Safe injecting and anaphlaxis

What are injections?

Injections are sterile solutions or occasionally emulsions. They are prepared by dissolving, emulsifying or suspending the active ingredient in water for injection or a suitable diluent liquid

Key principles of safe injection

Injections are invasive and strict aseptic technique is required during preparation and administration. Good injection technique makes the experience less painful and invasive for the patient

Before you start preparing a prescribed injectable drug, what should be checked?

• Ask the patient their name and DOB

• Do they have any allergies

• Check against prescription chart

• Check details about the indication of the drug

• Check dose

• Check route

• check expiry date

• Check contraindications with the BNF

• Make sure the date and time of administration is correct

What are the 5 R’s?

R-Right patient

R-Right drug

R-Right dose

R-Right time

R-Right route

What must be worn by the person administering the injection?

• staff should wear gloves for the preperation of drugs and during the injection procedure to avoid cross contamination by bacteria

• gloves will protect adminstrator from absorption of medication via the skin but will not protect against sharps injury.

Reconstitution of Powdered Medicine & Sharp Safety – Key Steps

Use a clean treatment room and confirm prescription and drug information. Read labels carefully and gather equipment (sharps bin, ampoules, diluent, syringe, needles, gloves, tray). Remove caps; open glass ampoules safely. Clean diluent top. Draw up required diluent with a green needle, inject into vial, and agitate to mix. Draw up the reconstituted drug while keeping the needle tip submerged to avoid air. Dispose of the drawing‑up needle and attach a fresh needle for SC or IM injection. After administration, place the entire used needle‑and‑syringe unit directly into the sharps bin without separating.

When is the only time you can remove a needle from a syringe?

When they are UNUSED. When a drug has been administered, the needle and syringe are placed straight into the sharps box unseperated

What colour needle do we use for SC injection?

Orange/25 guage - short needle unlikely to penetrate muscle layer

How much volume is injected via SC route? What syringe would we use?

1-2ml is injected via SC route, use 5ml syringe.

What colour needle is used for intramuscular injection?

Green (21 guage) or blue (23 guage)

Longer to penetrate the mucle but still allow a quarter of the needle to remain external to the skin.

When is it preferrable to use a blue needle for intramusclar injection?

for children (23 guage) so smaller

Before administrating injection, how do we prep the skin?

• if skin disinfecting is practiced then the skin should be cleansed with alcohol swab for 30 seconds and allowed to dry for 30 seconds.

What drugs are administered via subcutaneous injection?

• insulins

• anticoagulants

• typically slow sustained absorption medications

• relatively pain-free and sites are often suitable for frequent injections

What sites are recommended for S/C injection?

Upper arms are a favourable choice - they do not cause discomfort to the patient. Avoid areas of bruising, tenderness, hardness, infection or inflammation

Why must care be taken in particular when administering insulin?

• care must be taken when administering insulin because…

• It should not enter the muscle as this could cause rapid absorption and hypoglycaemia

At what angle should S/C injection be administered?

90 degrees

True or false: you should aspirate the needle following SC injection

False: do not aspirate the needle

This means drawing blood from the body into the needle

What volume of liquid is injected intramuscularly in the deltoid?

1ml is injected into the deltoid

What volume is injected intramuscularly into the ventrogluteal site

5ml can be injected into the ventrogluteal site

What must we do before delivering medication to elderly frail patients via intramuscular route?

Ensure you ‘bunch up’ the muscle to ensure adequate bulk before injecting

Where would you inject intramuscular injection going into the deltoid muscle?

About 2 finger widths below the acromial process

At what angle do you inject intramuscular injections?

90 degrees

When is the only time it would be recommended to aspirate an IM injection?

when injecting into the ventrogluteal route

Before delivering SC injection what should you do?

stretch the skin

What is anaphylaxis?

A severe life threatening generalised or systemic hypersensitivity reaction

How is anaphylaxis characterised?

Rapidly developing, life threatening airway and / or breathing and or circulation problems

usually with skin or mucosal changes

Who gets anaphylaxis?

• mainly children and young adults

• Common in females

• Incidence seems to be increasing

What causes anaphylaxis?

• bee sting, wasp sting

• nuts

• food e.g. milk, fish, chickpea, banna, snail

• antibiotics e.g. penicillin, cephalosproin, vancomycin

• anaesthetic drugs - suxamethonium

• other drugs - NSAIDs, ACEi, gelatins, protamine, vitamin K, diamorphine

• Contrast media

• Latex, hair dye,

How is anaphylaxis recognised?

ABCDE approach

A – Airway
Look for airway swelling: hoarse voice, stridor, tongue/lip swelling, difficulty speaking.
Treat immediately with high‑flow oxygen. Call for senior help early.
Airway obstruction is life‑threatening and must be managed first.

B – Breathing
Assess respiratory rate, work of breathing, wheeze, cyanosis, reduced air entry.
Give high‑concentration oxygen (15 L/min via non‑rebreather).
Be alert for bronchospasm → treat with adrenaline IM (first‑line for anaphylaxis).

