medication. Have the patient describe the
opened are recorded on the vial label (Figure 5-7), then included. If no diluent is included, check the powdered syringe for injection into the diluent vial.
reactions in their own words. Check with the MO to
place it back into storage. Discard single-dose vials medication label for instructions on what diluent a. The amount of air to draw up equals the
see if the patient described an allergy that would
and multi-dose vials if they are empty or expired, in should be used (Figure 5-8). Once the contents of both amount of fluid in the diluent vial.
contraindicate use of the medication.
accordance with local SOP. vials are mixed together and the medication is dis- b. Recheck to ensure that the medication
solved, it is now in its proper form for administration. 2. Don PPE. The minimum PPE for reconstitut- being drawn up into the syringe is the
Check on Learning correct medication and concentration (if
ing a drug is exam gloves and eye protection.
Warning: The reconstituted powder shown in applicable) ordered by the MO. This is
7. How are clean needles recapped? the skill drills (at the back of the chapter) is Practi- the second check for accuracy.
3. Check and assemble equipment.
8. How do you determine that the correct Powder White, by Wallcur (San Diego, CA). Wallcur a. Select the correct medication from the
amount of medication has been drawn? Practi-Products are NOT medicines and are NOT storage area.
for human or animal use. They are for training pur-
poses only.

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7. Insert the 18 G (or blunt) needle into the dilu- 14. After conducting the third medication check,
ent vial on the table. withdraw the prescribed amount (using the Caution: If a female patient believes there is a
a. Place the diluent vial upright on a table. 21 G needle-syringe unit), verify the correct chance she could be pregnant, contact your super-
Insert the 18 G (or blunt) needled syringe dosage, and administer properly. visor or the prescribing MO. Do not administer the
through the rubber stopper, ensuring the a. Remove the protective cap from the 21 injection without written authorization.
needle tip passes completely through. G needle-syringe unit safely. Pull the
b. Pick up the 18 G (or blunt) needle and needle cover safely off without bending
syringe and diluent vial and turn them Caution: Always check allergies before administer-
or touching the needle.
upside down. ing any medication. Have the patient describe the
b. Place the medication vial onto the table
c. Elevate the syringe and vial to eye level. reactions in their own words. Check with the MO to
and insert the 21 G needle into the vial.
see if the patient described an allergy that would
Pick up the syringe and medication vial
8. Push the plunger forward to inject air from contraindicate use of the medication.
and turn them upside down. Elevate the
the syringe into the diluent vial. The amount syringe and vial to eye level.
of air injected should be equal to the total 2. Don PPE. The minimum PPE required for
amount of fluid in the diluent vial. All fluid Note: Cleanse the rubber stopper again with an drawing medication from an ampule is exam
must be withdrawn. alcohol prep pad if it is touched by anything unsterile gloves and eye protection.
during the preparation (mixing) of the medication.
9. Pull back on the plunger, drawing up the
3. Check and assemble the equipment.
correct amount of diluent fluid from its vial. c. Pull back on the plunger of the syringe, a. Select the correct medication from the
drawing up the correct amount of medi- storage area and conduct the first verifica-
10. Withdraw the 18 G (or blunt) needle from the cation from the medication vial. tion that the medication and concentra-
diluent vial and insert it into the medication d. If any air bubbles are visible in the sy-
Figure 5-9. An ampule of 1:1,000 epinephrine. tion (if applicable) are exactly what was
vial on the table. ringe, point the needle up and tap the ordered by the MO.
syringe to move the air bubbles to the i. Verify that the medication was prop-
11. Inject the diluent into the medication vial. If needle. Slightly depress the plunger to • blue chux pad
erly stored (eg, refrigerated).
the vial with powdered medication contains expel the air from the needle-syringe. • filter needle
ii. Premixed medications may have to
air, the diluent may be difficult to inject; air e. Verify the correct dosage. • appropriate size needle for desired type of
be shaken or rolled in your hands to
may have to be withdrawn to allow injection. injection
ensure that the medication is resus-
Check on Learning • alcohol prep pad
pended in the solution; always check
12. Withdraw the needle and syringe from the • 2 × 2 gauze pad
the medication label for instructions.
medication vial and discard it into a sharps 9. While attempting to dilute powdered medi- • 3 to 5 mL syringe
b. Obtain the required equipment.
container. cation, the diluent is difficult to inject. What c. Ensure that all packaging is properly
should you do? Use the following steps for drawing up medication
sealed and undamaged. Verify that noth-
13. Mix the medication well. 10. How do you determine whether to mix re- from an ampule:
ing is expired.
a. Check the medication vial label or pack- constituted medication gently or vigorously? d. If possible, check the medication for
age because some medications should 1. After receiving the MO’s order to administer
floating particles and changes in color
only be inverted gently, while others re- Drawing Medication from an Ampule a drug from an ampule, ask the patient if they
and consistency by holding the ampule
quire vigorous mixing. Mix the contents have known allergies, ask female patients if
up to light. If it is a dark, light-obscuring
IAW package instructions until all the An ampule is a glass container of medication that they could be pregnant (some medications
ampule, this check must be done when
power is dissolved. resembles a small bottle. The neck of an ampule con- can harm the fetus), and verify the 6 Rights.
drawing up the medication into the sy-
b. Visually inspect the solution to ensure it sists of a break line, which is the spot where the glass Verifying the 6 Rights ensures that the combat
ringe. Discard any ampules with contents
is well mixed. ampule is broken to access the medication inside (Fig- medic has the correct:
that appear corrupted or deteriorated
i. Check the medication for abnormali- ure 5-9). A filter needle is normally used when drawing a. patient—confirm the patient’s identity
into a sharps container.
ties such as undissolved crystals. medications from ampules. This prevents small glass using two patient identifiers IAW your
e. Open and place a blue chux pad on the
ii. Refer to the enclosed manufacturer’s particles, which may be in the ampule after opening, local MTF SOP—usually by asking them
table.
insert for acceptable variations in from being drawn up into the syringe and injected to state their name and DOB,
f. Open the needle packaging on both the
medication. If the insert is unavail- into the patient. When filter needles are used to draw b. medication,
filter and administration needles, as well
able or if you have any questions, up medication, the needle must be changed before the c. dosage,
as the 3 to 5 mL syringe. Connect the hub
stop the process and check with your medication is given to the patient. d. route,
of the filter needle to the needle adapter
MO or noncommissioned officer in Use the items listed below for drawing medication e. time, and
on the syringe.
charge (NCOIC) prior to injecting the from an ampule: f. documentation.
g. Open the alcohol prep pad.
patient with the medication.

