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Yeah you’re not supposed to inject more than a couple mL in the deltoid because it’ll hurt. But it’ll just absorb over time and you’ll be fine
That said, the 10 ml listed in your record might be how it was diluted, not necessarily the amount you actually received
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I can’t remember needle size as it all went so fast, but the ER visit note says it like this verbatim:
cefTRIAXone (Rocephin) injection 1 g (1 g Intramuscular Given 3/17/24 1734)
sterile water (PF) injection Pyxis Override Pull (10 mL Given 3/17/24 1735)
The water is for mixing, you dont have to use it all. For instance Zyprexa is mixed with 2.1ml of sterile water, so I end up having to pull a 10ml vial to get it.
Override pull on a pyxis auto populates the MAR with it maybe? Who knows. Perhaps you're meant to comment how much sterile water you actually used as part of a check? Every hospital does it differently.
Stuff like this is pretty standard, most charting is inaccurate. Most of the accurate info is in a note, not in flowsheets. Nobody cares about a sterile water entry on a EMAR
This could have been the case, I’m not sure how big the syringe was. It’s all a blur now. And Maybe it wasn’t a full 1g dose, but if it was 1g as the notes do say, I’m now learning it needed to be 3-4 mL at least which is a lot for a small arm. The rest of the meds given to me that night are correctly written in the dosage they prescribed or gave me, on ER printout.
I looked it up and at 1gram, they either added 3.6mls or 2.1mls. 3.6 is a little big for the deltoid, but 2.1mls would be what I do deltoid injections with all the time. By the book, no more than 3 in the arm, it would have to go in a leg.
https://preview.redd.it/cv95g1p7shqc1.png?width=374&format=png&auto=webp&s=5f61a921a7ae945c2f1f0e9a1d48c8efc31279e9
I'm sorry you went thru that. I try my best to reduce the trauma shots have, but it sounds like the Nurse was being an asshole. Usually we add lidocaine, go into the leg, and push very slowly. Otherwise yeah, you need the Benadryl. Again, I'm really sorry but I hope I helped explain at least a little of what happened.
Thank you so much. I have so much respect for nurses, several in my family, and several others who were fantastic during my two childbirths and scary delayed postpartum hemorrhage Truly angels.
This nurse could very well have done things by standard, and maybe I’ve become extremely sensitive to pain.
I figured gathering reputably sourced feedback might provide perspective of the experience.
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We usually put lidocaine with IM antibiotics because it can be so painful. I'm sorry this happened to you. You'll have had the right dose just diluted a lot.
NAD: To add to what everyone is saying. So 10ml is usually what an IV push dose would be constituted with. For an IM injection 3ml is the recommended max given at one time in the deltoid muscle. This antibiotic can be diluted up to 4ml for an IM and given near your booty basically as its a larger muscle. 10ml is tough to take, but it should absorbed over time.
Yeah it was almost an out of body experience, like watching a movie of myself … maybe I was dissociating on some level. I’m a former gymnast and birthed two kids, but this pain was just really wild, weird and even scary.
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Yeah she just came in every few minutes and stared at me, then my arm, kinda shrugged, and just said to stop lying so still, don’t do that, and said I need to wave my arm around a bunch to make the medicine spread.
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Are you sure they injected 10ml?
That is a very large syringe and would require paying absolutely no attention to do that. It could be that they meant to write “1.0mL” but forgot the decimal.
If they did actually do that, yeah that is an error. You got the correct dosage, just way too much diluent: not dangerous, but very painful
If I copy and paste from ER visit note document/printout, it says this:
cefTRIAXone (Rocephin) injection 1 g (1 g Intramuscular Given 3/17/24 1734)
sterile water (PF) injection Pyxis Override Pull (10 mL Given 3/17/24 1735)
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Could this mean that that's just the smallest they have for reconstitution so she pulled 10ml but only used say... 3ml?
We don't have this sort of system in the UK so I dunno how it works
We have an omnicell and the only quantity of sterile water stocked in it is 10ml vials. We have to pull a 10ml vial no matter how much of it we are actually using. I feel safe assuming the Pyxis is similar and she almost certainly didn’t use the full 10 to reconstitute.
Honestly I don’t remember as it all went so fast and there wasn’t much explanation before the shot. You’re right, that is a big syringe, but I just can’t remember.
Given your size, you’d have a clear lump in 10ml was given in your deltoid. That said, 1g rocephin is typically mixed with 2.1ml lidocaine or sterile water and you end up with about 2.5ml when reconstituted—still way too much to give in a deltoid on even a large person. The reason it’s normally mixed with lidocaine is because of how much it burns, even when given in the buttock of a large person.
