Vaccine administration: preventing serious shoulder injuries

1 Vaccine Update Vaccine administration: preventing second surgical intervention. Many patients (69%) had residual symp- serious shoulder injuries toms, and 31% experienced full re- covery. The authors proposed seat- Stephan Foster and McLisa V. Davis ing both the injector and the patient Erroneous administration of Vaccine and the remainder received to reduce the probability of injecting intramuscular vaccines, particu- tetanus diphtheria toxoids, Td high into the deltoid muscle. larly above the deltoid muscle, can acellular pertussis, or human papil- Injecting into the thickest, most result in serious shoulder injuries lomavirus Vaccine . The proposed central portion of the deltoid muscle and diminished Vaccine mechanism of injury was that vac- is important in preventing these se- With few studies published ad- cine, an antigenic substance, injected vere shoulder injuries . The injection dressing injection technique before into synovial tissue resulted in an must be administered into the mus- 2002, inconsistencies arose regard- immune-mediated inflammatory re- cle at a 90-degree angle to the skin.

2 Ing optimal Vaccine administration, sponse. Of patients, 46% stated that Health professionals need to remain thus causing variations in current the Vaccine was injected too high knowledgeable about the anatomy We will examine cases of into the deltoid muscle. Magnetic of the shoulder (Figure 1) to avoid serious shoulder injuries as a result resonance images revealed fluid col- injecting too high. Further, review- of incorrect technique and provide lections in the deep deltoid or over- ing current recommendations for in- a step-by-step guide to the proper lying the rotator cuff tendons, bur- tramuscular injections helps ensure administration of intramuscular in- sitis, fluid buildup within the bursa, that proper technique is used. jections. or rotator cuff tears. About one-third Recommendations for intra- In 2006, Bodor and Montalvo3 of patients (31%) required surgery, muscular Vaccine administration reported two cases of Vaccine -re- with one-half of those requiring a are as follows5 7: lated shoulder dysfunction.

3 One patient received the 23-valent pneu- Articular mococcal Vaccine and the other an capsule influenza Vaccine . Both patients re- Acromion Clavicle ported receiving injections high into the deltoid muscle, within 1 to 2 cm of the acromion. Both patients no- Subacromial bursa Supraspinatus muscle ticed severe shoulder pain and loss and tendon of range of motion within 2 days and increasing pain during a period of 2. to 5 months. One patient was diag- Humerus nosed with subacromial bursitis that later progressed to adhesive capsuli- Deltoid tis or frozen shoulder ; the other was muscle diagnosed with bicipital tendonitis, subacromial bursitis, and a mild C6 Synovial sensory radiculopathy. The authors membrane recommended that guidelines spec- ify avoiding Vaccine injections in the Figure 1. Cross-section of the shoulder joint upper third of the deltoid muscle. They recommended that health pro- fessionals consider Vaccine -related Send your immunization questions to the japha Contributing Editors who coor- shoulder dysfunction in patients dinate the Vaccine Update column: presenting with shoulder pain and Mary S.

4 Hayney, PharmD, BCPS, Associate Professor of Pharmacy, School weakness following a Vaccine injec- of Pharmacy, University of Wisconsin, Madison tion. ). Atanasoff et reported a series John D. Grabenstein, PhD, Director of Scientific Affairs, Merck Vaccine Division (john_gra- of 13 cases submitted to the Vaccine Injury Compensation Program be- This article is supported by a Cooperative Agreement provided by the Centers for Disease Control tween 2006 and 2010, in which pa- and Prevention (CDC) entitled pharmacists : Connecting, Communicating and Collaborating for tients experienced shoulder injury Improved Community Health (1U66 IP000114). The opinions expressed in this article do not related to Vaccine administration. represent the viewpoints of the CDC. Of the cases, 62% received influenza 102 japha | 5 3:2 | M ar/Apr 2013 ja p h a .org Journal of the american pharmacists association Vaccine Update Document each immunization. Give patient appropriate edu- cation, documentation, and re- minders about future doses.

5 Stephan L. Foster, PharmD, FAPhA. Professor and Vice Chair College of Pharmacy University of Tennessee The red circle Memphis APhA Liaison Representative to the marks the Advisory Committee on Immunization target area of Practices (ACIP). intramuscular McLisa V. Davis, PharmD. injection. Specialty Practice Resident Wexner Medical Center Ohio State University Columbus, OH. doi: References 1. National Center for Immunization and Re- spiratory Diseases. General recommenda- tions on immunization: recommendations of the Advisory Committee on Immunization Figure 2. Injection location Practices (ACIP). MMWR Recomm Rep. 2011;60(2):1 64. 2. Petousis-Harris H. Vaccine injection tech- Wash and dry hands thoroughly Wipe site with alcohol swab to nique and reactogenicity: evidence for prac- with bactericidal soap and water or clean oils and dirt from injection tice. Vaccine . 2008;26(50):6299 304. use bactericidal hand sanitizer to pre- site. Allow skin to dry. 3. Bodor M, Montalvo E.

6 Vaccination- vent contamination of syringe or vac- Control the limb with the non- related shoulder dysfunction. Vaccine . cine. Gloves are optional. dominant hand. 2007;25(4):585 7. Verify the correct Vaccine . Ex- With the dominant hand, hold 4. Atanasoff S, Ryan T, Lightfoot R, Johann- amine the Vaccine solution for the syringe like a dart with your Liang R. shoulder injury related to vac- cloudiness or sedimentation index finger and thumb. Us- cine administration (SIRVA). Vaccine . and check the expiration date. ing a dart-like motion, insert the 2010;28(51):8049 52. Discard the solution and never needle at a 90 angle with a quick 5. american Pharmacist association . Module 5: administer to the patient if any thrust into the patient's skin. administering vaccines. In: Pharmacy-based of these changes are found or the Aspiration is not necessary. immunization delivery. 12th ed. Washing- ton, DC: american Pharmacist association ;. Vaccine is expired. Push the plunger in quickly and 2011:99.

7 Using aseptic technique, load smoothly. 6. Hunter J. Intramuscular injection techniques. dose into the syringe. Pick an ap- Remove the needle in a smooth Nurs Stand. 2008;22(24):35 40. propriate needle size. Use a 1-in motion at the same angle of inser- 7. Immunization Action Coalition. How to ad- needle for most adult patients. tion with the dominant hand. Ac- minister IM and SC Vaccine injections to For male patients weighing more tivate the safety device. Discard adults. than 118 kg or female patients the used needle and syringe into pdf. Accessed September 26, 2011. more than 90 kg, use a a biohazard sharps container. Do 8. Poland GA, Borrud A, Jacobson RM, et al. needle. For adults weighing less not take your eyes off the used Determination of deltoid fat pad thickness: than 60 kg, use a needle. needle until it is safely inside the implications for needle length in adult immu- (General rule: Women have more sharps container. Never recap nization. JAMA.)

8 1997;277(21):1709 11. subcutaneous fat than ,9) the needle after it has been ex- 9. Zuckerman JN. The importance of inject- Organize Vaccine -filled syringe, posed to the patient. ing vaccines into muscles: different pa- alcohol swab, cotton ball, ban- Apply slight pressure to the in- tients need different needle sizes. BMJ. 2000;321(7271):1237 8. dage, and biohazard sharps con- jection site with a cotton ball to tainer near the patient. discourage bleeding. Apply ad- Locate the thickest and central hesive bandage. portion of the deltoid muscle Remove gloves (if used), then (Figure 2). wash hands. Journal of the american pharmacists association j Mar /Apr 2013 | 53:2 | japha 103.