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4. Cleanse the neck of the ampule with the not to touch the outside edge or bottom of Prefilled Syringe • 18 G or blunt needle used for drawing the
alcohol prep pad. the ampule with the needle while draw- medication from the vial
a. Place the ampule upright and lightly tap ing up the medication. A prefilled syringe provides a single medication • 25 to 27 G needle, 1/4 to 1/2 in.
to force any trapped medication out of d. Withdraw the needle from the ampule dose or unit dose medication prepared by a manufac- • two alcohol prep pads
the top of the ampule. and verify the dosage. Check the syringe turer or pharmacy. Prefilled syringes are convenient
b. Remove the alcohol prep pad from the for air bubbles. and easy to use. They improve health care by minimiz-
open package and place it on the break e. Hold the syringe with the filter needle ing microbial contamination and reducing medication
line of the ampule. pointing up and pull back on the plunger dosing errors.
c. Clean the entire circumference of the slightly to clear all the medication from Despite their advantages, prefilled syringes are not
ampule’s neck and break line. the needle shaft. widely used. There are no prefilled syringes with inte-
f. Tap the barrel lightly to force bubbles to grated safety features, and some medications cannot
5. Using your nondominant hand, pick up the the top. be packaged in a prefilled syringe.
ampule, and with your dominant hand, place g. Pull slightly back on the plunger to re- If the entire amount of medication in a prefilled
the 2 × 2 gauze pad on the ampule, covering move any medication in the filter needle. syringe is not needed, the excess should be discarded
the neck and break line. into a designated receptacle before administration.
a. The 2 × 2 gauze pad should be on the side 9. Recap the needle (using the correct technique) This is done by pushing the plunger until the correct
of the ampule facing you, and held in to prevent an accidental needlestick. Then quantity is obtained.
place by the thumbs of both hands. The twist the filter needle to remove it from the
2 × 2 gauze pad protects you from any syringe and put the needle into a sharps TYPES OF INJECTIONS
small glass pieces. container.
Intradermal Injections
6. Break the neck of the ampule, directing the Caution: The needle recapping technique is only
breaking away from your body. performed on clean needles. Never recap a dirty ID injections are used to test for exposure to diseases Figure 5-10. An example of a proper intradermal injection
needle. (eg, tuberculosis or mumps), and for sensitivity to en- with wheal formation. The needle is inserted at a 5° to 15°
7. Inspect the ampule for glass. vironmental allergens and medications. Because little angle.
a. Raise the broken ampule to eye level, 10. Attach the appropriate size needle and ad- systemic absorption of intradermally injected agents
toward a light source, and look for any minister the medication properly. takes place, this type of injection is used primarily to Use the following steps for administering an ID
small shards of glass that may have fallen a. Once the administration needle has been produce a localized effect. injection:
into the ampule accidentally. connected to the needle adapter of the ID injections are administered in small volumes,
b. If any small shards of glass are visible syringe, advance the plunger slightly usually 0.5 mL or less, into the outer layers of the skin. 1. After receiving the MO’s order to adminis-
inside of the ampule, discard it into a forward to expel any air bubbles and Intradermal injections require a 1/4 to 1/2 in. needle, ter a drug as an ID injection, ask the patient
sharps container, obtain another ampule fill the administration needle with the from 25 to 27 G. A tuberculin syringe or other 1 mL if they have known allergies, ask female
of the same medication, and repeat steps medication. syringe will also be necessary. Ensure the injection patients if they could be pregnant (some
1 through 7. b. Verify the medication and dosage again, site is free of hair, tattoos, and scars. Do not inject over medications can harm the fetus), and verify
then cover the needle with the protective a vein or bony area. Place medication just below the the 6 Rights. Verifying the 6 Rights ensures
8. Using the syringe with the attached filter cover if not administering the medication epidermis. that the combat medic has the correct:
needle, withdraw the prescribed amount of immediately. Recap the administration The primary injection site for ID injection is the a. patient—confirm the patient’s identity
verified medication from the ampule. needle if the cap had been removed. ventral forearm (on the inner, flat portion). This site using two patient identifiers IAW your
a. Pick up the assembled needle and syringe is most commonly used because it is easily accessible local MTF SOP—usually by asking them
with your dominant hand. Safely remove 11. Discard the needle and attached syringe and lacks hair (Figure 5-10). Other appropriate sites to state their name and DOB,
the protective cover with your free hand into the sharps container immediately after include the back of the upper arm and on the back b. medication,
by pulling it straight off without bending administering the medication. below the shoulder blades. c. dosage,
or touching the needle. d. route,
b. Do not pull the plunger back and draw Check on Learning Preparing and Administering an Intradermal e. time, and
air into the syringe in preparation for Injection f. documentation.
drawing medication. 11. You snapped the neck of the ampule and are
c. Hold the ampule vertically with your inspecting the ampule. What are you looking Use the items listed below for administering an ID Caution: If a female patient believes there is a
nondominant hand or place the ampule for? injection: chance she could be pregnant, contact your super-
upright on a flat surface, insert the filter 12. What should you do if you find something visor or the prescribing MO. Do not administer the
needle and syringe, and withdraw the in the ampule? • blue chux pad injection without written authorization.
prescribed dose of medication. Be careful • tuberculin or other 1 mL syringe

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d. Inspect the vial by holding it up to light 8. Push the plunger forward to inject air from 16. Advise the patient of the stick, then insert the
Caution: Always check allergies before administer-
to check for foreign particles and changes the syringe into the vial. The amount of air needle at a 5° to 15° angle.
ing any medication. Have the patient describe the
in color and consistency. If it is a dark, injected should equal the amount of fluid that a. With your dominant hand, position the
reactions in their own words. Check with the MO to
light-obscuring vial, this check must be must be withdrawn. syringe, with the needle bevel up, at a 5°
see if the patient described an allergy that would
done when drawing up the medication to 15° angle to the skin surface.
contraindicate use of the medication.
into the syringe. 9. Withdraw the prescribed amount of medica- b. Advance until the bevel is under the skin
tion from the vial. Pull back on the plunger surface.
2. Don PPE and perform a patient care hand
Note: If there is any evidence of medicine or pack- to the desired milliliter mark, withdrawing i. Insert the needle just until the bevel
wash. The minimum PPE for administering an
age contamination or damage, or if the vial is out- the correct amount of medication. disappears under the skin’s surface,
ID injection is exam gloves and eye protection.
dated, discard the product into the sharps container about 1/8 in. (0.3 cm) below the epi-
and obtain another. 10. Remove the 18 G (or blunt) needle and recap dermis.
3. Check and assemble equipment.
the needle using the scoop method. Replace ii. If more than one ID injection is re-
a. Select the correct medication from the
e. Open the packaging on the 18 G (or the 18 G (or blunt) needle with the adminis- quired, ensure that the injections are
storage area.
blunt) needle and syringe. Some 1 mL tration needle. 2 in. (5 cm) apart.
i. Conduct the first verification by en-
syringes come with the appropriate 25 a. Withdraw the plunger slightly to remove
suring that the medication and con-
G needle already attached. If this is the any medication in the 18 G (or blunt) 17. With the thumb of your nondominant hand,
centration (if applicable) are exactly
case, separate the 25 G needle from the 1 needle. push the plunger forward slowly until all the
what was ordered by the MO.
mL syringe and attach the 18 G (or blunt) b. Discard the needle used to withdraw the medication has been injected and a wheal ap-
ii. Verify that the medication vial was
needle. medication into the sharps container. pears at the injection site. Remove the needle-
stored properly (eg, refrigerated).
f. Open the alcohol prep pad. c. Connect the administration needle (25 G) syringe and place it into a sharps container.
iii. Premixed medications may have to
to the medicine-filled syringe and slightly
be shaken or rolled in your hands to
4. Remove the cap from the medication and push on the plunger to fill the administra- Note: Do not aspirate when performing an intra-
ensure that the medication is resus-
cleanse the vial with an alcohol prep pad. tion needle with medication. dermal injection.
pended in the solution; always check
d. Perform a final recheck prior to adminis-
the medication label for instructions.
5. Remove the cap from the needle safely by tration. Ensure that the medication and a. The appearance of a wheal indicates the
b. Obtain the required equipment.
pulling it straight off without bending or concentration (if applicable) match the medication has entered the area between
c. Ensure that the packaging of all items is
touching the needle. MO’s order. This is the third and final the epidermis and the dermis.
properly sealed, not damaged, and not
check prior to administration. b. If a wheal does not appear, withdraw the
expired.
6. Pull back on the plunger of the syringe to needle completely from the arm at the
i. Examine the medication container.
draw in air for injection into the vial. 11. Ensure that the proposed injection area (fore- angle of insertion, and discard the needle
If it is a multi-dose vial that has been
a. The amount of air to draw up equals the arm) is completely exposed and the muscle is and syringe into a sharps container. Pre-
opened, check the rubber stopper for
amount of fluid to be administered. relaxed. Have the patient sit down and place pare a new set, and repeat the procedure
defects, such as small holes or torn
b. Follow the directions on the medication the forearm on a table with the anterior side at another site at least 2 in. away from the
plugs.
vial, if provided. facing up. initial test site.
c. Recheck to ensure that the medication c. If the injection is successful and a wheal
Note: If the vial being used is not a multi-dose
being drawn up into the syringe is the 12. Identify the injection site (anterior mid- does appear, finish injecting the remain-
vial, the protective cap should be in place and not
correct medication and concentration (if forearm). Ensure that the injection site is free ing medication. When finished, quickly
removed. If the protective cap has been removed,
applicable) ordered by the MO. This is of hair, tattoos, and scars. withdraw the needle at the same angle in
discard the vial and select a new one from the medi-
the second check for accuracy. which it was inserted.
cation storage area.
13. Clean the injection site with an alcohol prep d. Without applying pressure to the skin’s
7. Insert the 18 G (or blunt) needle into the pad. surface, cover the injection site with dry,
ii. Check the date the multi-dose vial was
medication vial on the table. a. Clean in a spiral motion outward to 3 in. sterile gauze.
opened and check the expiration date
a. Place the medication vial upright on a from the injection site.
of the medication. Multi-dose vials
table. Insert the needled syringe through b. Allow the skin to dry completely before Caution: Instruct the patient not to rub, scratch, or
should have the following informa-
the rubber stopper, ensuring the needle administering the injection. wash the injection site. Scratching could irritate the
tion written on the label once opened:
tip passes completely through, and that area and cause the injected material to be absorbed
time, date, and initials detailing first
the hub of the needle does not touch the 14. Remove the cap from the needle safely by systemically, as well as give a false positive or nega-
use. Multi-dose vials are good for 28
rubber stopper. pulling it straight off without bending or tive reading.
days from the date of first use unless
b. Pick up the syringe and vial and turn touching the needle.
the manufacturer specifies otherwise.
them upside down. 18. Monitor the patient for 20 minutes; watch for
c. Elevate the syringe and vial to eye level. 15. Using your nondominant hand, pull the skin signs and symptoms of a developing allergic
taut toward the patient’s hand. reaction.

