Adrenaline auto-injector injuries: Practical considerations in emergency management in a tertiary hand surgery unit.

Adrenaline auto-injectors are the first line treatment for anaphylaxis in the community setting. Both anaphylaxis and auto-injector carriage are increasing in prevalence. Adrenaline auto-injector injuries are common and most often involve the hand or digits. Such injuries carry a risk of ischemic necrosis due to profound vasoconstriction, especially if there is undying vascular pathology such as Raynaud's disease. The effects can be readily reversed with local infiltration of phentolamine. A survey was circulated to 40 clinicians working in the emergency and hand surgery departments of a major urban center. Knowledge of adrenaline duration of action and its reversal (agent, dose and location in the hospital) was assessed. All clinicians working within the two departments were eligible for participation. Only 25% of clinicians surveyed were aware of the duration of action of adrenaline. Half were aware of the correct reversal agent and only 20% knew the correct dose. Only one person was aware of phentolamine's location within the hospital. There is relatively poor clinician knowledge surrounding adrenaline reversal and a lack of easily accessible information available about dosing and drug location within the hospital. Given the time dependent nature of adrenaline auto-injector injuries Emergency Departments should consider stocking phentolamine in an emergency drugs fridge within the department along with a dosing guide. This is likely to greatly reduce time from presentation to treatment and thus the chances of digital ischemia progressing to necrosis.

[Nicolau syndrome]. / Síndrome de Nicolau.

Nicolau syndrome is a rare complication of the parenteral application of various drugs. It is characterized by the appearance of pain, followed by edema, erythema, and then a necrotic plaque. We present the case of a 31-year-old male with this syndrome, after the application of intramuscular benzathine penicillin. The diagnosis was supported by the biopsy. He received treatment with enoxaparin and cilostazol with subsequent improvement.

El síndrome de Nicolau es una complicación infrecuente de la aplicación parenteral de diversos fármacos. Se caracteriza por la aparición de dolor, seguido de edema, eritema y luego una placa necrótica. Se reporta el caso de un hombre de 31 años que presenta este síndrome luego de la aplicación de penicilina benzatínica intramuscular. La biopsia apoyó el diagnóstico. Recibió tratamiento con enoxaparina y cilostazol con posterior mejoría.

A Novel 3-Point Injection Technique for OnabotulinumtoxinA in the Upper Depressor Anguli Oris.

BACKGROUND AND OBJECTIVE: To evaluate the efficacy and safety of onabotulinumtoxinA (ONA) injections to the depressor anguli oris (DAO) to improve downturned mouth. PATIENTS AND METHODS/MATERIALS: This prospective, placebo-controlled, study enrolled subjects aged 18 to 65 years. Injections were performed using a novel 3-point technique in the upper DAO (1.5 U/injection site). The primary end point was a DAO contraction scale 1-grade improvement. Subjective evaluation was performed using the Global Aesthetic Improvement Scale (GAIS). RESULTS: Ten subjects received ONA and 10 placebo (saline) injections. In ONA-treated subjects, DAO scores showed significant improvements at Weeks 4 and 12 ( p < .001) compared with baseline. No significant difference between visits was observed for placebo-injected subjects. Global Aesthetic Improvement Scale scores showed that 100% of subjects were improved compared with baseline at Week 4% and 90% at Week 12. By contrast, 90% and 80% of placebo-treated subjects had "no change" in their DAO appearance at Weeks 4 and 12. Subject GAIS assessments matched the live evaluator at Week 4; 60% continued to report improvement at Week 12. Treatment was well tolerated. CONCLUSION: OnabotulinumtoxinA injections to the DAO using a 3-point technique provide clinically meaningful improvements in appearance. Treatment was well tolerated and in most individuals lasted at least 12 weeks. IDENTIFIER: ClinicalTrials.gov NCT04240535.

Effectiveness of physical stimulation for reducing injection pain in adults receiving intramuscular injections: a systematic review and meta-analysis.

