Checklist for Intramuscular injection for vaccinations and medications

Check if there is any contraindication or previous adverse reaction for the vaccine or medication

Check the type, dose, and route of administration

Procedure

1. Prepare the supplies with one inch (23-25 gauges) needle

2. Select site of injection

3. Position the patient comfortably and expose the chosen site

4. Perform hand hygiene and don gloves.

5. Clean the chosen site with isopropyl 70% swab and allow to air dry.

6. Ensure the site is completely dry before performing the injection.

7. Remove the needle cap and hold the syringe in the dominant hand.

8. Stretch the skin tautly prior to injection.

9. Insert the needle at a 90 angle.

10. Withdraw the plunger to observe for blood.

11. If blood is visible:

Withdraw the needle completely.

Explain what has happened to the patient.

Dispose of the needle and syringe in the sharps container.

Draw up new solution and repeat the procedure in a different site.

12. If no blood is visible in the syringe, slowly depress the plunger until the full dose of medication is

administered.

13. Withdraw the needle and release the skin.

14. Apply gentle pressure with a dry swab.

15. Do not recap the used needle.

16. Dispose of the needle and syringe in a sharps container.

17. Assist the patient to reposition as required.

18. Perform hand hygiene.

19. Sign the medication chart

Intraosseous Access

Intraosseous (IO) access is an effective route for fluid resuscitation, drug delivery and

laboratory evaluation that may be attained in all age groups and has an acceptable safety

profile.

Indications:

IO access is the recommended technique in emergency situations as decompensated

shock (if other attempts at venous access fail, or if they will take longer than ninety

seconds to carry out.)

The exception is the newborn, where umbilical vein access continues to be the

preferred route.

Contraindications:

o Proximal ipsilateral fracture

o Ipsilateral vascular injury

o Osteogenesis imperfecta

Complications:

o Failure to enter the bone marrow, with extravasation or subperiosteal infusion

o Osteomyelitis (rare in short term use)

o Physeal plate injury

o Local infection, skin necrosis, pain, fat and bone microemboli have all been reported

but are rare

Equipment

o Alcohol swabs

o 18G needle with trochar (at least 1.5 cm in length)

o 5 ml syringe

o 20 ml syringe

o Infusion fluid

Analgesia, Anaesthesia, Sedation

Local anaesthesia may be required if the patient is conscious.

Procedure

o Identify the appropriate site

Proximal tibia: Anteromedial surface, 2-3 cm below the tibial tuberosity

Distal tibia: Proximal to the medial malleolus

Distal femur: Midline, 2-3 cm above the external condyle

o Prepare the skin

o Insert the needle through the skin, and then with a screwing motion perpendicularly /

slightly away from the physeal plate into the bone. There is a give as the marrow

cavity is entered

o Remove the trocar and confirm position by aspirating bone marrow through a 5 ml

syringe. Send marrow blood for laboratory sampling (suitable for most standard

laboratory values, blood gases, ABO and Rh typing.)

o Marrow cannot always be aspirated but it should flush easily.

o Secure the needle and start the infusion

Post-Procedure Care

Intraosseous infusion should be limited to emergency resuscitation of the child and

discontinued as other venous access has been obtained.

NASOGASTRIC (NG) TUBE INSERTION

The supplies:

NGT (size 5-6 Fr for neonate-6 mo, 8 Fr for 1-2 yr, 10 Fr for 3-7 yr) Lubricant (water soluble) Tape, ½ inch Syringe (5-10cc) Non sterile gloves ______________

Indications

1- Enteral rehydration, feeding and administration of medications

2- Drain gastric contents and decompress the stomach

3- Obtain a specimen of the gastric contents

4- Allow for drainage and/or lavage in drug over-dosage or poisoning

Steps and checklist

1- Introduce yourself to the patient/parents and explain the procedure

2- Prepare supplies and necessary equipments

3- Wash hands and put on gloves

4- Measure tubing from tip of nose to earlobe, then to the point halfway between the end of the

sternum and the umbilicus

5- Mark measured length with a marker or note the distance

6- Lubricate 2-4 inches of tube with lubricant or sterile water

7- Pass tube via nasal opening posteriorly, past the pharynx into the esophagus and then the

stomach. In case of older children, instruct the patient to swallow.