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a. Check the site for bleeding, then circle

the test with a marking pen, and label Note: Do not administer an injection within 2 in. of
the skin according to the test given. a scar, a bruise, or the umbilicus. Do not aspirate
b. Document the injection in the patient’s to check for blood return because this can cause
medical record. On the appropriate bleeding into the tissues at the site. Do not rub or
forms, record the date, time the injection massage the site after injection. Rubbing can cause
was given, amount of medication given, localized small hemorrhages or bruising.
site of administration, patient’s response
to the injection, and any adverse reactions Preparing and Administering Subcutaneous
to the injection. Injections
c. Instruct the patient when and where to
Use the items listed below for administering an SQ
have the test read IAW the local SOP.
injection:
Warning: Have an emergency tray available for the • blue chux pad
immediate treatment of serious reactions. Include a • 3 to 5 mL syringe—appropriate size for type
syringe containing a 1:1,000 solution of epinephrine. of medication
• 18 G or blunt needle used for drawing the
medication
Check on Learning • 25 G or 27 G needle, 5/8 to 1/2 in.
• two alcohol prep pads
13. What are the recommended sites for intra- • 2 × 2 gauze pad
dermal injections?
14. At what angle should the needle be inserted Use the following steps for administering an SQ
to deliver an intradermal injection? Figure 5-11. A combat medic preparing to administer a injection:
15. If a wheal does not appear, what is your next subcutaneous injection.
course of action? 1. After receiving the MO’s order to administer
16. Do intradermal injections require aspiration? a drug as an SQ injection, ask the patient
When administering SQ injections, use needles that Figure 5-12. The vastus lateralis injection site, appropriate if they have known allergies, ask female
Subcutaneous Injections range from 25 to 27 G, with a length of 5/8 to 1/2 in., or for subcutaneous and intramuscular injections. patients if they could be pregnant (some
an insulin syringe. Needle length and gauge will vary medications can harm the fetus), and verify
SQ injections place the medication within the tissue depending on the amount of SQ tissue and the patient’s the lateral thigh, and from one hand’s width below the the 6 Rights. Verifying the 6 Rights ensures
under the skin (Figure 5-11). They are used when the age, size, and condition. It is important to have a needle hip joint to one hand’s width above the knee. Medica- that the combat medic has the correct:
desired absorption rate is slower than that achieved that is short enough to just reach the SQ tissue. tion volume at this site should not exceed 2 mL. Tell the a. patient—confirm the patient’s identity
via the IM route. SQ injections also cause minimal tis- patient where you will be administering the injection using two patient identifiers IAW your
sue trauma and carry little risk of striking large blood Note: Injection at the correct angle is important. and position them lying face up or seated. local MTF SOP—usually by asking them
vessels and nerves. Absorbed mainly through the cap- The usual rule is a 45° angle for a 5/8 in. needle. SQ injections of medications such as insulin and to state their name and DOB,
illaries, drugs recommended for SQ injection include Always check your local SOP. heparin can be administered in the abdomen. Tell the b. medication,
nonirritating aqueous solutions and suspensions in patient where you will be administering the injection c. dosage,
small amounts (up to 2 mL) of fluid (eg, heparin and SQ injections are usually given in the rear lateral and position them lying face up. d. route,
insulin). SQ medications must be soluble and of suf- aspect of the upper arm, halfway between the shoul- e. time, and
ficient strength to be effective, yet safe for surrounding der and the elbow and one-third of the way around f. documentation.
tissues. The absorption rate for SQ injection is 15 to 30 laterally (see Figure 5-11). Medication volume should Note: The amount of medication given will vary ac-
minutes. The duration is hours to weeks (comparable not exceed 0.5 mL. Take care not to inject the medica- cording to the needs of the patient; a physician will Caution: If a female patient believes there is a
to that of the IM route). Drugs and solutions for SQ tion too close to the skin’s surface because doing so prescribe the dosage. chance she could be pregnant, contact your super-
injection are injected through a relatively short needle, may cause faster absorption and onset of action of the visor or the prescribing MO. Do not administer the
using sterile technique. SQ injections are given in areas medication, possibly causing local irritation. Tell the injection without written authorization.
where bones and blood vessels are not near the skin’s patient where you will be giving the injection and posi- Caution: Seated or lying positions are preferred for
surface. Injection is contraindicated in sites that are tion them sitting or standing, with the area completely injections. Although it is permissible to use a stand-
Caution: Always check allergies before administer-
inflamed, edematous, scarred, or covered by a mole, exposed, muscle relaxed, and arm at the side. ing position, some patients (even young, healthy
ing any medication. Have the patient describe the
birthmark, or other lesion. It may also be contraindicat- The vastus lateralis is another appropriate site for soldiers), may experience a vasovagal response
reactions in their own words. If there is a known
ed in patients with impaired coagulation mechanisms. an SQ injection (Figure 5-12). This injection site extends to an injection. A vasovagal response can lead to
allergy, do not administer the medication; contact
from the middle of the anterior thigh to the middle of dizziness or syncope (loss of consciousness).
your supervisor or the prescribing MO.

