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Pediatric vaccine gone wrong

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by Kazed Kazed (New) New Student

Specializes in Family practice. Has 2 years experience.

So I work in a family practice, being trained on vaccines. Have done 100 so far, minimal issues. 18 month is in for his 12 month shots (delayed), first injection went bad... child flung free from fathers grip with needle still in arm, lost some vaccine, some mild bleeding. Wait and then go in for last 2 injections. Did subcutaneous first. Kid again jerked his arm, lost some vaccine and again bleeding. Nurse supervising told father he needs to get a better grip and advised me to just do last one. I tried but the kid kept squirming. Needle went in then slipped back out. Had to quickly do it again.

Child's arm was red, Puffy, Slightly swollen at injection site. Advised parent to wait 20 minutes to check for reaction they declined. Explained the doctor should assess the injection site as it was a rough injection and it looked puffy. They declined. I told the doctor and noted in the chart. I feel like I never want to do pediatric injections again. The nurse said it happens sometimes but unless we get someone else to restrain the child I feel I cannot trust the parents to secure them.

I personally am not a fan of having parents do the restraining but sometimes it must be done. How did you have the parent restrain the toddler?

Kazed

Specializes in Family practice. Has 2 years experience.

We had the father hold the arm not in use around his body and place his other arm around the in use arm. The child was tiny for his age but strong and squirming. I've done lots of 2 mth to 4 year olds and have never had it go so wrong. I agree.. parents should not be in charge of restraining however the practice I work at usually only has 1 person a day in charge of administering and it's impossible to give the injection and restrain at the same time. At least for me

NICU Guy, BSN, RN

Specializes in NICU. Has 6 years experience.

Maybe purchase a Papoose board?

Is it necessary to give imms in the arms of toddlers that are tiny for age?

- There are a couple of effective holding positions that facilitate thigh/leg access.

- You will become more comfortable with helping to secure the injection site while performing the injection.

- If you encounter trouble as you did in this situation, regroup and make sure things are going to be secure before proceeding.

- Make sure your own wrist is stabilized. Either the child, the injector or both have to move quite a bit in order for the needle to actually come back out accidentally. An example of what I mean by stabilizing yourself would be using the thigh and in doing so, find your site, place your lateral forearm/wrist of your injecting hand down onto the leg and then use only wrist motion to gently (but quickly) "dart" the needle into the skin. Don't just come at the skin with a 'whole arm' movement...if that makes sense.

Good luck!

Nunya, BSN

Specializes in NICU/Mother-Baby/Peds/Mgmt. Has 39 years experience.

First of all, if there was another nurse there she should have helped hold the kid after the first shot. I know you're in training but the most important thing here is to make sure the kids gets the entire dose. Secondly, you can use the thigh for an 18 month old. I think it's easier to immobilize a kid for a thigh injection.

9 hours ago, Kazed said:

We had the father hold the arm not in use around his body and place his other arm around the in use arm.

The best way I have found, if a parent must be utilized, to restrain a child is to have the child sit facing the parent (chest to chest) on the parents lap with the child's arms under the parent's arms and legs straddling the parent's torso. The parent then wraps their arms around the child in a big bear hug which holds their arms and body in place and because of the position of their legs they cannot effectively twist or kick while still allowing them to comfort their child. This works well for immunizations, blood draws and IV starts.

comfort-positions-during-procedures-toddler-chest-to-chest-2.jpgcomfort-positions-during-procedures-toddler-chest-to-chest-16x9.jpg

Kazed

Specializes in Family practice. Has 2 years experience.

I would much prefer giving the injection in the thigh. The 2 nurses training me keep telling me 'after 12 months, move to the deltoid' I have questioned it a few times as some toddlers are very thin and id prefer the thigh. That hold seems much better and I'll get the parents to that.

I too feel we should have regrouped after the first one went so badly. I do need to improve my injection method. Im too slow I feel for pediatric patients. Thank you all for responding!