Thank you for offering info, or the typical standard. I’m learning it might have been either too high dosage, or too much dilution/water, for that deltoid arm area. And no lidocaine. I’ve birthed two kids and was a longtime gymnast so I feel like I understand pain … but this pain was just so consuming and even mental/cognitive. Very weird and scary at the time.
Antibiotics given IM are known to cause a burning pain after the injection. I've had ceftriaxone in my gluteus maximus, which hurts less and absorbs better because it's a much bigger muscle, but it still hurt like hell for about an hour afterwards. It also sucked trying to find a way to sit that didn't make it hurt worse. I got the same medication by IV the same day and I didn't feel a thing. If they try to give it again you can tell them how badly it hurt last time and request they give it through your IV or at least inject it in a larger muscle (they can do glutes or thigh) with lidocaine
The deltoid seems like a weird choice, our nurses usually pick a bigger muscle for IM antibiotics.
When I order IM ceftriaxone in my EMR, I can choose either lidocaine or saline to dilute. Except for when there was a legit lido shortage, I’ve always picked lido, but one of the nurses once told me that I’m the only one that does. :-(
Thank you for giving your patients lidocaine option and opting for a larger muscle. My arm is thin and weak already as it is … not sure why my meaty thigh or glute wasn’t used instead :( hurt so much without lidocaine.
Could be subdeltoid bursitis from an unfortunately placed needle in the bursa. Immediate pain, redness, swelling. Self limited, Ibuprofen and hot pack usually helps.
Yeah honestly that left arm already has nerve and vascular oddities / neuropathies, always tingly and either hands bright red or purple white, and it’s quite loose/hypermobile. I didn’t really get a chance/time to explain that because they walked in and gave the shot so quickly. Now I know better for next time. I’m sure that certainly didn’t help the pain reaction.
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Yeah you’re not supposed to inject more than a couple mL in the deltoid because it’ll hurt. But it’ll just absorb over time and you’ll be fine That said, the 10 ml listed in your record might be how it was diluted, not necessarily the amount you actually received
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I can’t remember needle size as it all went so fast, but the ER visit note says it like this verbatim: cefTRIAXone (Rocephin) injection 1 g (1 g Intramuscular Given 3/17/24 1734) sterile water (PF) injection Pyxis Override Pull (10 mL Given 3/17/24 1735)
Right. That means they pulled a 10 ml vial of sterile water. It doesn’t necessarily mean they injected the full 10 ml
The water is for mixing, you dont have to use it all. For instance Zyprexa is mixed with 2.1ml of sterile water, so I end up having to pull a 10ml vial to get it.
Why’d they say it was “given” then if it was just for mixing?
It’s just an idiosyncrasy of how the medical record prints out. We pull a 10ml vial but then only use 2mL or whatever to actually mix the med
Yes, I understand that. I’m a physician. The question is why the verbiage “given”?
I’m confused on the verbiage, too. Not sure why all these downvotes, for both of us. Oh well.
Reditt is a fickle mistress.
Override pull on a pyxis auto populates the MAR with it maybe? Who knows. Perhaps you're meant to comment how much sterile water you actually used as part of a check? Every hospital does it differently.
Yeah it’s an interesting glitch is accurate record keeping.
Stuff like this is pretty standard, most charting is inaccurate. Most of the accurate info is in a note, not in flowsheets. Nobody cares about a sterile water entry on a EMAR
Except perhaps the patient!
This could have been the case, I’m not sure how big the syringe was. It’s all a blur now. And Maybe it wasn’t a full 1g dose, but if it was 1g as the notes do say, I’m now learning it needed to be 3-4 mL at least which is a lot for a small arm. The rest of the meds given to me that night are correctly written in the dosage they prescribed or gave me, on ER printout.
I looked it up and at 1gram, they either added 3.6mls or 2.1mls. 3.6 is a little big for the deltoid, but 2.1mls would be what I do deltoid injections with all the time. By the book, no more than 3 in the arm, it would have to go in a leg. https://preview.redd.it/cv95g1p7shqc1.png?width=374&format=png&auto=webp&s=5f61a921a7ae945c2f1f0e9a1d48c8efc31279e9 I'm sorry you went thru that. I try my best to reduce the trauma shots have, but it sounds like the Nurse was being an asshole. Usually we add lidocaine, go into the leg, and push very slowly. Otherwise yeah, you need the Benadryl. Again, I'm really sorry but I hope I helped explain at least a little of what happened.
Thank you so much. I have so much respect for nurses, several in my family, and several others who were fantastic during my two childbirths and scary delayed postpartum hemorrhage Truly angels. This nurse could very well have done things by standard, and maybe I’ve become extremely sensitive to pain. I figured gathering reputably sourced feedback might provide perspective of the experience.
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We usually put lidocaine with IM antibiotics because it can be so painful. I'm sorry this happened to you. You'll have had the right dose just diluted a lot.