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2. Don PPE and perform a patient care hand iv. If there is any evidence of medicine 10. Remove the 18 G (or blunt) needle and recap 15. Using your nondominant hand, reach over
wash. The minimum PPE for SQ injection is or package contamination or damage, the needle using the scoop method. Replace the top of the site, placing the index finger
exam gloves and eye protection. or if the vial is outdated, discard the the 18 G (or blunt) needle with the adminis- and thumb on each side of the injection
product into the sharps container and tration needle. location. Squeeze the fingers and thumb
3. Check and assemble equipment. obtain another. a. Withdraw the plunger slightly to remove together, slightly pinching the skin. This
a. Select the correct medication from the c. Open the packaging on the needle and any medication in the 18 G (or blunt) technique will elevate the subcutaneous
storage area. syringe. If the needle and syringe are needle. tissue, forming a 1 in. (2.5 cm) fat fold.
i. Conduct the first verification by en- packaged separately, open both and at- b. Discard the needle used to withdraw the
suring that the medication and con- tach the needle to the syringe. medication into the sharps container. 16. Advise the patient of the stick, then insert the
centration (if applicable) are exactly d. Open the alcohol prep pad. c. Connect the administration needle (23 G) needle, in an upward motion at a 45° angle.
what was ordered by the MO. to a medicine-filled syringe and slightly a. With your dominant hand, position the
ii. Verify that the medication was prop- 4. Remove the cap from the medication and push on the plunger to fill the administra- syringe 1/2 in. from the skin surface with
erly stored (eg, refrigerated). cleanse the vial with alcohol prep pad. tion needle with medication. the needle bevel up at a 45° angle to the
iii. Premixed medications may have to d. Perform a final check prior to adminis- skin surface.
be shaken or rolled in your hands to 5. Remove the cap from the needle safely by tration. Ensure that the medication and b. Plunge the needle firmly and quickly
ensure that the medication is resus- pulling it straight off without bending or concentration (if applicable) match the through the skin and into the subcutane-
pended in the solution; always check touching the needle. MO’s order. This is the third and final ous tissue.
the medication label for instructions. check prior to administration. c. Using a slow, continuous movement,
b. Ensure that all items are properly pack- 6. Pull back on the plunger of the syringe to completely depress the plunger and inject
aged and sealed, not damaged, and not draw in air for injection into the vial. 11. Ensure that the proposed injection site (lateral the medication.
expired. a. The amount of air to draw up equals the aspect of the upper arm or the vastus lateralis
i. Examine the medication container. amount of fluid to be administered. of the anterior thigh) is completely exposed Caution: Do not administer the injection if an air
If it is a multi-dose vial that has been b. Follow the directions on the medication and the muscle is relaxed. Have the patient bubble is in the syringe. Syringes are calibrated to
opened, check the rubber stopper for vial, if provided. sit in a manner that will allow easy access to administer the correct dose of medication, which will
defects, such as small holes or torn c. Recheck to ensure that the medication either injection site. Remember that sitting is be altered if an air bubble exists.
plugs. being drawn up into the syringe is the the preferred position.
correct medication and concentration (if d. Place either an alcohol pad or sterile
Note: If the vial being used is not a multi-dose applicable) ordered by the MO. This is 12. Identify the injection site—lateral aspect of gauze pad lightly over the injection site
vial, the protective cap should be in place and not the second check. the upper arm (halfway between the shoul- and withdraw the needle at the same
removed. If the protective cap has been removed, der and the elbow and one-third of the way angle in which it was inserted.
discard the vial and select a new vial from the medi- 7. Insert the 18 G (or blunt) needle into the around laterally) or the vastus lateralis of the e. Discard the used needle into a sharps
cation storage area. medication vial on the table. anterior thigh. container.
a. Place the medication vial upright on a a. Ensure that the injection site is free of hair,
ii. Check the date the multi-dose vial table. Insert the 18 G (or blunt) needled tattoos, and scars. Warning: Never attempt to recap a dirty needle.
was opened and check the expiration syringe through the rubber stopper, b. If the patient requires SQ injections rou-
date of the medication. Multi-dose ensuring the needle tip passes com- tinely, always rotate the injection sites, 17. Rub the area in a circular motion using the
vials should have the following in- pletely through and that the hub of the which will prevent injury to the subcuta- 2 × 2 gauze to disperse the medication into
formation written on the label once needle does not touch the rubber stopper. neous tissue due to multiple SQ injections the tissue.
opened—time, date, and initials de- b. Pick up the syringe and vial and turn at the same site. a. Ensure that this is not contraindicated for
tailing first use. Multi-dose vials are them upside down. the type of medication injected.
good for 28 days from the date of first c. Elevate the syringe and vial to eye level. 13. Clean the injection site with an alcohol prep b. Remove the gauze and check the injection
use unless the manufacturer specifies pad. site for bleeding or bruising.
otherwise 8. Push the plunger forward to inject air from a. Clean in a spiral motion outward 3 in. c. Place an adhesive bandage over the site.
iii. If possible, check the medication for the syringe into the vial. The amount of air from the injection site.
floating particles and changes in color injected should equal the amount of fluid that b. Allow the skin to dry completely before 18. Monitor the patient for 20 minutes; watch
and consistency by holding the vial up must be withdrawn. administering the injection. for signs and symptoms of a developing al-
to light. If it is a dark, light-obscuring lergic reaction. Document the injection in the
vial, this check must be done when 9. Withdraw the prescribed amount of medica- 14. Remove the cap from the needle safely by patient’s medical record. On the appropriate
drawing up the medication into the tion from the vial. Pull back on the plunger pulling it straight off without bending or forms, record the date, time the injection was
syringe. to the desired milliliter mark, withdrawing touching the needle. given, amount of medication given, site of ad-
the correct amount of medication. ministration, patient’s response to injection,
and any adverse reactions to the injection.

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68W Combat Medic Textbook Injections

given at this site. This IM injection site may be more

Warning: Have an emergency tray available for the painful than the other sites due to a larger number
immediate treatment of serious reactions. Include a of small nerve endings located there. Although it is
syringe containing a 1:1,000 solution of epinephrine. permissible to use a standing position for injections,
seated or lying positions may be preferable to avoid a
vasovagal response.
Check on Learning The ventrogluteal site is used for larger medication
volumes (up to 5 mL) and may require a long needle
17. When should SQ injections be used rather (2 in. or longer in large adults). The ventrogluteal site
than ID or IM injections? is preferred for IM injections in anyone over the age
18. What are possible sites for SQ injections? of 7 months. This site provides the greatest thickness
19. At what angle should the needle be inserted of gluteal muscle, does not have nerves and blood
for SQ injections? vessels, and has the most consistent and thinnest layer
20. Into what type of tissue is the medication of adipose tissue. Because of these characteristics,
being delivered in SQ injections? injuries from IM injections at the ventrogluteal site
are rare. An injection given in an area outside this site
Intramuscular Injections could cause damage to the sciatic nerve or puncture
Figure 5-14. The deltoid intramuscular injection site. the superior gluteal artery, causing either paralysis or
IM injections (Figure 5-13) are used when rapid severe bleeding.
absorption rate (10–20 min) and long duration (hours When administering an IM injection, position the
to weeks) are desired. They are preferred when admin- For IM injections, choose a needle that is no less patient in a ventrogluteal position. The patient can be
istering viscous or irritating medications and when a than 1 in. long for an adult (unless the patient is thin, placed in the prone position with the toes pointing
large volume of medication is needed for a stronger in which case you may use a smaller size). For obese inward. This will help relax the gluteal muscle. An-
effect. patients, needles up to 2 in. may be needed. Selecting other form of the ventrogluteal position is to have the Figure 5-15. The ventrogluteal intramuscular injection site.
a needle long enough to reach the muscle is essential; patient lying on their side and flexing the upper legs.
Caution: Because absorption of medications ad- using a needle that is too short will cause the medica- Identify the ventrogluteal area by placing the patient
ministered by the IM route relies on adequate blood tion to be injected into SQ tissue, potentially reducing in the prone or side position. If identifying an injection
absorption and effectiveness. Needle bore diameter Use the following steps for administering an IM
flow to the muscles, IM injections should not be used site on the patient’s right hip, use your left hand. If
should range from 20 to 22 G. The exact length and injection:
in individuals with poor circulation or symptoms of identifying the injection site on the patient’s left hip,
shock. gauge selected will vary depending on the patient’s use your right hand. With the heel of your hand on the
amount of muscle mass, age, size, and overall condi- 1. After receiving the MO’s order to administer
lateral portion of the greater trochanter of the patient’s
tion. a drug as an IM injection, ask the patient
hip, point your thumb toward the patient’s groin. Point
Primary IM injection sites include the deltoid, vastus if they have known allergies, ask female
your index finger toward the anterior iliac spine, and
lateralis, ventrogluteal, and dorsogluteal muscles. The patients if they could be pregnant (some
extend your middle finger along the iliac crest (toward
deltoid muscle, located in the outer one-third of the medications can harm the fetus), and verify
the buttocks as far as possible). This hand position will
arm between the shoulder bone (acromion process) the 6 Rights. Verifying the 6 Rights ensures
create a V shape with the index and middle fingers.
and axilla, is used for medication volumes from 0.5 to that the combat medic has the correct:
The injection site is directly in the middle of the V
1 mL in adults and allows for faster absorption than a. patient—confirm the patient’s identity
shape (Figure 5-15).
other IM sites. The injection site is approximately two using two patient identifiers IAW your
or three finger widths below the shoulder bone, in local MTF SOP—usually by asking them
Preparing and Administering Intramuscular
the middle of the deltoid muscle mass (Figure 5-14). to state their name and DOB,
Injections
When administering the injection, position the patient b. medication,
standing or sitting with the area completely exposed, c. dosage,
Use the items listed below for administering an IM
muscle relaxed, and the arm at the side. d. route,
injection:
The safest site to perform an IM injection is the vas- e. time, and
tus lateralis. This site is the muscle mass located on the f. documentation.
• blue chux pad
lateral thigh, extending from the middle of the anterior • 3 to 5 mL syringe—appropriate size for type
thigh to the middle of the lateral thigh, and from one Caution: If a female patient believes there is a
of medication
hand’s width below the hip joint to one hand’s width chance she could be pregnant, contact your super-
Figure 5-13. A combat medic administering an intramuscular • 18 G or blunt needle
above the knee (see Figure 5-12). This site is consid- visor or the prescribing MO. Do not administer the
injection. • 20 to 22 G needle, 1 1/2 to 2 in.
ered the safest because there are no major nerves or injection without written authorization.
• two alcohol prep pads
blood vessels. An injection up to 5 mL of fluid can be • 2 × 2 gauze pad