It isn't wrong to use the deltoid for 1 year olds but it wouldn't be my preference. A blanket age-based "rule" is kinda wrong though...you have to assess your muscle options for size/development.

https://www.immunize.org/catg.d/p3085.pdf

This reference lists the thigh as the preferred site up to age 3.

Also wouldn't consider papoose board. That is not good optics for routine, non-emergent peds/family wellness care. Particularly when very brief assistance from another set of hands can make it completely unnecessary the grand majority of the time.

Kazed

Specializes in Family practice. Has 2 years experience.

I totally agree. Deltoid after 12 months seems an unnecessary rule. I've also been instructed after 14 years old it always has to be 1" needle for IM. I had a frail old lady and really think 5/8" would have sufficed. I don't want to disagree when they are training me however it's not what my class taught me

HiddencatBSN, BSN

Specializes in Peds ED. Has 10 years experience.

After the first shot went bad your preceptor should have guided you and dad into a more secure situation for the shot and assisted in holding. In peds it’s not uncommon to need an extra set of hands for painful procedures and holding is everything. Telling dad to do a better job rather than finding a more secure hold and seeking assistance is a set up for the experience you had.

The chest to chest comfort hold pictured above is a great one, plus coaching dad that he needs to give a really tight bear hug. Be very specific and never be afraid to ask for extra help- when the attending is the one closest by when I need more muscle then I am asking the attending to hold an arm for a moment.

A papoose for an injection is OTT- the injection is fast and the time spent fighting a kicking toddler in to one doesn’t balance out for how long you need them held still enough to hit your target.

Kazed

Specializes in Family practice. Has 2 years experience.

I really wish she would have taken over. I did not have control. The dad did not have control. The poor kids arms are definitely going to be sore for awhile. I felt like a failure. Thank you for the advice

38 minutes ago, Kazed said:

I felt like a failure.

You did the best you could in a new, stressful situation with what sounds like very little guidance. You did not fail then and you are not a failure now.

I cannot say the same for your "preceptors".

Edited by Wuzzie

HiddencatBSN, BSN

Specializes in Peds ED. Has 10 years experience.

34 minutes ago, Kazed said:

I really wish she would have taken over. I did not have control. The dad did not have control. The poor kids arms are definitely going to be sore for awhile. I felt like a failure. Thank you for the advice

I think your supervisor is the one who dropped the ball here. This was a situation where they needed to either guide you and the dad into a better position or help with positioning. Some kids have a ton of fight and things are still challenging but it sounds like your supervisor could have helped things and that the issue is perhaps your supervisor not having the tools herself to manage this type of common pediatric situation. This is why I always get peds specific care for my kids though- peds specific practices tend to be better at the holding/distracting/expecting kids to fight certain things skills.

Sweetheart2005, ASN

Specializes in Med surg/tele. Has 10 years experience.

I’ve been out of family practice for five years now, but almost always went with the thigh up through age two as my injection site of choice. Seems easier to hold the younger ones effectively.  
I agree with the others. Some of these kiddos are strong! The other nurse should have stepped in to assist in restraining and provide specific  instructions to dad on how she wanted him to hold. 

This was a difficult situation, and sounds like you did nothing wrong. 

On 8/25/2020 at 7:31 AM, JKL33 said:

Also wouldn't consider papoose board. That is not good optics for routine, non-emergent peds/family wellness care. Particularly when very brief assistance from another set of hands can make it completely unnecessary the grand majority of the time.

Yes, papoose only for suturing if absolutely necessary.

Don't get too discouraged. We learn from these types of scenarios. The photo example above is a good one. It sounds like this patient is an exception for you. You should have another nurse or MA help in the future if necessary. 

Edited by 2BS Nurse

1 minute ago, 2BS Nurse said:

Yes, papoose only for suturing if absolutely necessary.

 They can also be used for blood draws and IV starts. The bad optics can be ameliorated with good teaching/preparation and using kid friendly words. I have never had a parent get upset or a kid fight me using one. In fact, most parents seem relieved to not have to hold their child down themselves.  I also always let the parent "rescue" the child by being the one to get them off the board. Papoose boards get a bad rap that they really don't deserve.