OBJECTIVE: The objective of this review was to synthesize the best available research evidence regarding the effectiveness of physical stimulation for reducing injection pain in adults receiving intramuscular injections. INTRODUCTION: Pain associated with intramuscular injections continues to be a challenge for nurses. Various physical stimulation methods to alleviate pain and improve satisfaction for patients receiving intramuscular injections have been reported; however, the evidence surrounding the effectiveness of these methods remains inconclusive. INCLUSION CRITERIA: This systematic review considered randomized and quasi-experimental studies that used any physical stimulation strategies (eg, skin tapping, manual pressure, massage, pinch, traction) for adults aged 18 years and over receiving intramuscular injections. Studies that evaluated pain using validated instruments were considered for inclusion. METHODS: A three-step search strategy was conducted. MEDLINE, Embase, CINAHL, the Cochrane Library (Cochrane CENTRAL), Google Scholar, Dissertation Abstracts International, ProQuest Dissertations and Theses, and MedNar were searched from inception until 2020. We restricted the inclusion of studies to trials published in English. Two independent reviewers conducted the critical appraisal of eligible studies using the JBI checklists for randomized controlled and quasi-experimental trials. Data were extracted using the JBI data extraction tool, and meta-analysis and subgroup analysis were undertaken, where appropriate. RESULTS: Twenty-five studies were included with a total sample size of 1956 patients. Pooled results demonstrated that pain was significantly less with the use of the Helfer skin tap technique compared to no intervention (two studies; RR 0.73; 95% CI 0.66, 0.81; P <0.00001) or standard intervention (three studies; SMD -2.25; 95% CI -3.65, -0.85; P =0.002). Intervention with acupressure using standard treatment as control showed significant reduction in pain intensity (MD -4.78; 95% CI -5.32, -4.24; P <0.00001). Similarly, pain was significantly lower with manual pressure (two studies; SMD -0.42; 95% CI -0.69, 0.15; P =0.002) when compared to standard treatment. Pain scores were significantly lower in patients who received pinch technique, ShotBlocker, massage, or combination intervention (skin traction, pressure, and rapid muscle release) compared with no intervention, standard treatment, or placebo control. CONCLUSIONS: The evidence from this review demonstrates that physical stimulation - particularly the Helfer skin tap technique, acupressure, manual pressure, pinch technique, ShotBlocker, massage, and combination - can significantly lower intramuscular injection pain; however, this is based on low or very low certainty of evidence. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42020168586.

Comparison of two multimodal intramuscular anaesthetic protocols in uncooperative feline patients: effects on sedation and echocardiographic measurements.

OBJECTIVES: The aims of this study were to compare the sedative effect, feasibility of venous angiocatheter placement and influence on heart rate (HR), systemic blood pressure (SBP) and echocardiographic variables of two multimodal anaesthetic protocols in uncooperative cats; and to compare their influence on HR, SBP and echocardiographic variables 20 mins after sedation and after elective ovariectomy. METHODS: Eighteen stray female cats randomly received intramuscular (IM) ketamine (2 mg/kg) and methadone (0.3 mg/kg) plus dexmedetomidine (7 µg/kg; group D, n = 9) or alfaxalone (2 mg/kg; group A, n = 9). A sedation score (0-15 [from none to good sedation]) was assigned at 5 mins, 10 mins, 15 mins and 20 mins after IM injection. Venous angiocatheter placement and echocardiographic examination feasibility scores (both from 0 to 3 [from very difficult to very easy]) were recorded at 20 mins. Echocardiography, HR and blood pressure measurements (Doppler and oscillometric methods) were performed at 20 mins and at the end of surgery. RESULTS: Sedation and angiocatheter feasibility scores did not differ significantly between groups (P >0.05); the feasibility score of echocardiographic examination was higher in cats in group D (P = 0.01). HR was higher in group A at 20 mins and after surgery (P <0.05). The systolic arterial pressure obtained with the Doppler method was statistically significantly higher in cats in group D than in group A at 20 mins (P = 0.01), while postoperatively there were no differences between groups. Cats in group D showed significantly higher atrial diameters (P <0.05) and slower atrial flows (P = 0.04) compared with group A; ventricular thickness and atrial function did not differ between groups (P >0.05). Most echocardiographic variables were not different at 20 mins vs postoperatively. CONCLUSIONS AND RELEVANCE: Both protocols allowed for effective sedation; however, cats in group D presented alterations in some echocardiographic measurements; the use of alfaxalone, combined with ketamine and methadone, is recommended to obtain a reliable echocardiographic evaluation in uncooperative cats.