C – Circulation
Check pulse, blood pressure, capillary refill, signs of shock (pale, clammy, weak pulse).
Anaphylaxis can cause rapid circulatory collapse.
Lay patient flat, elevate legs, give IM adrenaline immediately.
Prepare for IV fluids if hypotensive.

D – Disability
Assess consciousness (AVPU), agitation, confusion.
Hypoxia and hypotension can cause reduced GCS.
Check glucose if possible.

E – Exposure
Look for urticaria, flushing, angio‑oedema, abdominal symptoms.
Remove allergen if still present (e.g., stop infusion).
Maintain dignity and prevent heat loss.

Treat life threatening problems, assess effects of treatment, call for help early, diagnosis not always obvious

Anaphylactic reaction is highly likely when the following 3 criteria are fulfilled…

• sudden onset and rapid progression of symptoms

• life threatening airway/ and or breathing and or circulation problems

• skin and or mucosal changes such as uriticaria, angioedema, flushing

What helps support the diagnosis of anaphylaxis?

Exposure to a known allergen / trigger for the patient helps to support the diagnosis

True or false: skin or mucosal changes must be present for it to be anaphylaxis

False - subtle/absent in 20% of reactions

True or false: Anaphylaxis can cause GI symptoms

True - can cause vomiting, abdominal pain, incontinence etc

What are the airway problems which present in anaphylaxis?

• Airway swelling e.g. throat, tongue swelling

• Difficulty in breathing and swallowing

• Sensation that the throat is closing up

• Hoarse voice

• stridor

What breathing problems present in anaphylaxis?

• shortness of breath

• increased respiratory rate

• wheeze

• patient becoming tired

• confusion caused by hypoxia

• cyanosis - appears blue - a late sign

• respiratory arrest

What cardiac problems occur in anaphylaxis?

• signs of shock - pale, clammy

• increased pulse rate (tachycardia)

• low blood pressure (hypotension)

• decreased conscious level

• myocardial ischaemia/angina

• cardiac arrest

• DO NOT STAND THE PATIENT UP

What Disability signs does anaphylaxis cause?

• sense of impending doom

• anxiety/ panic

• decreased conscious level caused by airway, breathing or circulatory problems

Exposure in anaphylaxis - what do we look for?

• skin changes are often the first feature

• present in over 80% of anaphylactic reactions

• skin mucosal or both skin and mucosal changes

• erythema - a patchy or generalised rash

• urticaria - also called hives, nettle rash, weals or welts anywhere on the body

• angioedema - similar to urticaria but involves swelling of deeper tissues e.g. eyelids and lips, sometimes in the mouth and throat

What differential diagnosis must be made if someone has anaphylaxis?

• are they have an asthma attack - can present as similar signs, especially in children

• septic shock - hypotension with petechial / purpuric rash - bleeding under the skin as seen in meningitis

What non-threatening conditions present similarily to anaphylaxis?

• panic attack

• breath holding episode in children

• vasovagal episode

How do we treat anaphylaxis?

Patient should lie flat and raise legs

Adrenaline should be administered / epinephrine

injected into the muscle - faster onset

Dose of adrenaline in adults and children over 12…

500mcg IM

Dose of adrenaline for children aged 6-12 years…

300 mcg

Dose of adrenaline for children 6months to 6 years

150 mcg

Dose of adrenaline for children less than 6 months

150mcg

Caution the use of adrenaline administered via the…

Intravenous route

Once patient has been admitted to hospital/ when skills and equipment are available and patient has recieved adrenaline, what is next step?

Administer high flow oxygen

Following introduction of high flow oxygen, what should we administer?

IV fluids - fluid challenge

• used to treat shock and hypotension

• 500 - 1000mL IV bolus in adult

• 20mL/Kg in children

• Monitor response - give further bolus as necessary

When adminsitering fluids, would we prefer to use a colloid or crystalcolloid?

Avoid colloids due to risks of allergic reactions and kidney dysfunction

crystalcolloid - small particles in an aqueous solution e.g. glucose and electrolytes whereas colloids have large particles such as proteins and starch

After giving fluids, what do we want to deliver? Second line drugs

Steroids, e.g. hydrocortisone

What do we deliver alongside hydrocortisone

Antihistamine e.g. chloramphenamine

How do we confirm if a patient has had anaphylaxis reaction?

Mast cell tryptase is an enzyme released from mast cells during anaphylaxis. Measuring its level in the blood helps confirm whether a patient has had a true anaphylactic reaction.

When is best time to sample for mast cell tryptase?

after initial resuscitation and feasible to do so,

• They peak at 1–2 hours.

• They return to baseline within 6–8 hours.

What are autoinjectors?

e.g. epipen/ Anapen

For self use by patients or carers

Should be prescribed by allergy specialist

For those with severe reactions and difficult to avoid triggers

ensure patient is well trained as to how to use the device