a. If resistance is felt and tube cannot be advanced, try the other nostril and tilt the head forward towards chest (chin to chest procedure)

b. Withdraw tube immediately if changes occur in patient's respiratory status or color, or

if tube coils in mouth

8- Advance tube until mark is reached

9- Check for placement by attaching syringe to free end of the tube, aspirate sample of gastric

contents. Do not inject an air bolus, as the best practice is to test the pH of the aspirated

contents to ensure that the contents are acidic. The pH should be below 6. Obtain an x-ray to

verify placement before instilling any feedings/medications or if you have concerns about the

placement of the tube.

10- Secure tube with tape

11- Label the tube with date and time

12- Remove gloves and wash hands

Risk

Vomiting, aspiration

Tissue trauma (esophageal erosion, perforation)

Esophagitis

Epistaxis or ulceration of the nares

Orogastric tubes

Reasons for oro-gastric feeding include:

A baby who has choanal atresia.

A baby requiring nasal prong continuous positive airway pressure (CPAP).

A baby whose airway would be compromised if a nasogastric tube was inserted, for example

a baby with a craniofacial anomaly.

Orogastric tubes must be inserted in children with a suspected or confirmed basal skull

fracture

Umbilical vessel catheterization

Indications:

- Arterial blood sampling - Arterial blood gas analysis - Arterial blood pressure monitoring - Venous blood sampling - Central line for venous infusion - Exchange blood transfusion

Contraindications:

- Omphalocele - Omphalitis - Cord anomalies - Peritonitis - Uncontrolled bleeding disorder

Complications:

- Bleeding - Infection - Thrombosis - Lower limb ischemia - Misplacement opposite renal artery may cause renal hypertension

Procedure: 1. Preparation of umbilical catheter kit and lines in sterile fashion 2. Prepares additional equipment

a. Syringes – 5ml x 6 b. 3-way stop cocks x 3 c. Sterile flush

3. Prepare an appropriate catheter size to use: a. Infants < 1500gms use 3.5fr catheter b. Infants > 1500gms use 5fr catheter

4. Calculate for UAC and UVC depth Birth weight formula

a. High UAC depth (cm) = weight in kg x 3 + 9 b. Low UAC depth (cm) = weight in kg + 7 c. UVC depth (cm) = ½ UAC depth + 1 cm

Tape measurement method UVC: Umbilical stump-xyphoid process distance + 0.5-1 cm High UAC: Umbilical-shoulder distance + 1 cm Low UAC: 2/3 of distance from umbilicus to mid-portion of the clavicle 5. Simulates sterile precautions: (mask, hat, gown, gloves) 6. The infant's abdomen and cord are cleaned with alcohol.

7. Tie a piece of umbilical tape around the base of the umbilical cord 8. Using a scalpel, the cord is cut cleanly 1.0 cm from the skin. 9. Identifies umbilical vessels?

a. One vein b. Two arteries

10. Stabilize the cord with a forceps and use a curved iris to dilate the artery 11. Gently insert the previously flushed catheter into the target vessel, direct UVC to point

cephalad follow the pathway of the umbilical vein and direct UAC caudally to internal

iliac A

12. Verify position in lumen by drawing back blood into syringe

13. After the catheter is advanced the appropriate distance, the position of the catheter should be confirmed by x-ray.

The proper location of catheters on X-ray?

a. High UAC: T6-T9 b. Low UAC: L3-L5 c. UVC: at level of diaphragm

14. After placement of the catheter, a purse-string suture is placed around the umbilicus

15. Disposes of sharps?

Examination for Developmental Dysplasia of the Hip (DDH) Definition Developmental Dysplasia of the Hip (DDH) is a condition that affects the neonatal and infant hip joint. DDH is a term used to describe a spectrum of abnormalities affecting the relationship of the femoral head to the acetabulum. These may include an immature hip, a hip with mild acetabular dysplasia, a hip that is dislocatable, a hip that is subluxated, or a hip that is frankly dislocated.