What variables should inform needle length choice for deltoid intramuscular injection? A systematic review.

OBJECTIVES: (1) Assess the distribution of skin-to-deltoid-muscle distance (SDMD) at the deltoid intramuscular (IM) injection site; (2) its relationship with demographic and anthropometric variables and (3) Consider the findings in relation to clinical guidance on IM injection, such as COVID-19 vaccines. DESIGN: Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: MEDLINE, EMBASE, ClinicalTrials.gov, Cochrane Library, CINAHL and SCOPUS between June and July 2021 with no publication date limit. ELIGIBILITY CRITERIA: Studies reporting measurements of the SDMD in living adults aged 16 years and older, at the deltoid IM injection site, published in English were considered. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers performed each stage of screening, data extraction and quality assessments using the Joanna Briggs Institute Critical Appraisal Checklist for analytical cross sectional studies. RESULTS: 16 105 papers were identified, of which 11 studies were suitable for review, representing 1414 participants. Heterogeneity in the definition of the deltoid IM injection site, locations measured and methods of measurement precluded meta-analysis. Evidence from ultrasound SDMD measurements demonstrated some patients in all but 'underweight' body mass index (BMI) categories, may require needles longer than 25 mm for successful IM injection. Calliper measurements overestimated SDMD compared with ultrasound. Female sex, higher BMI categories and greater weight in women were associated with greater SDMD. CONCLUSIONS: The reviewed evidence was insufficient to inform definitive needle length 'cut points' for IM injection based on demographic or anthropomorphic variables. Contemporary clinical guidance currently based on this evidence, including the site of injection and choice of needle length, may result in subcutaneous administration in a small proportion of recipients, particularly if obese or of female sex. PROSPERO REGISTRATION NUMBER: CRD42021264625.

Attention to diseases that re-emerge due to refusal of vitamin K: an infant case.

Intramuscular vitamin K injection is recommended for all newborns to prevent bleeding. However, the number of parents who reject vitamin K is at an increase. We present a 1-month girl who presented with haemorrhagic shock due to extraordinary intra-thoracic bleeding. The patient was treated with thoracentesis and blood transfusion. Parents were informed the about the benefits of Vitamin K and they were convinced to continue a routine immunization programme.

Canadian Physicians' Use of Intramuscular Botulinum Toxin Injections for Shoulder Spasticity: A National Cross-Sectional Survey.

Spasticity of the upper extremity can result in severe pain, along with many complications that can impair a patient's activities of daily living. Failure to treat patients with spasticity of the upper limb can result in a decrease in the range of motion of joints and contracture development, leading to further restriction in daily activities. We aimed to investigate the practice patterns of Canadian physicians who utilize Botulinum toxin type-A (BoNT-A) injections in the management of shoulder spasticity. 50 Canadian Physical Medicine and Rehabilitation (PM&R) physicians completed a survey with an estimated completion rate of (36.23%). The demographics of the survey participants came from a variety of provinces, clinical settings, and patient populations. The most common muscle injected for shoulder adduction and internal rotation spasticity was the pectoralis major, this was followed by latissimus dorsi, pectoralis minor, subscapularis and teres major. Injection of BoNT-A for problematic post-stroke shoulder spasticity was common, with (81.48%) of participants responding that it was always or often used in their management of post-stroke spasticity (PSS). Dosing of BoNT-A demonstrated variability for the muscle injected as well as the type of toxin used. The goals of the patients, caregivers, and practitioners were used to help guide the management of these patients. As a result, the practice patterns of Canadian physicians who treat shoulder spasticity are varied, due to numerous patient factors. Future studies are needed to analyze optimal treatment patterns, and the development of algorithms to standardize care.