112 113
68W Combat Medic Textbook Injections

iii. If there is any evidence of medicine 9. Withdraw the prescribed amount of medica- b. Vastus lateralis IM injection site (see Fig-
Caution: Always check allergies before administer- or package contamination or damage, tion from the vial. Pull back on the plunger ure 5-12):
ing any medication. Have the patient describe the or if the vial is outdated, discard the to the desired milliliter mark, withdrawing i. Locate the anterior thigh and place
reactions in their own words. If there is a known product into a sharps container and the correct amount of medication. one hand just below the hip to iden-
allergy, do not administer the medication; contact obtain a new vial. tify one hand’s width below the hip
your supervisor or the prescribing MO. d. If possible, check the medication for 10. Remove the 18 G (or blunt) needle and recap (this identifies the superior landmark
floating particles and changes in color the needle using the scoop method. Replace border). Place one hand above the
2. Don PPE and perform a patient care hand and consistency by holding the vial up to the 18 G (or blunt) needle with the adminis- knee to identify one hand’s width
wash. The minimum PPE for IM injection is light. If it is a dark, light-obscuring vial, tration needle. above the knee (this identifies the
exam gloves and eye protection. this check must be done when drawing a. Withdraw the plunger slightly to remove inferior landmark border).
up the medication into the syringe. any medication in the 18 G (or blunt) ii. After locating the superior and infe-
3. Check and assemble equipment. e. Open the packaging on the needle and needle. rior landmarks, draw an imaginary
a. Select the correct medication from the syringe. If the needle and syringe are b. Discard the needle used to withdraw the vertical line down the center of the
storage area. packaged separately, open both and at- medication into a sharps container. anterior thigh, and an imaginary
i. Conduct the first verification by en- tach the needle to the syringe. c. Connect the administration needle (23 G) vertical line down the center of the
suring that the medication and con- f. Open the alcohol prep pad. to the medicine-filled syringe and slightly lateral thigh.
centration (if applicable) are exactly push on the plunger to fill the administra- iii. The space between the superior and
what was ordered by the MO. 4. Remove the cap from the medication vial and tion needle with medication. inferior landmarks, as well as be-
ii. Verify that the medication was prop- cleanse with the alcohol prep pad. d. Perform a final recheck prior to adminis- tween the anterior and lateral vertical
erly stored (eg, refrigerated). tration. Ensure that the medication and lines, indicates the vastus lateralis IM
iii. Premixed medications may have to 5. Remove the protective cap from the needle concentration (if applicable) matches the injection site.
be shaken or rolled in your hands to safely by pulling it straight off without bend- MO’s order. This is the third and final c. Ventrogluteal IM injection site (see Figure
ensure that the medication is resus- ing or touching the needle. check prior to administration. 5-15):
pended in the solution; always check i. If providing an IM injection into
the medication label for instructions. 6. Pull back on the plunger of the syringe to 11. Ensure that the proposed injection area (del- the patient’s right hip, identify the
b. Obtain the required equipment. draw in air for injection into the vial. toid, ventrogluteal, or the vastus lateralis) is injection site with your left hand. If
c. Ensure that the packaging of all items is a. The amount of air to draw up equals the completely exposed and the muscle relaxed. providing an IM injection into the
properly sealed, not damaged, and not amount of fluid to be administered. a. Remove all clothing at the injection site. patient’s left hip, identify the injec-
expired. b. Follow the directions on the medication b. Place the patient in the proper position to tion site with your right hand.
i. Examine the medication container. vial, if provided. receive the specific type of IM injection. ii. Identify the greater trochanter of the
If it is a multi-dose vial that has been c. Recheck to ensure that the medication i. For an IM injection into the deltoid hip, and place the heel of your oppo-
opened, check the rubber stopper for being drawn up into the syringe is the muscle, the patient can either stand site hand on the lateral portion of the
defects, such as small holes or torn correct medication and concentration (if or sit. greater trochanter with your fingers
plugs. applicable) ordered by the MO. This is ii. For an IM injection into the vastus pointing toward the patient’s head.
the second check for accuracy. lateralis muscle, the patient should iii. Your middle finger should point
Note: If the vial being used is not a multi-dose sit or lie in the supine position. directly vertical along the lateral
vial, the protective cap should be in place and not 7. Insert the 18 G (or blunt) needle into the iii. For an IM injection into the ventro- midline of the patient.
removed. If the protective cap has been removed, medication vial on the table. gluteal muscles, the patient should iv. Spread your index finger from the
discard the vial and select a new vial from the medi- a. Place the medication vial upright on a lie straight on their side. middle finger toward the patient’s
cation storage area. table. Insert the 18 G (or blunt) needled anterior iliac spine and spread your
syringe through the rubber stopper, en- 12. Identify the injection site. thumb from your index finger toward
ii. Check the date the multi-dose vial suring the needle tip passes completely a. Deltoid muscle IM injection site (see Fig- the patient’s groin. The V shape
was opened and check the expiration through and that the hub of the needle ure 5-14): formed between your middle and in-
date of the medication. Multi-dose does not touch the rubber stopper. i. Locate the acromion process located dex finger identifies the IM injection
vials should have the following in- b. Pick up the syringe and vial and turn on the lateral, superior aspect of the site (directly in the middle of the V).
formation written on the label once them upside down. shoulder.
opened—time, date, and initials de- c. Elevate the syringe and vial to eye level. ii. Place two or three fingers below the 13. Clean the injection site with an alcohol prep
tailing first use. Multi-dose vials are acromion process and in the middle pad in a spiral motion outward 3 in.
good for 28 days from the date of first 8. Push the plunger forward to inject air from of the deltoid muscle mass.
use unless the manufacturer specifies the syringe into the vial.
otherwise.

