Injections Flashcards
1
Q
Indications for injections?
A
- OA
- RA
- gouty arthritis
- synovitis
- bursitis
- tendonitis
- muscle trigger pts
- carpal tunnel syndrome
- wound anesthesia
2
Q
Components of local infiltration?
A
- injecting into subq tissue open wounds: provides good anesthesia: little discomfort while injecting
- b/f injecting: clean and sterilize the wound
- epi decreases blood loss
- avoid toxic doses of lidocaine
3
Q
What are field blocks used for?
A
- good for superficial lesions such as skin abscesses: local anesthesia not effective and painful, may spread infection
- skin prep w/ betadine or alcohol
- inject slowly while advancing needle, only need to go through skin 2x
4
Q
Components of digital blocks?
A
- use small needle (25-27 gauge)
- start dorsally, go down each side of proximal phalanx: inject as you go and change angle
- don’t use if there is vascular compromise
5
Q
When are trigger pt injections?
A
- inflamed tendon/bursa by bony prominence:
combo of lidocaine and steroid, when conservative tx fails and for Dx - tennis elbow: lateral epicondylitis (pain w/ resisted wrist dorsiflexion)
- greater trochanteric bursitis (pain w/ stretching of lateral side of hip)
- ischial tuberosity bursitis: Weaver’s bottom (pain w/ resisted knee flexion)
- skin prep w/ betadine swab x3 or chloraprep x1 (let dry)
- slow injection into pt of max tenderness: advance needle to bone and then withdraw 2 mm
6
Q
Why inject jts?
A
- can be jt or soft tissue
- inflammation: degenerative jt disease, bursitis, tendinitis
- corticosteroid injection helps decrease inflammatory rxn (includes limiting capillary dilation + vascular permeability)
7
Q
What are basic principles b/f starting jt injection?
A
- hx and exam
- try conservative tx: NSAIDs and cont after jt injection
- careful pt selection
- consent
- know your anatomy
- undertake as few injections as possible to settle problem, max 3-4 in a single jt
8
Q
Risks of jt injections?
A
- infections in healthy pts
- soft tissue infection
- acceleration of septic jt
- subq atrophy and skin depigmentation in less than 1%: where steroid injected subq
- steroid flare: facial flushing, first 24-48 hrs: clears in 1-2 days
- exacerbation of diabetes: warn pts to monitor their BGs
- cartilage damage (rare)
- tendon rupture: only if injecting around tendon
- allergic rxn
- anaphylactic rxn: w/in 5-10 min of injection
9
Q
CIs to jt injection?
A
- adjacent osteomyelitis
- evidence of bacteremia or febrile illness
- hemarthosis
- impending (scheduled w/in days) jt replacement surgery
- infectious arthritis
- jt prosthesis
- osteochondral fx
- periarticular cellulitis/severe dermatitis/ soft tissue infection
- poorly controlled DM
- uncontrolled bleeding disorder or coag
- clotting disorder and anticoagulation (Correct b/f injecting): prob ok if INR is less than 1.8
- broken skin or cellulitis over injection site
- jt infection
- allergy to local anesthetic or steroid preservative
- immunosuppressed (by drugs or disease)
10
Q
When should you inject jts w/ caution?
A
- charcot jt (neuropathic sensory loss)
- tumor
- neurogenic disease
- active infections (TB)
- hypothyroidism
- bleeding dyscrasias
- diabetics (likely to raise BG for several days)
11
Q
What informed consent should you go over w/ your pt?
A
- risks: infection, bleeding, allergic rxn, pain
- benefits: simple office procedure - may provide relief for pts too frail for definitive tx
- realistic expections:
may not help or only for a few months, may have increased pain for a day or 2 after the injection, may take several days to take effect
12
Q
What are the steroids used for jt injections?
A
- some take quicker effect, others last longer
- short acting preps (soluble):
hydrocortisone
prednisilone - long acting preps:
kenalog, aristospan, depo-medrol, decadron, triamcinolone acetonide - combo preps: (soluble and depot): celestone soluspan
- half life of intra-articular injections:
depo medrol 6 days
kenalog 22 days
aristospan 33 days
13
Q
Approach to the knee injection?
A
- best approach is path of least obstruction and max access to synovial cavity: which would be superolateral** (or anteromedial - can inject into fat pad rather than jt, or anterolateral, superomedial)
- plain XRs recommended for assessment of bony anatomy of individual knee jt
- knee injection site can be selected according to pt’s bony anatomy and marked w/ the tip of retracted ball pt pen b/f sterile prep
- 5 ml 1% lidocaine and 20-80 methylprednisolone
- this is one of the MC jts for PCP to aspirate and inject
14
Q
Reasons for shoulder injections?
A
- intra-articular: arthritis, rotator cuff tear, and frozen shoulder
- subacromial:
rotator cuff tendinitis, bursitis - AC jt: infammation/arthritis
15
Q
Routes for shoulder injections?
A
- posterior:
MC (have pt sitting), 2 cm below base of acromion, 2 cm medial to edge of humerus, can feel jt move in towards tip of coracoid process - anterior:
not used as much, have pt supine, fingertip below clavicle and lateral to tip of coracoid process (inject into upper half of jt, avoid brachial plexus) - can usually feel the jt move
- AC jt: pt sitting w/ hands behind back, palpate the jt, inject from above, angle medially