Dermatologic features of chronic intramuscular use of ketamine: a case report.

A 33-year-old female presented with lethargy due to multidrug toxicity. At physical examination, both gluteal regions showed brown patchy scars. The atrophic scars surrounding necrotic lesions were round and brown in appearance, and gluteal mass had gradually been lost. The patient disclosed using intramuscular ketamine injections for 3.5 years along with smoking hashish, alcohol use, intranasal use of methamphetamine (sniffing), and oral use of methadone. Since recreational drug use can affect multiple organs, dermatologists should be familiar with the dermatologic features of intravenous or intramuscular injecting drug use.

Comparison of pain levels developed during intramuscular injections to laterofemoral and ventrogluteal regions in children: a randomized controlled study.

OBJECTIVE: The aim of this study was to compare the levels of pain developed during intramuscular injections to the laterofemoral and ventrogluteal regions in children. METHODS: The study population consisted of all children aged between 7 and 12 years who presented to the pediatric emergency clinic of a hospital. The sample consisted of 62 children who met the inclusion criteria and agreed to participate in the study, and the children were randomly assigned to each group (laterofemoral n=31, ventrogluteal n=31). "Buzzy" and "deep breathing" were applied to children in both groups to relieve pain during the procedure. The data were obtained using an Information Form, a visual analog scale, and the Facial Pain Scale-Revised. RESULTS: It was determined that the children in the ventrogluteal group during the intramuscular injections had lower visual analog scale and faces pain scale-revised scores immediately after the procedure compared with the vastus lateralis group, that is, they experienced less pain, and the difference between the two groups was significant (p<0.001). CONCLUSION: In children, it is recommended to choose the less painful ventrogluteal region for intramuscular injection and to inform health professionals about it.

Botulinum toxin in the management of myalgia in temporomandibular disorders: are all injections equal?

Botulinum toxin (BTX) is becoming widely used as an adjunct to conservative management of myalgia-predominant temporomandibular disorders (TMDs) with reports of improved quality of life. There is, however, no consensus on the optimal dosage. Based on previous studies, dose regimens vary between clinicians, and we know of no standard dose protocol for the administration of BTX for the purpose of TMD management. A survey was sent to members of the British Association of Oral and Maxillofacial Surgeons (BAOMS) Temporomandibular Joint Sub-Specialty Interest Group (TMJ SSIG) and an international mailing list of high-volume TMJ surgeons (the TMJ Internetwork) to ascertain variations in dose regimens between different clinicians. The survey found that 41 respondents offered BTX to patients. The masseter muscle group was the most commonly injected site, and the majority of respondents (34/41) used Botox® (Allergan). Brands less commonly used included Dysport® (Ipsen), and Xeomin® (Merz Pharma). Botox® doses varied between 30 and 100 units, whilst Dysport® doses ranged from 50 - 300 units/muscle. The number of injection sites/muscle also varied. This survey demonstrates the wide variation in practice amongst clinicians with respect to BTX administration. To ensure optimal dose and response titration, further studies and evidence-based research are needed to standardise its use for the treatment of TMDs.

Pharmacokinetics of Long-Acting Aqueous Nano-/Microsuspensions After Intramuscular Administration in Different Animal Species and Humans-a Review.

Formulating aqueous suspensions is an attractive strategy to incorporate poorly water-soluble drugs, where the drug release can be tailored to maintain desired release profiles of several weeks to months after parenteral (i.e., intramuscular or subcutaneous) administration. A sustained drug release can be desirable to combat chronic diseases by overcoming pill fatigue of a daily oral intake, hence, improving patient compliance. Although the marketed aqueous suspensions for intramuscular injection efficiently relieve the daily pill burden in chronic diseases, the exact drug release mechanisms remain to be fully unraveled. The in vivo drug release and subsequent absorption to the systemic circulation are influenced by a plethora of variables, resulting in a complex in vivo behavior of aqueous suspensions after intramuscular administration. A better understanding of the factors influencing the in vivo performance of aqueous suspensions could advance their drug development. An overview of the potential influential variables on the drug release after intramuscular injection of aqueous suspensions is provided with, where possible, available pharmacokinetic parameters in humans or other species derived from literature, patents, and clinical trials. These variables can be categorized into drug substance and formulation properties, administration site properties, and the host response towards drug particles. Based on the findings, the most critical factors are particle size, dose level, stabilizing excipient, drug lipophilicity, gender, body mass index, and host response.

