Intramuscular injections and a missed opportunity

1. Intramuscular injections and a missed opportunity Talenie de Bruyn September 2012

2. Clinical case • 15 yr old netball player • Presents pain over left buttock with decreased movement in left leg due to pain • Presented on Wednesday • Had Voltaren imi on Monday, Tuesday x 2 and Wednesday morning before presenting to enable participation in tournament • Injections given by assistant coach • Pain only increased • Took Myprodol in between injections to alleviate pain and discomfort • No known chronic diseases • Invited to Free State U/18 netball trials the following week

3. Examination • Overall healthy • Antalgic gait – favouring the left leg • Tender over gluteus medius and piriformis • Haematoma lateral aspect left buttock • Haematoma lateral aspect right buttock • Haematoma medial-inferior aspect left buttock • Haematoma middle of right buttock • 1+ oedema lower limbs • Urine test 1+ protein and 2+ blood • Pain with extension and adduction of hip

4. Special investigations • Advised to have UK+E done • Pt did not go for blood tests

5. 3 Stage assessment • Biological: multiple haematomas on buttocks probable kidney involvement repetitive gluteus injuries • Psychological: will miss FS netball trials due to injuries and Voltaren overuse – decreased self confidence • Social: • pressure from mother and coach to compete despite injuries • social standing dependant on netball performance • Self image reliant on netball performance

6. Differential diagnosis • Repetitive muscle strain • Muscle damage due to injections • Kidney compromise by high dose anti-inflammatories • Nicolau syndrome

7. Diagnosis • Muscle strain gluteus medius • Haematoma gluteus muscles • Kidney involvement not proven

8. Problem list • Active: • Gluteus injury – old and neglected • Haematomas both buttocks • Probable kidney function deterioration • Passive: • Performance pressure from mother and coach • Self image build on netball identity • Lack of knowledge re management of muscle injuries

9. Discussion • NSAID’s provide analgesic, antipyretic and anti-inflammatory relief • Available OTC • Lay persons expect some gastric side effects but little else • Adverse reactions include: GIT bleeds/ulcers, blood dyscrasias, allergic reactions, liver function changes and nephrotoxicity • Nephrotoxicity especially in states of fluid depletion ( Nakahura et al, 1998)

10. Discussion (2) • Mechanism of action NSAID’s: • Inhibit COX 1 and 2 with inhibition of PG synthesis from arachidonic acid • Inhibits migration, aggregation and neutrophile and macrophage functions • Inhibits COX 2 which locally is overexpressed in inflammation – PG synthesis from this supports lesional process • Alters natural healing process ( Ziltener, Leal and Fournier, 2010)

11. Nephrotoxicity • reduced renal perfusion as seen in various forms of cardio- renal disease, dehydration, and the aging kidney • the adequacy of renal prostaglandin production mediated predominantly by cyclooxygenase-1 (COX-1) and, potentially, by COX-2 enzyme activity becomes of major significance in the activation of compensatory renal hemodynamics. • Inhibition of renal prostaglandin production by the use of NSAIDs in these circumstances can potentially lead to the emergence of several distinct syndromes of disturbed renal function: fluid and electrolyte disorders, acute renal dysfunction, nephrotic syndrome/ interstitial nephritis, and renal papillary necrosis. • blunting the homeostatic renal effects of prostaglandins, NSAIDs can adversely influence blood pressure control, particularly during the use of angiotensin-converting enzyme (ACE) inhibitors, diuretics, and Beta-blockers. • (Whelton, 1999)

12. Discussion (3) • NSAID’s should be used lowest possible dose for shortest period just to alleviate pain • Prevent long term side effects on kidneys, GIT and repair of ligamentous and muscular injury • Parental vs oral administration more systemic toxicity (Ziltener, Leal and Fournier, 2010)

13. Discussion (4) • This case study focusses on intra muscular injections • Muscle subjected to trauma with weakening of muscle fibres • Creates inflammatory process in muscle fibres • Detrimental effect cell regeneration phase • Inhibit extracellular matrix synthesis with decreased collagen turnover and muscle regeneration • Increases fibrosis at injured site (Brukner and Khan, 2012)

14. Discussion (5) • Important that imi injections be given correctly • If intradermal or subcutaneous decreased drug absorption and greater possibility of local complications • WHO determines skin must be stretched flat between fingers and needle injected at 90⁰ angle on superolateral aspect of buttock • Aspiration must be done to determine whether blood vessel was punctured • Needle inserted to hilt • Buttocks various amounts of fat which determines whether injected in subcutaneous fat or intra muscularly

15. Correct injection site

16. Discussion (6) • Study by Chan et al in 2006 using a 30mm 23G needle followed by CT scan determined the following: • 32% intramuscularly • 68 % subcutaneous fat • Subcutaneous fat injections lead to higher incidence of abscesses and granulomas

17. True imi injection

18. Subcutaneous injection

19. Discussion (7) • People not trained to inject people may inadvertently inject into a bloodvessel • Can lead to tissue necrosis 2⁰ to damage to an end-artery with resultant massive inflammation • Starts as intense pain and pallor at site • Then erythema evolves into livedoid bluish reticular patch • Becomes haemorrhagic and then necrotic • Complications: neurological injury, extensive necrosis, limb ischaemia, sepsis sometimes resulting in death • Nicolau syndrome: livedo-like dermatitis or embolia cutis medicamentosa • Clinical improvement with anticoagulation therapy, intravenous steroids and vaso-active therapy (Uri and Arad, 2008)

20. Nicolau syndrome

21. Skin ulcer secondary to incorrect injection technique

22. Gluteal injection site granulomas

23. Subcutaneous abscess

24. Management • Advise regarding NSAID use • Avoidance of intramuscular injections during sport tournaments and by persons not trained to give imi • POLICE • Increased fluid intake during sporting events • Rehabilitation of gluteus muscle group after recovery of injury • Monitor kidney function and increase fluid intake

25. Prognosis • If she follows recuperation plan and avoids further NSAID use: good prognosis • Attitude of mother and coach makes this highly unlikely • If continues to play and use NSAIDs indiscriminately: kidney failure and severe muscular injury

26. Importance • Most pts only aware of possible GIT side effects • Little known in lay population about nephrotoxicity an impact on healing processes • Our responsibility to educate people and colleagues regarding these issues

27. References • Brukner and Khan. Clinical sports medicine. 4th edition. McGraw and Hill. Sydney. 2012. • Chan, V.O., Colville, J. et al. Intramuscular injections into the buttocks: Are they truly intramuscular? European journal of radiology. Vol 58. 2006. Elsevier. p.480- 484. • Nakahura, T. et al. Nonsteroidal Anti inflammatory drug use in adolescence. Journal of adolescent health. Vol 23. 1998. p 307 – 310. • Uri and Arad. Skin necrosis after self-administered intramuscular diclofenac. Journal of plastic, reconstructive and aesthetic surgery. 2010:63, e4-5. • Whelton, A. Nephrotoxicity and NSAIDs: Physiological foundation and clinical implications. American journal of medicine. Vol 106. 1999. p 13S – 24S. • Ziltener, J.L., Leal,S. Fournier, P.E. Non-steroidal anti-inflammatory drugs for athletes: An update. Annals for physical and rehabilitation medicine. Vol 53. 2010. Elsevier Masson. p 278-288.