TREAT ALL HUMAN BLOOD
AND OPIM AS IF...
KNOWN TO BE INFECTIOUS WITH A BLOODBORNE DISEASE
Yep, all in capitals. She shouted it at us in lecture
When do needle sticks typically occur?
40% during use,40% occur immediately after use or before disposal, 15% during disposal, 5% recapping
Serious or fatal infections like _____ and _____ have been aquired from needlesticks.
Hep B/C and HIV
What is the best approach to dealing with accidental needle sticks?
How do you protect yourself?
Wear other PPE - masks, gowns, etc.
What are two problems you must be aware of that patients commonly have with injections?
1.Fainting (pain, apprehension or needle phobia)
2.Allergic reaction (flushing, urticaria, itching, wheezing, SOB)
What are four major contraindications to injections?
- Known hypersensitivity to the drug or its excipients ( i.e. Flu vaccine contains egg)
- Skin is inflamed, irritated, excoriated or infected.
- Patient is pregnant or breastfeeding (drug may be contraindicated: Botox, Rubella, Hormones, opiates)
- Stopper is latex and patient is allergic to latex (switch needle before administering the shot)
What are the elements of the pre-procedure patient education?
Complications and side effects
Potential Outcomes from the injection procedure
What three things are involved in documenting patient's consent to injection?
Sign a consent form
Third party should witness the patient’s signing
Consent is kept in the patient’s chart
At what angle should you inject intradermally? What are the uses of these injections? What guage needles for this?
Used primarily for diagnostic purposes (allergy, TB, Candida) or applying local anesthetics
Usually uses small syringes and small gauge needles
What are 3 types of cutaneous injections?
ID injections usually create a _____ on the skin. Common sites inlude: _______ and ______
Arms and back
At what angle should a subcutaneous injection be administered?
What would this be used for and what is the absorption speed?
Allows for slow sustained absorption of medications, such as insulin, and opiates
uses a variety of syringe and needle sizes, depending on the medication being used.
Common sites of SQ injections>>
Lateral and posterior upper arm
Ventrolateral gluteal region
(Anywhere with a nice juicy layer of subcutaneous fat)
At what angle should intramuscular (IM) injections be given?
What must be done with this that is not necessary with other injections covered in this set.
Should aspirate first, then inject medication...
... No blood, continue with injection
... Blood present- withdraw slightly and redirect the needle, then inject; if needle comes out of skin, then start over.
What are some examples of things that IM injections are commonly used for?
Includes vaccines such as Hep A/B, MMR,DPT Pentacel, tetanus, B12, epinephrine, opiates, promethazine.
Common injection sites for IM?
What are some complications of injections?
Quite a few, so discuss
ÒToxic rxn. to local anesthetics
ÒUnintended intravascular delivery
ÒPneumothorax or Compartment syndrome
What are the indications for joint injections?
1.Acute or chronic symptoms present
2.Diagnosis is unclear or needs confirmation and
3. consideration of other diagnostic modalities has been made
4.Septic arthritis has been ruled out
1.Acute or chronic symptoms are present
2.After the diagnosis and therapeutic plan have been made
3.After consideration of obtaining radiographs
What are joint injections used for?
ÒAspiration/Arthrocentesis of fluid from a grossly swollen joint for pain relief or assessment of the synovial fluid (i.e. dx of gout, arthritis and joint infections)
ÒDelivery of local anesthetics for pain relief
ÒDelivery of corticosteroids or visco-supplementation (hyaluronic acid) for suppression of inflammation and improved ROM
Absolute contraindications of therapeutic joint injections?
Achilles or patella tendinopathies
History of allergy or anaphylaxis to injectable pharmaceuticals or constituents
More than 3 previous corticosteroid injections within the past year in a single joint*.
__________________: 27-30 gauge 1/2inch needles,
1-3 cc syringes
___________________: 22-25 gauge 1.5inch needles,
__________________: 18-20 gauge 1.5 inch needles, Sterile
3-60cc syringes, hemostat, culture tubes
What does epinephrine do with regard to lidocane?
Makes it stay put! Due to vasoconstriction cannot do on fingers, nose, hose (penis) toes, and earlobes. (the mnenonic kind of falls apart there at the end)
How is lidocaine administered?
What is its duration?
What can it cause besides local anesthesia?
ÒLocal Cutaneous infiltration (lac repair, skin biopsy), field blocks
ÒQuick onset, short duration (30-60 minutes)
ÒCan cause vasodilatation: Use if vascular disease is present or pt. is immuno-compromised or in contaminated wounds
What is the duration of bupivacaines? What is a problem with this? When might one use it though?
ÒLonger duration, but 4x toxicity than lidocaine; may cause cardiac arrythmia, contraindicated in pregnancy
ÒNerve blocks, when more time is needed
Instructions for injecting anesthesia?
ÒUse the smallest needle possible (27-30gauge)
To minimize pain:
ÒWarm the anesthetic in your hands before injecting
ÒBuffer if lidocaine is used
ÒGently pinching or vibrating the skin
ÒInject rapidly thru skin into the Sub Q level
ÒInject the anesthetic slowly and steadily while withdrawing the needle
What two major condition types are treated with corticosteroids? What are examples of each?
ÒArticular Conditions treated with steroids include: RA, OA, Gout and
Pseudogout, Ankylosing Spondylitis,
Reiter’s Syndrome, Psoriasis
ÒNon Articular Conditions:
Fibrositis, Bursitis, Tenosynovitis,
Tendonitis, Neuritis, Tender Points
What are some bad consequences of corticosteroids?
CAN HAVE ADVERSE CONSEQUENCES: In decreasing order of frequency.
ÒMay accelerate normal, aging related articular cartilage atrophy or periarticular calcification (43%)
ÒMay weaken tendons or ligaments
ÒPost-injection (Steroid) Flare (4%)
ÒInfection or bleeding into a joint
Ò Tendon rupture
Ò Facial flushing, skin atrophy and/or
ÒHypersensitivity rxn., transient paresis
What are the elements of a procedure note? This one is for you Michael Plump.
A clear but succinct description of procedure performed:
1.Patient ID: Name , sex and DOB
2.The names and titles of the providers performing the procedure (Physician and students)
3.Type of Procedure
4.Pertinent Pre (and Post) procedure diagnoses
5.Meds use, used before, during and after the procedure
6.Equipment used (Detailed list, include amounts and sizes)
7.Document that written informed consent was obtained and placed into chart
8.Procedure: Detailed description, step by step, start to finish; include anesthesia and cleansing, sterile technique)
9.Complications: if any occurred, include any blood loss) Document your post procedure instructions at the end of the note
10.Disposition of the patient: IS pt. stable, then what? Sent home, admitted into hospital, taken to surgery?? Also any directions given to the pt., such as wound care, signs of infections, etc.
11.Sign and Date the note
Choose the type/angle/location of injection and the syringe size, needle size and length for each of the following:
- 6 month old in office for a DPT vaccine (.5 cc)
- Adult patient requiring a PPD (.1cc)
- Adult patient requiring a flu shot (1cc)
- Adult patient requiring 125mg (1 cc)of antibiotic Ceftriaxone, mixed with 1 cc of lidocaine)
For these, also decide on what meds to use.?
- Patient has a 1 inch clean laceration on his arm. You plan to place 4 sutures.
- Patient has a ¾ avulsion type laceration near the tip of his finger. He will need 4 sutures to hold in place.
- Patient suffers from chronic pain and swelling of his right elbow. There is no effusion.
- Patient comes in with an effusion of his right knee, you suspect Gout. What do you do?