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14. Remove the cap from the needle safely. Pull Check on Learning Standard Approach to Anaphylactic Treatment
the needle cover straight off without bending Warning: The presence of blood indicates that you
or touching the needle. have entered a blood vessel. If blood is present, 21. When administering an IM injection, should When treating a patient experiencing anaphylaxis,
remove the needle, hold pressure on the injection you aspirate? Why or why not? perform or provide the following:
15. Using your nondominant hand, stabilize the site, discard the needle and syringe into a sharps 22. At what angle should the needle be inserted
site. container, and identify a new injection site. for IM injections? • A primary assessment addressing all immedi-
a. If providing an IM injection into the 23. When should IM injections be used rather ate life threats.
deltoid muscle or vastus lateralis, take than SQ or ID injections? • High-flow oxygen (15 L/min) via a non-
your nondominant hand and reach over Warning: Never inject medication into a sensitive 24. What are the preferred IM injection sites? rebreather (NRB) or bag valve mask (if the
the top of the site with your index finger muscle, especially a muscle that may be twitching or patient requires manual ventilation).
and thumb on each side of the injection trembling when assessed. An injection into a sensi- ALLERGIC REACTIONS • Baseline vital signs (blood pressure, pulse,
location. Squeeze your thumb and index tive, twitching muscle may cause sharp or referred and respirations).
finger together, slightly pinching the skin pain; such as the pain caused by nerve trauma. Allergic reactions (Figure 5-16), including anaphy- • Albuterol at 2.5 mg nebulized for minor dys-
and underlying muscle. laxis (the most extreme form of an allergic reaction), pnea or wheezing.
b. If providing an IM injection into the ven- a. Using a slow, continuous movement, are always possible when administering an injection • Cardiac monitoring if capable.
trogluteal site, use your non-dominant completely depress the plunger and inject to a patient. Patients who suffer an anaphylactic aller- • If systolic blood pressure is greater than 90
hand to identify proper landmarks before the medication. gic reaction are experiencing a life-threatening event mmHg, establish an IV with normal saline at
inserting the needle. b. Place either an alcohol pad or sterile that if untreated may quickly lead to death. Definitive “to keep open” (TKO).
gauze pad lightly over the injection site signs of anaphylaxis are stridor, bronchospasms, and
16. Advise the patient of the stick, then insert the and withdraw the needle at the same hypotension. Symptoms of an allergic reaction may Note: If systolic blood pressure is lower than 90
needle at a 90° angle. angle in which it was inserted. begin within seconds or up to one hour; however, mmHg, administer a 10 to 20 mL/kg fluid bolus to
a. Hold the syringe in your dominant hand c. Discard the used needle into a sharps typical allergic reactions begin within minutes of ex- maintain a systolic blood pressure greater than 90
between your thumb and index finger, container. posure and may affect the skin, cardiovascular, and mmHg.
and position the needle bevel up, at a 90° respiratory systems.
angle to the skin surface and about 1/2 in. Warning: Never attempt to recap a dirty needle.
from the skin’s surface. Note: Patients suffering true anaphylaxis rarely
b. Plunge the needle firmly and quickly into 19. Rub the area in a circular motion using the 2 present with normal blood pressure.
the muscle. × 2 gauze to disperse the medication into the
tissue. • Diphenhydramine. For adults with moderate
Note: Always encourage the patient to relax the a. Ensure that this is not contraindicated for allergic reactions, administer 25 mg IM or IV
muscle you will be injecting because injections into the type of medication injected. push. For adults with severe allergic reactions
tense muscles are more painful and may bleed b. Remove the gauze and check the injection or anaphylaxis, administer 50 mg IM or IV
more readily. site for bleeding or bruising. push.
c. Place an adhesive bandage over the site. • Epinephrine. For adults with respiratory
Caution: Do not administer the injection if an air 20. Monitor the patient for 20 minutes; watch distress indicators (eg, wheezing or stridor),
bubble is in the syringe. Syringes are calibrated to for signs and symptoms of a developing al- administer an adult dose of epinephrine or 0.3
administer the correct dose of medication, which will lergic reaction. Document the injection in the mg (1:1,000 concentration) SQ or IM.
be altered if an air bubble exists. patient’s medical record. On the appropriate
forms, record the date, time the injection was Note: If treating a pediatric patient, consult the MO
17. Using your nondominant hand, grasp the given, amount of medication given, site of ad- for dosages.
plunger and slowly aspirate. Look for blood ministration, patient’s response to injection,
in the syringe. Release your hold on the skin and any adverse reactions to the injection.
with the nondominant hand and use it to Note: For patients suffering severe allergic reac-
support the syringe while you aspirate by Warning: Have an emergency tray available for the tions, subcutaneous injections are absorbed very
pulling back slightly on the plunger of the immediate treatment of serious reactions. Include a slowly and may not provide the needed medication
syringe with your dominant hand. syringe containing a 1:1,000 solution of epinephrine. fast enough to help the patient. Slow absorption is
made worse when the patient is hypotensive. These
18. If there is no blood in the syringe, inject the Figure 5-16. A patient displaying urticaria, an allergic reac- patients should have medication administered via
medication, remove the needle-syringe, hold tion. Photograph by James Heilman, MD. Reproduced from intramuscular injection.
pressure, and discard the needle and syringe Wikimedia Commons. https://commons.wikimedia.org/
into a sharps container. wiki/File:EMminor2010.JPG

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Check on Learning SUMMARY ASSEMBLING THE NEEDLE AND SYRINGE, CONT.

25. What are definitive signs of anaphylaxis? The ability to provide an injection is a basic skill
26. Symptoms of an allergic reaction may begin for a combat medic. Proficiency in performing injec-
within (time) __________ or up to _________. tions is paramount to ensuring that medication is
27. What concentration of epinephrine is used provided properly and no harm is caused. Because
to treat a patient suffering from anaphylaxis, significant harm can be caused by improper technique,
through SQ or IM injection? standardization in preparation and administration
28. What is the dose of epinephrine to administer is critical for patient protection. Proper selection of
through SQ or IM injection to a patient suf- equipment, proper preparation of the patient, sterile
fering from anaphylaxis? technique during administration, proper disposal of
29. What is the dose of diphenhydramine to contaminated equipment, and proper documenta-
administer to a patient suffering from ana- tion will minimize risk of injury to both patients and
phylaxis? combat medics.

ASSEMBLING THE NEEDLE AND SYRINGE STEP 5b: If it is packaged in a hard plastic tube, twist the
cap of the tube until a “pop” is felt and remove the cap to
expose the needle hub.

STEP 4b: Grasp the flared end of the syringe and move the
plunger back and forth to test for smooth, easy movement.
Visually check the rubber stopper (inside the syringe) to
ensure that it is attached securely to the top end of the
STEP 1: Don PPE. plunger, forming a seal.
STEP 2: Select and inspect equipment. Ensure that all
packaging is properly sealed, not damaged, and not STEP 6: To assemble the needle and syringe, first join
expired. them together by inserting the needle adapter of the
syringe into the hub of the needle. Tighten the needle by
turning it 1/4 of a turn to ensure that it is securely attached.

STEP 7: Place the assembled needle and syringe on the work

surface, leaving the protective cover on the needle. Leave
STEP 3: Unpack the syringe. Peel the sides of the wrapper STEP 4a: Inspect the syringe. Pull on the plunger and feel STEP 5a: Unpack the needle. Peel the sides of the flexible the plunger pushed fully into the barrel. Keep the assembled
and expose the rear end of the syringe. for the distinct “pop.” wrapper apart to expose the needle hub. needle and syringe within sight.

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RECAPPING THE NEEDLE DRAWING AND ADMINISTERING MEDICATION FROM A VIAL

STEP 1: Prepare to slide the needle into the cap by placing STEP 2: Insert the needle into the open end of the cap and STEP 1: Verify the 6 Rights. If the patient is female, ask if STEP 2: Don PPE.
the cap on a hard, cleared surface. lift the cap up, causing it to slide onto the needle. she could be pregnant.

STEP 3: Cover the needle with the cap, ensuring that the cap STEP 3a: Check and assemble equipment. Select the proper medi- STEP 3b: Examine the vial. Inspect and ensure
is secured to the needle hub. cation. Ensure that all packaging is properly sealed, not damaged, that the medication is not discolored and does not
and not expired. contain floating particles.

STEP 4a: Remove the cap from the medication. STEP 4b: Clean the rubber stopper with an alcohol prep
pad.

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DRAWING AND ADMINISTERING MEDICATION FROM A VIAL, CONT. DRAWING AND ADMINISTERING MEDICATION FROM A VIAL, CONT.

STEP 5: Remove the cap from the needle safely. STEP 6: Pull back on the plunger of the syringe, drawing STEP 10: Remove the needle from the vial and recap it STEP 11a: Detach the 18 G needle and discard it into a
up the correct amount of air into the syringe. Follow the using the scoop method. sharps container. Attach the administration needle.
directions on the vial, if provided.

STEP 11c: Administer the injection.

STEP 8: Push the plunger forward so air is pushed into the
vial (see directions on insert of medication).

STEP 11b: Slowly advance the plunger of the syringe to

expel the air bubble from the new administration needle
prior to injecting the medication.
STEP 12: Discard both the needle and the attached syringe;
place them into a sharps container.
STEP 7: Insert the needle into the medication vial on the table,
pick up the needle and vial, and turn them upside down. STEP 9: Withdraw the prescribed amount of medication
Elevate the syringe and vial to eye level. from the vial.

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RECONSTITUTING MEDICATION RECONSTITUTING MEDICATION, CONT.

STEP 1: Verify the 6 Rights. If the patient is female, ask if STEP 2: Don PPE. STEP 5: Remove the protective cap from the 18 G needle- STEP 6: Pull back on the plunger of the syringe, drawing
she could be pregnant. syringe unit safely. up the correct amount of air into the syringe. Follow the
directions on the vial, if provided.

STEP 3a: Check and assemble equipment. Select the STEP 3b: Open the packaging on both the needle-syringe STEP 7b: Pick up the syringe and vial and turn them up-
proper medication from the storage area. Ensure that units and connect the hubs of the needles to the needle STEP 7a: Insert the 18 G (or blunt) needle into the diluent side down. Elevate the syringe and vial to eye level.
all packaging is properly sealed, not damaged, and not adapters on the syringes. vial on the table.
expired.

STEP 4a: Remove the caps from the diluent and medica- STEP 4b: Cleanse both vials with alchohol prep pads.
tion vials. STEP 8: Push the plunger forward so air is pushed into the STEP 9: Pull back on the plunger, drawing up the correct
diluent vial. amount of diluent from the vial.