Safety of an Intravenous Formulation of Voriconazole as an Intramuscular Injection in Pigeons (Columba livia f. domestica).

Aspergillosis is a common disease in birds. Currently, avian aspergillosis is treated with voriconazole administered orally, although intramuscular (IM) administration increases bioavailability and is more effective in treating generalized aspergillosis. The objective of this study was to evaluate the safety of the intravenous formulation of voriconazole as an IM injection in the pectoral muscles of pigeons (Columba livia f. domestica) as a model for other avian species. Sixteen healthy pigeons received IM injections of voriconazole (12.5 mg/kg) and sterile saline in the right and left pectoral muscles, respectively, twice a day for 7 days. Additionally, 4 birds acted as controls (no injections). Eight birds in the treatment group and 2 of the control pigeons were humanely euthanized 1 day (group 1) and 14 days (group 2) after the final injection. Hematologic and plasma biochemistry panels were performed prior to the birds being euthanized. Gross and histopathological evaluations of the pectoral muscles were completed postmortem. Statistical analysis revealed significant differences in multiple parameters, including aspartate aminotransferase and lactate dehydrogenase, but all biochemical analytes remained within the reference intervals for the species. The group 1 birds had advanced gross and histopathological pectoral muscle lesions associated with the voriconazole injections compared with the contralateral side, the group 2 birds, and the negative controls. After 14 days, the pectoral muscles did not reveal any gross or histopathological changes associated with the voriconazole or sterile saline injections. These results indicate that the intravenous formulation is safe for IM use twice per day for 1 week in pigeons. Further investigation is needed to extrapolate these findings to other avian species and to evaluate the roles of longer treatment periods and higher doses of voriconazole.

Extended-release naltrexone for people with alcohol use disorder on therapeutic anticoagulation: A case series.

WHAT IS KNOWN AND OBJECTIVE: Individuals with medication adherence challenges or a preference for long-acting medications may benefit from extended-release naltrexone (XR-NTX) for treatment of alcohol use disorder (AUD). Individuals on therapeutic anticoagulation were excluded from XR-NTX studies and its safety in this population has not been reported. CASE SUMMARY: We conducted structured retrospective chart review of six individuals who received XR-NTX for AUD while on therapeutic anticoagulation between November 2019 and Deccember 2020. We found no documented complications among six individuals who received up to 11 doses of XR-NTX while on therapeutic anticoagulation. WHAT IS NEW AND CONCLUSION: XR-NTX may be safely tolerated by patients on therapeutic anticoagulation. We need larger studies evaluating XR-NTX administration in patients on therapeutic anticoagulation and those with coagulopathies, including individuals with alcohol-related liver disease, to better quantify risks and benefits for shared decision-making.

Intramuscular alfaxalone with or without buprenorphine or hydromorphone provides sedation with minimal adverse effects in healthy rabbits (Oryctolagus cuniculus) in a randomized blinded controlled trial.

