Intramuscular injection

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. The medication may not be considered 100% bioavailable as it must still be absorbed from the muscle, which occurs over time. 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. Certain substances, including ketamine, may be injected intramuscularly for recreational purposes. 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. However, it has been estimated that for every vaccine injected intramuscularly, 20 injections are given to administer drugs or other therapy. In a case of severe allergic reaction, or anaphylaxis, a person may use an epinephrine autoinjector to self-administer epinephrine into the muscle. ==Contraindications==

Because an intramuscular injection can be used to administer many types of medications, specific contraindications depend in large part on the medication being administered. 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. 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. ==Risks and complications==

. As an injection necessitates piercing the skin, there is a risk of infection from bacteria or other organisms present in the environment or on the skin before the injection. This risk is minimized by using proper aseptic technique in preparing the injection and sanitizing the injection site before administration. The most frequent complications of a deltoid injection include pain, redness, and inflammation around the injection site, which are almost always mild and last only a few days at most. The dorsogluteal site of injection is associated with a higher risk of skin and tissue trauma, muscle fibrosis or contracture, hematoma, nerve palsy, paralysis, and infections such as abscesses and gangrene. ==Technique==

An intramuscular injection can be administered in multiple different muscles of the body. Common sites for intramuscular injection include: deltoid, dorsogluteal, rectus femoris, vastus lateralis and ventrogluteal muscles. Sites that are bruised, tender, red, swollen, inflamed or scarred are generally avoided. The specific medication and amount being administered will influence the decision of the specific muscle chosen for injection. The injection site is first cleaned using an antimicrobial and allowed to dry. The injection is performed in a quick, darting motion perpendicular to the skin, at an angle between 72 and 90 degrees. The practitioner will stabilize the needle with one hand while using their other hand to depress the plunger to slowly inject the medication – a rapid injection causes more discomfort. The needle is withdrawn at the same angle inserted. Gentle pressure may be applied with gauze if bleeding occurs. Pressure or gentle massage of the muscle following injection may reduce the risk of pain. There is no evidence that aspiration is useful to increase safety of intramuscular injections when injecting in a site other than the dorsogluteal site. Z-track method The Z-track method is a method of administering an IM injection that prevents the medication being tracked through the subcutaneous tissue, sealing the medication in the muscle, and minimizing irritation from the medication. Using the Z-track technique, the skin is pulled laterally, away from the injection site, before the injection; then the medication is injected, the needle is withdrawn, and the skin is released. This method can be used if the overlying tissue can be displaced. Injection sites The deltoid muscle in the outer portion of the upper arm is used for injections of small volume, usually equal to or less than 1 mL. This includes most intramuscular vaccinations. The deltoid site is located by locating the lower edge of the acromion process, and injecting in the area which forms an upside down triangle with its base at the acromion process and its midpoint in line with the armpit. The vastus lateralis site is used for infants less than 7 months old and people who are unable to walk or who have loss of muscular tone. The dorsogluteal site of the buttock site is not routinely used due to its location near major blood vessels and nerves, as well as having inconsistent depth of adipose tissue. Many injections in this site do not penetrate deep enough under the skin to be correctly administered in the muscle. While current evidence-based practice recommends against using this site, many healthcare providers still use this site, often due to a lack of knowledge about alternative sites for injection. This site is located by dividing the buttock into four using a cross shape, and administering the injection in the upper outer quadrant. This is the only intramuscular injection site for which aspiration is recommended of the syringe before injection, due to higher likelihood of accidental intravenous administration in this area. It is also recommended to consider using the anterolateral thigh as an injection site in infants under one year old. ==History==

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. 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. 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. ==Veterinary medicine==

In animals common sites for intramuscular injection include the quadriceps, the lumbodorsal muscles, and the triceps muscle. ==See also==