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RECONSTITUTING MEDICATION, CONT. RECONSTITUTING MEDICATION, CONT.

STEP 14a: Safely remove the protective cap from the STEP 14c: Pick up the syringe and medication vial and turn
unused needle-syringe unit. them upside down. Elevate them to eye level. Pull back on
the plunger and draw up the correct amount of medica-
tion from the vial.

STEP 10: Withdraw the needle from the diluent vial and STEP 11: Inject the diluent into the medication vial.
insert it into the medication vial on the table.

STEP 14d: Verify the correct dosage.

STEP 12: Withdraw the needle and syringe from the medi- STEP 13: Mix the medication well.
cation vial and discard it into a sharps container.

STEP 14b: Place the medication vial on the table and insert
the unused needle-syringe unit into vial.

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DRAWING MEDICATION FROM AN AMPULE DRAWING MEDICATION FROM AN AMPULE, CONT.

STEP 1: Verify the 6 Rights. If the patient is female, ask if she STEP 2: Don PPE. STEP 7: Inspect the ampule for glass particles. STEP 8: Using a syringe with an attached filter needle, with-
could be pregnant. draw the prescribed amount of medication from the ampule.

STEP 3: Check and assemble equipment. Select the correct

medication from the storage area. Ensure that all packaging
is properly sealed, not damaged, and not expired. Inspect
and ensure that the medication is not discolored and does not STEP 4: Cleanse the neck of the ampule with an alcohol STEP 9: Remove the filter needle from the syringe and place STEP 10: Attach the appropriate size administration needle
contain floating particles. prep pad. it into a sharps container. to the syringe and administer the medication properly.

STEP 5: Using your nondominant hand, pick up the ampule. STEP 6: Break the neck of the ampule away from your body. STEP 11: Directly after medication administration, discard
With your dominant hand, place the 2 × 2 gauze pad on the the needle and attached syringe into a sharps container.
ampule, covering the neck and break line.

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INTRADERMAL INJECTION INTRADERMAL INJECTION, CONT.

STEP 1: Verify the 6 Rights. If the patient is female, ask if STEP 2: Don PPE.
she could be pregnant.

STEP 7a: Insert the needle into the vial on the table, pick STEP 7b: Elevate the syringe and vial to eye level.
up the syringe and vial, and turn them upside down.

STEP 3: Check and assemble equipment. Select the correct

medication from the storage area. Ensure that all packag-
ing is properly sealed, not damaged, and not expired.
Inspect and ensure that the medication is not discolored STEP 4: Remove the cap from the medication and cleanse
and does not contain floating particles. the vial with an alcohol prep pad.

STEP 8: Push the plunger forward so air is pushed into the STEP 9: Withdraw the prescribed amount of medication
STEP 5: Remove the cap from the needle safely. STEP 6: Pull back on the plunger of the syringe, drawing
vial. from the vial by pulling back on the plunger to the desired
up the correct amount of air in the syringe.
milliliter mark.

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INTRADERMAL INJECTION, CONT. INTRADERMAL INJECTION, CONT.

STEP 10: Remove the needle and recap it using the scoop STEP 14: Remove the cap from the needle safely. STEP 15: Using your nondominant hand, pull the skin taut
method. Replace the 18 G (or blunt) needle with the toward the patient’s hand.
administration needle.

STEP 11: Ensure the proposed injection area (forearm) is

completely exposed with the muscle relaxed.

STEP 16: Advise the patient of the stick, then insert the STEP 17: Inject the medication, ensuring the presence of a
needle at a 5°–15° angle. Advance until the bevel is under wheal. Do not aspirate. Remove the needle-syringe and place
the skin surface. it into a sharps container. Do not rub the site.

STEP 12: Identify the injection site (anterior mid-forearm).

Ensure the site is free of hair, tattoos, and scars.

STEP 13: Clean the injection site with an alcohol prep pad in
a spiral motion outward 3 inches.
STEP 18: Monitor the patient for 20 minutes and document
the injection in the patient’s medical record.

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SUBCUTANEOUS INJECTION SUBCUTANEOUS INJECTION, CONT.

STEP 1: Verify the 6 Rights. If the patient is female, ask if she STEP 2: Don PPE.
could be pregnant.

STEP 6: Pull back on the plunger of the syringe, drawing STEP 7a: Insert the needle into the vial, pick up the syringe
up the correct amount of air. Follow the directions on the and vial, and turn them upside down.
vial, if provided.

STEP 3: Check and assemble equipment. Select the correct

medication from the storage area. Ensure that all packag-
ing is properly sealed, not damaged, and not expired. STEP 4a: Remove the cap from the medication.
Inspect and ensure that the medication is not discolored
and does not contain floating particles.

STEP 4b: Cleanse the vial with an alcohol prep pad. STEP 5: Remove the cap from the needle safely.
STEP 7b: Elevate the syringe and vial to eye level. STEP 8: Push the plunger forward so air is pushed into the
vial.

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SUBCUTANEOUS INJECTION, CONT. SUBCUTANEOUS INJECTION, CONT.

STEP 10: Remove the 18 G (or blunt) needle and recap Step 14: Remove the cap from the needle safely.
it using the scoop method. Replace the 18 G (or blunt)
needle with the administration needle.

STEP 9: Pull back on the plunger, drawing up the correct

amount of medication. STEP 13: Clean the injection site with an alcohol prep pad
in a spiral motion outward 3 inches.

STEP 16a: Advise the patient of the stick, then insert the
needle in an upward motion at a 45° angle.

STEP 15: Using your nondominant hand, reach over the

STEP 11: Ensure the proposed injection area is completely STEP 12: Identify the injection site (halfway between the top of the site, placing your index finger and thumb on
exposed, with the muscle relaxed. shoulder and the elbow, 1/3 of the way around later- each side of the injection location. Squeeze your fingers
ally). The vastus lateralis of the anterior thigh is an together, slightly pinching the skin.
alternate site.

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SUBCUTANEOUS INJECTION, CONT. INTRAMUSCULAR INJECTIONS

STEP 16c: Remove the needle-syringe and place it into STEP 1: Verify the 6 Rights. If the patient is female, ask if she STEP 2: Don PPE.
a sharps container. could be pregnant.

STEP 16b: Inject the medication.

STEP 3: Check and assemble equipment. Select the correct

medication from the storage area. Ensure that all packag-
ing is properly sealed, not damaged, and not expired.
STEP 18: Monitor the patient for 20 minutes and document STEP 4a: Remove the cap from the medication.
Inspect and ensure that the medication is not discolored
the injection in the patient’s medical record. and does not contain floating particles.

STEP 17: Rub the area in a circular motion, using the 2 × 2

gauze to disperse the medication into the tissue.
STEP 4b: Cleanse the vial with an alcohol prep pad. STEP 5: Remove the cap from the needle safely.

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INTRAMUSCULAR INJECTION, CONT. INTRAMUSCULAR INJECTION, CONT.

STEP 6: Pull back on the plunger of the syringe, drawing STEP 8: Push the plunger forward so air is pushed into STEP 11: Ensure the proposed injection area is completely STEP 12: Identify the injection site.
up the correct amount of air into the syringe. the vial. exposed, with the muscle relaxed.

STEP 9: Pull back on the plunger, drawing up the correct STEP 13: Clean the injection site with an alcohol prep pad in STEP 14: Remove the cap from the needle safely.
amount of medication. a spiral motion outward 3 inches.

STEP 7: Insert the 18 G (or blunt) needle into the vial on

the table, pick up the needle and vial, and turn them STEP 10: Remove the 18 G (or blunt) needle and recap it STEP 15: Using your nondominant hand, reach over the STEP 16: Advise the patient of the stick, then insert the
upside down. Elevate the syringe and vial to eye level. using the scoop method. Discard the needle into a sharps top of the site with your index finger and thumb on each needle at a 90° angle.
container and replace it with the administration needle. side of the injection location. Squeeze your finger and
thumb together, slightly pinching the skin and underlying
muscle.