OBJECTIVE: To evaluate the effects of alfaxalone administered IM with or without buprenorphine or hydromorphone in healthy rabbits (Oryctolagus cuniculus). ANIMALS: 24 male rabbits undergoing elective orchiectomy between August 21, 2021, and November 6, 2021. PROCEDURES: In this controlled clinical trial, rabbits were randomly assigned to receive alfaxalone (4 mg/kg, IM) alone (group A; n = 8) or with buprenorphine (0.03 mg/kg, IM; group BA; 8) or hydromorphone (0.1 mg/kg, IM; group HA; 8). Vital signs and sedation scores were recorded immediately prior to (T0) and 10 minutes after (T1) treatment. Ease of IV catheter placement and pain scores were also evaluated. All rabbits received ketamine (2.5 mg/kg, IV), midazolam (0.13 mg/kg, IV), and meloxicam (0.5 mg/kg, SC) before orchiectomy but after IM treatments. Results were compared across groups with ANOVA or Fisher exact tests and across time with paired t tests. RESULTS: Sedation score, median time to recumbency, and ease of catheter placement did not differ among groups. Supraglottic airway device placement was possible for 1 rabbit in group A, 1 in group BA, and 2 in group HA. Mean respiratory rate at T1 versus T0 was significantly decreased for groups BA (63.8 vs 128.6 breaths/min) and HA (66.7 vs 123.2 breaths/min). Mean postoperative pain scores were significantly lower for rabbits in group HA (0.58), compared with those in groups A (2.25) and BA (2.06). CLINICAL RELEVANCE: All 3 treatments provided reliable sedation; however, alfaxalone (4 mg/kg, IM) combined with hydromorphone (0.1 mg/kg, IM) may be a better choice for painful procedures.

All aspects of sciatic nerve injection injury: an experiment with 78 rats.

BACKGROUND: In this study, we evaluate sciatic nerve injuries due to intramuscular injections, which is an important medicolegal problem frequently encountered in medical practice, with an extended experimental rat model of peripheral nerve injury. METHODS: A total of 78 male Wistar albino rats were divided into five main groups, including a control group, a sham saline group, and groups that received benzathine penicillin G, diclofenac sodium, and dexamethasone, respectively. These pharmaceutical agents were applied to the sciatic nerves of all rats after exploration in the epineurial, endoneurial, and intrafascicular compartments, excluding the control group. Outcomes were evaluated for all rats and their sciatic nerves according to functional, electrophysiological, and histopathological results. RESULTS: Injuries were most evident in the groups that received penicillin G and diclofenac sodium, and this finding was statistically significant. It was also found that endoneurial and intrafascicular injections may cause more harm than epineurial injections. DISCUSSION: We have demonstrated that any medical injections applied to the epineurial, endoneurial, or intrafascicular compartments of the sciatic nerve may cause functional and electrophysiological loss with or without deterioration of the peripheral nerve architecture.

Enhancing Immunogenicity of Influenza Vaccine in the Elderly through Intradermal Vaccination: A Literature Analysis.

BACKGROUND: Aging and immunosenescence lead to a gradual decline in immune responses in the elderly and the immunogenicity of influenza vaccines in this age group is sub-optimal. Several approaches have been explored to enhance the immunogenicity of influenza vaccines in the elderly, including incorporating vaccine adjuvant, increasing antigen dosage, and changing the route of vaccine administration. METHOD: We systematically compared the immunogenicity and safety of influenza vaccines administered by intradermal (ID) route and either intramuscular (IM) or subcutaneous (SC) routes in older adults aged ≥ 65. RESULTS: Of 17 studies included in this analysis, 3 studies compared the immunogenicity of ID vaccination to that of SC vaccination and 14 studies compared ID and IM vaccinations. ID vaccination was typically more immunogenic than both IM and SC routes at the same dosage. Importantly, a minimum of 3 µg of hemagglutinin antigen could be formulated in an ID influenza vaccine without a significant loss of immunogenicity. ID administration of standard-dose, unadjuvanted influenza vaccine was as immunogenic as IM injection of adjuvanted influenza vaccine. Waning of influenza-specific immunity was significant after 6 months, but there was no difference in waning immunity between vaccinations in ID, IM, or SC routes. While ID vaccination elicited local adverse reactions more frequently than other routes, these reactions were mild and lasted for no more than 3 days. CONCLUSIONS: We conclude that ID vaccination is superior to IM or SC routes and may be a suitable approach to compensate for the reduced immunogenicity observed in elderly adults. We also conclude that the main benefit of ID influenza vaccine lies in its dose-sparing effect. Additional research is still needed to further develop a more immunogenic ID influenza vaccine.