Intramuscular injection
Intramuscular injection, often abbreviated IM, is the injection of a substance into a muscle. In medicine, it is one of several methods for parenteral administration of medications. Intramuscular injection may be preferred because muscles have larger and more numerous blood vessels than subcutaneous tissue, leading to faster absorption than subcutaneous or intradermal injections. Medication administered via intramuscular injection is not subject to the first-pass metabolism effect which affects oral medications.
Intramuscular injection
Common sites for intramuscular injections include the deltoid muscle of the upper arm and the gluteal muscle of the buttock. In infants, the vastus lateralis muscle of the thigh is commonly used. The injection site must be cleaned before administering the injection, and the injection is then administered in a fast, darting motion to decrease the discomfort to the individual. The volume to be injected in the muscle is usually limited to 2–5 milliliters, depending on injection site. A site with signs of infection or muscle atrophy should not be chosen. Intramuscular injections should not be used in people with myopathies or those with trouble clotting.
Intramuscular injections commonly result in pain, redness, and swelling or inflammation around the injection site. These side effects are generally mild and last no more than a few days at most. Rarely, nerves or blood vessels around the injection site can be damaged, resulting in severe pain or paralysis. If proper technique is not followed, intramuscular injections can result in localized infections such as abscesses and gangrene. While historically aspiration, or pulling back on the syringe before injection, was recommended to prevent inadvertent administration into a vein, it is no longer recommended for most injection sites by some countries.
Uses[edit]
Intramuscular injection is commonly used for medication administration. Medication administered in the muscle is generally quickly absorbed in the bloodstream, and avoids the first pass metabolism which occurs with oral administration.[1] The medication may not be considered 100% bioavailable as it must still be absorbed from the muscle, which occurs over time.[2]: 102–103 An intramuscular injection is less invasive than an intravenous injection and also generally takes less time, as the site of injection (a muscle versus a vein) is much larger. Medications administered in the muscle may also be administered as depot injections, which provide slow, continuous release of medicine over a longer period of time.[3] Certain substances, including ketamine, may be injected intramuscularly for recreational purposes.[4] Disadvantages of intramuscular administration include skill and technique required, pain from injection, anxiety or fear (especially in children), and difficulty in self-administration which limits its use in outpatient medicine.[5]
Vaccines, especially inactivated vaccines, are commonly administered via intramuscular injection.[6] However, it has been estimated that for every vaccine injected intramuscularly, 20 injections are given to administer drugs or other therapy.[6] This can include medications such as antibiotics, immunoglobulin, and hormones such as testosterone and medroxyprogesterone.[5] In a case of severe allergic reaction, or anaphylaxis, a person may use an epinephrine autoinjector to self-administer epinephrine into the muscle.[7]
Contraindications[edit]
Because an intramuscular injection can be used to administer many types of medications, specific contraindications depend in large part on the medication being administered.[8] Injections of medications are necessarily more invasive than other forms of administration such as by mouth or topical and require training to perform appropriately, without which complications can arise regardless of the medication being administered. For this reason, unless there are desired differences in rate of absorption, time to onset, or other pharmacokinetic parameters in the specific situation, a less invasive form of drug administration (usually by mouth) is preferred.[8]
Intramuscular injections are generally avoided in people with low platelet count or clotting problems, to prevent harm due to potential damage to blood vessels during the injection. They are also not recommended in people who are in hypovolemic shock, or have myopathy or muscle atrophy, as these conditions may alter the absorption of the medication.[5] The damage to the muscle caused by an intramuscular injections may interfere with the accuracy of certain cardiac tests for people with suspected myocardial infarction and for this reason other methods of administration are preferred in such instances.[5] In people with an active myocardial infarction, the decrease in circulation may result in slower absorption from an IM injection.[9]: 368–369 Specific sites of administration may also be contraindicated if the desired injection site has an infection, swelling, or inflammation.[9]: 368–369 Within a specific site of administration, the injection should not be given directly over irritation or redness, birthmarks or moles, or areas with scar tissue.[9]: 368–369
History[edit]
Injections into muscular tissue may have taken place as early as the year 500 AD. Beginning in the late 1800s, the procedure began to be described in more detail and techniques began to be developed by physicians. In the early days of intramuscular injections, the procedure was performed almost exclusively by physicians.[8] After the introduction of antibiotics in the middle of the 20th century, nurses began preparing equipment for intramuscular injections as part of their delegated duties from physicians, and by 1961 they had "essentially taken over the procedure".[8] Until this delegation became virtually universal, there were no uniform procedures or education for nurses in proper administration of intramuscular injections, and complications from improper injection were common.[8]
Intramuscular injections began to be used for administration of vaccines for diphtheria in 1923, whooping cough in 1926, and tetanus in 1927.[30] By the 1970s, researchers and instructors began forming guidance on injection site and technique to reduce the risk of injection complications and side effects such as pain.[8] Also in the early 1970s, botulinum toxin began to be injected into muscles to intentionally paralyze them for therapeutic reasons, and later for cosmetic reasons.[31] Until the 2000s, aspiration after inserting the needle was recommended as a safety measure, to ensure the injection was being administered in a muscle and not inadvertently in a vein. However, this is no longer recommended as evidence shows no safety benefit and it lengthens the time taken for injection, which causes more pain.[29]
Veterinary medicine[edit]
In animals common sites for intramuscular injection include the quadriceps, the lumbodorsal muscles, and the triceps muscle.[32]