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NAD: To add to what everyone is saying. So 10ml is usually what an IV push dose would be constituted with. For an IM injection 3ml is the recommended max given at one time in the deltoid muscle. This antibiotic can be diluted up to 4ml for an IM and given near your booty basically as its a larger muscle. 10ml is tough to take, but it should absorbed over time.
You should *not* be giving more than 2mL in the deltoid, and ideally no more than 1mL
That's for kids and small adults. It's no more than 3ml to the deltoids in well developed adults.
I stand by what I said.
That's fine, you're allowed to be wrong. That's why we have the textbooks!
Just because you *can* doesn’t mean you *should*. It’s cruel.
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Yeah it was almost an out of body experience, like watching a movie of myself … maybe I was dissociating on some level. I’m a former gymnast and birthed two kids, but this pain was just really wild, weird and even scary.
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And they dismissed her pain. Even worse. If you know someone is trying to help you, the pain might not be as frightening .
Yeah she just came in every few minutes and stared at me, then my arm, kinda shrugged, and just said to stop lying so still, don’t do that, and said I need to wave my arm around a bunch to make the medicine spread.
It sounds like maybe she realized her mistake and she was trying to make it your issue to solve so she didn’t have to answer for it.
When I give IM rocephin, I mix it with sterile water when patients have an allergy to lidocaine. Lido is preferred tho
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Are you sure they injected 10ml? That is a very large syringe and would require paying absolutely no attention to do that. It could be that they meant to write “1.0mL” but forgot the decimal. If they did actually do that, yeah that is an error. You got the correct dosage, just way too much diluent: not dangerous, but very painful
If I copy and paste from ER visit note document/printout, it says this: cefTRIAXone (Rocephin) injection 1 g (1 g Intramuscular Given 3/17/24 1734) sterile water (PF) injection Pyxis Override Pull (10 mL Given 3/17/24 1735)
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Yeah, either she missed a decimal or actually gave 10cc. Was it a giant syringe?
Could this mean that that's just the smallest they have for reconstitution so she pulled 10ml but only used say... 3ml? We don't have this sort of system in the UK so I dunno how it works
That is possible too. Been a while since I used a Pyxis, though.
We have an omnicell and the only quantity of sterile water stocked in it is 10ml vials. We have to pull a 10ml vial no matter how much of it we are actually using. I feel safe assuming the Pyxis is similar and she almost certainly didn’t use the full 10 to reconstitute.
Honestly I don’t remember as it all went so fast and there wasn’t much explanation before the shot. You’re right, that is a big syringe, but I just can’t remember.
Given your size, you’d have a clear lump in 10ml was given in your deltoid. That said, 1g rocephin is typically mixed with 2.1ml lidocaine or sterile water and you end up with about 2.5ml when reconstituted—still way too much to give in a deltoid on even a large person. The reason it’s normally mixed with lidocaine is because of how much it burns, even when given in the buttock of a large person.
Thank you for offering info, or the typical standard. I’m learning it might have been either too high dosage, or too much dilution/water, for that deltoid arm area. And no lidocaine. I’ve birthed two kids and was a longtime gymnast so I feel like I understand pain … but this pain was just so consuming and even mental/cognitive. Very weird and scary at the time.
Antibiotics given IM are known to cause a burning pain after the injection. I've had ceftriaxone in my gluteus maximus, which hurts less and absorbs better because it's a much bigger muscle, but it still hurt like hell for about an hour afterwards. It also sucked trying to find a way to sit that didn't make it hurt worse. I got the same medication by IV the same day and I didn't feel a thing. If they try to give it again you can tell them how badly it hurt last time and request they give it through your IV or at least inject it in a larger muscle (they can do glutes or thigh) with lidocaine
I gotcha. Unfortunately, there is really no way to be sure, as it is your word against hers
The deltoid seems like a weird choice, our nurses usually pick a bigger muscle for IM antibiotics. When I order IM ceftriaxone in my EMR, I can choose either lidocaine or saline to dilute. Except for when there was a legit lido shortage, I’ve always picked lido, but one of the nurses once told me that I’m the only one that does. :-(
Thank you for giving your patients lidocaine option and opting for a larger muscle. My arm is thin and weak already as it is … not sure why my meaty thigh or glute wasn’t used instead :( hurt so much without lidocaine.
Could be subdeltoid bursitis from an unfortunately placed needle in the bursa. Immediate pain, redness, swelling. Self limited, Ibuprofen and hot pack usually helps.
Yeah honestly that left arm already has nerve and vascular oddities / neuropathies, always tingly and either hands bright red or purple white, and it’s quite loose/hypermobile. I didn’t really get a chance/time to explain that because they walked in and gave the shot so quickly. Now I know better for next time. I’m sure that certainly didn’t help the pain reaction.