Vital points to note regarding the screening and management of DDH include: • All newborns should undergo a hip examination, including the Barlow and Ortolani tests, following birth, prior to discharge from hospital. • High risk infants should be booked for an Ultrasound at 6 weeks of age. This includes all breech presentations and those with a family history (parent or sibling) of DDH. • Hip examination should occur at birth, 6-8 weeks and 6 months of age • Any child with a dislocatable hip should be referred immediately to an Orthopaedic Surgeon. • Concerns regarding an infant’s hips should be acted on immediately – delays in treatment may have adverse effects on the outcomes for the infant.

Risk Factors associated with DDH include: • Breech Presentation • Family History of DDH (especially if in parent or sibling) • Female Baby (DDH is four times more likely to occur in a female infant) • Large Baby (>4kg) • Overdue > 42 weeks • Oligohydramnios • Associated with foot deformities • First born baby or multiple pregnancies

The most significant risk factors for DDH are breech presentation and family history

Routine ultrasound screening at 6 weeks of age should be offered to: 1. All breech presentations 2. Children with a family history (parent or sibling) with DDH

Prior to physical examination, the examiner should:

• Ensure a warm, quiet environment for the examination to occur • Ensure the infant is well, relaxed and fed • Remove clothing from the lower limbs • Place the child on a firm, flat examination surface

Birth to 3 months of age • Ortolani Test (reduction test) The Ortolani is performed with the newborn supine and the examiner’s index and middle fingers placed along the greater trochanter with the thumb placed along the inner thigh. The hip is flexed to 90° but not more, and the leg is held in neutral rotation. The hip is gently abducted while lifting the leg anteriorly. With this maneuver, a “clunk” -not a click- is felt as the dislocated femoral head reduces into the acetabulum. • Barlow Test (stress test) The Barlow provocative test is performed with the newborn positioned supine and the hips flexed to 90°. The leg is then gently adducted while posteriorly directed pressure is placed on the knee. A palpable clunk or sensation of movement is felt as the femoral head exits the acetabulum posteriorly. This is a positive Barlow sign” After 3 months of age, the Ortolani and Barlow tests may be unreliable, therefore additional means of examination, used in combination with the Ortolani and Barlow tests, are necessary. The screening techniques described below may also be used with infants 0-3 months of age.

Older Infants (> 3 months of age) • Check for restricted abduction at the hips Limited abduction is the most sensitive sign associated with DDH in the older infant. With the infant in supine, on a firm, flat surface with pelvis stabilised and hips and knees at 90°, abduct and adduct the hips to check for restricted range of motion. This manoeuvre should be performed gradually and may need to be repeated a number of times, to ensure an accurate result is obtained. Normal range of motion at the hip is abduction to 60° or more, with range less than this suggestive of DDH. • Check for leg length discrepancy Total leg length discrepancy should be assessed in prone with hips and knees extended, as well as assessing for leg length discrepancy using the Galeazzi Test. This test should be conducted with

the infant in supine, on a firm, flat surface with the pelvis stabilised . Hips are flexed to 90° and placed in neutral adduction/abduction, with knees in flexion. In this position, the vertical level of the knees can be assessed for asymmetry. • Check for asymmetrical thigh and gluteal skin folds With the infant in prone, check for asymmetrical thigh or gluteal folds. Note that asymmetrical skin folds alone do not constitute a diagnosis of DDH, however this information can be used in combination with other physical signs during assessment. In children who are walking, a limp may be present

Children who are diagnosed with DDH in the first 6 months of life may be treated with the application of a hip brace (The Pavlik Harness)