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INTRAMUSCULAR INJECTION, CONT. KEY TERMS AND ACRONYMS

Ampule. A small glass container that can be sealed and its contents sterilized. This is a French
invention for containing hypodermic solutions; it holds a premeasured, single medication dose.
Anaphylaxis. A systemic hypersensitivity reaction to an antigen, which can be life threatening if not
treated quickly.
Aspirate. To draw in or out by suction.
Atrophy. A decrease in size or wasting away of a body part or tissue.
Bronchospasms. Contractions of smooth muscles in the airways that line the lungs. This narrows
the airways.
Diluent. An agent that dilutes the substance or solution when mixed together.
DOB. Date of birth.
Dorsogluteal. Pertaining to the buttocks; the anatomic area just behind the back of hip.
Enteral. Through the gastrointestinal tract.
G. Gauge.
Gauge. The needle’s inner diameter (also known as the bore), through which medication is
STEP 17: Using your nondominant hand, grasp the plung- STEP 18: If there is no blood in the syringe, inject the
administered. The gauge is stated using numbers; the larger the number, the smaller the bore or
er and slowly aspirate, observing for blood in the syringe. medication, remove the needle-syringe, hold pressure,
hole of the bevel.
and discard it into a sharps container.
Hub. The sterile piece that attaches to the tip of the syringe, also known as the hilt.
Hypotension. Abnormally low blood pressure.
IAW. In accordance with.
Injection. The forcing of a fluid into a vessel, tissue, or cavity.
Intracutaneous. Injection into the skin; used in giving serums and vaccines when a local reaction is
desired.
Intradermal. Intracutaneous, or more specifically, within the dermis (ID); often used for diagnostic
testing (skin tests). ID injections are shallow, given just beneath the epidermis. The inner aspect of the
forearm is the most common injection site.
Intramuscular. Injection into muscle tissue (IM); usually the anterior thigh, deltoid, or buttocks. IM
injection is used primarily in the administration of vaccines, immune globulins, corticosteroids, some
antibiotics, some hormones, and sedatives.
MO. Medical officer.
MTF. Military treatment facility.
Needlestick. Accidental puncturing of the skin with an unsterilized needle; health care workers are
STEP 20: Monitor the patient for 20 minutes and document especially at risk for injury while handling needles. Prevention of needlestick injury is essential
the injection in the patient’s medical record. because of the danger of exposure of those involved to infection from diseases transmitted by blood
(eg, HIV, hepatitis B or C).
Parenteral. Medication administration through any other route other than the mouth and
gastrointestinal tract.
Prefilled syringe. A single medication dose prepared by a manufacturer or pharmacy. If the
entire amount of medication is not needed, the excess is discarded into a designated receptacle
before dose administration.
STEP 19: Rub the area in a circular motion using the 2 × 2 Reconstituted. To restore to a former condition by adding liquid.
gauze pad to disperse the medication into the tissue. Sharps container. A container for disposal of needles, syringes, vials, ampules, and prefilled syringes
according to local protocols.
SOP. Standard operating procedures.
Stridor. A harsh, high-pitched breath sound that occurs when there is obstruction of the airways.
Subcutaneous. An injection beneath the skin, into the adipose (fatty) tissues located below the dermis
(SQ); typical sites include the abdomen, upper or outer arm, or the thigh.
Syringe. An instrument for injecting fluids into the body or its cavities.

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Tuberculin syringe. A syringe commonly used for intradermal (ID) injections. The turberculin syringe 11. You snapped the neck of the ampule and are inspecting the ampule. What are you looking for?
has a very small diameter and can measure in hundredths of a milliliter, resulting in a very accurate
Small glass particles.
measurement of very small amounts of liquid medication.
Vasovagal. Concerning the action of stimuli from the vagus nerve on blood vessels. 12. What should you do if you find something in the ampule?
Vastus lateralis. One of the three large muscles of the thigh.
Discard the ampule and get a new one.
Ventrogluteal. An anatomic area of the upper lateral thigh.
Vial. A glass container equipped with a self-sealing rubber stopper; it may contain a single 13. What are the recommended sites for intradermal injections?
premeasured medication dose, or it may be a multi-dose vial.
The ventral forearm (most common), the back of the upper arm, and on the back below the shoulder blade.
Wheal. An elongated mark or ridge, such as a ridge produced by an intradermal injection.
14. At what angle should the needle be inserted to deliver an intradermal injection?
CHECK ON LEARNING ANSWERS A 5° to 15° angle.
15. If a wheal does not appear, what is your next course of action?
1. What parts of the needle are sterile?
If a wheal does not appear, withdraw the needle completely from the arm at the angle of insertion and
All parts of the needle (except the protective cover).
discard the needle and syringe into a sharps container. Prepare a new set, and repeat the procedure at
2. Put these needles in order from the largest to smallest diameters: 25 G, 18 G, 22 G. another site at least 2 in. away from the initial test site.
18 G > 22 G > 25 G. 16. Do intradermal injections require aspiration?
3. What factors influence the length of the needle that should be used for a particular injection? No.
Type of injection, size of the patient, injection site. 17. When should SQ injections be used rather than ID or IM injections?
4. What parts of the syringe are sterile? SQ injections should be used when an absorption rate slower than that of IM injections is desired.
SQ absorption rate is slower than that achieved via the IM route.
Needle adapter, inside the barrel, plunger.
18. What are possible sites for SQ injections?
5. How do you know which syringe to select?
SQ injections are usually given in the rear lateral aspect of the upper arm, halfway between the shoulder
The syringe should be large enough to hold the entire dose and the calibration small enough to draw up
and the elbow and one-third of the way around laterally; in the vastus lateralis muscle; and in the abdomen.
an accurate dose.
19. At what angle should the needle be inserted for SQ injections?
6. While preparing to administer an injection, the needle is removed from the flexible wrapper. In-
advertently, you drop the needle on the floor. The protective cap was in place when the needle Bevel up, at a 45° angle to the skin surface.
touched the floor. Can the needle still be used? Why or why not?
20. Into what type of tissue is the medication being delivered in SQ injections?
No, the needle should not be used. All parts of the needle are considered sterile, including the hub. If the
Subcutaneous tissue.
sterile hub touches the floor, it is no longer sterile. The contaminated hub could cause an infection.
21. When administering an IM injection, should you aspirate? Why or why not?
7. How are clean needles recapped?
Yes. Aspiration of the syringe will determine if the needle unintentionally entered a blood vessel, which
Place protective cover on work surface. With your dominant hand holding the syringe, scoop the needle
could harm the patient if the drug or vaccine is directly injected into the blood vessel.
into the cover. DO NOT hold the protective cover with your nondominant hand.
22. At what angle should the needle be inserted for IM injections?
8. How do you determine that the correct amount of medication has been drawn?
A 90° angle.
Ensure the forward edge of the plunger is on the prescribed milliliter mark.
23. When should IM injections be used rather than SQ or ID injections?
9. While attempting to dilute powdered medication, the diluent is difficult to inject.
What should you do? IM injections are used when rapid absorption rate (10–20 minutes) and long duration (hours to weeks)
are desired. They are also preferred when administering viscous or irritating medications and when a
If the vial with the powdered medication contains air, some air may have to be withdrawn to allow the
large volume of medication is needed for a stronger effect.
diluent to be injected.
24. What are the preferred IM injection sites?
10. How do you determine whether to mix reconstituted medication gently or vigorously?
Deltoid, vastus lateralis, and ventrogluteal muscles.
Check the medication label or package insert.

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25. What are definitive signs of anaphylaxis?

Stridor, bronchospasm, and hypotension.
26. Symptoms of an allergic reaction may begin within (time) __________ or up to _________.
Seconds or up to 1 hour.
27. What concentration of epinephrine is used to treat a patient suffering from anaphylaxis,
through SQ or IM injection?
1:1,000.
28. What is the dose of epinephrine to administer through SQ or IM injection to a patient suffering
from anaphylaxis?
0.3 mg of 1:1,000 epinephrine.
29. What is the dose of diphenhydramine to administer to a patient suffering from anaphylaxis?
50 mg IV/IM.

SOURCES

Lippincott’s Visual Encyclopedia of Clinical Skills. Lippincott Williams & Wilkins; 2009.

Rosdahl C, Kowalski M. Textbook of Basic Nursing. 11th ed. Wolters Kluwer; 2017.

Stedman’s Pocket Medical Abbreviations. Wolters Kluwer/Lippincott Williams & Wilkins; 2006.

Taber’s Cyclopedic Medical Dictionary. 22nd ed. F.A. Davis Co; 2013.

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