Some references for you to look at. The URL’s are at:
http://www.cahsupportforum.com/injection.html
and
http://www.cahsupportforum.com/adrenalcrisis.html
When Hydrocortisone (Solu-Cortef) is to be given as an intramuscular injection you need to give the injection in the middle outer third of the thigh as illustrated above in the diagram.
1. Clean and dry hands thoroughly in preparation making sure to scrub under nails.
2. Gather your equipment together. You will need needles, syringes, alcohol wipe, sterile gauze padding and also a plastic container which is long enough to put the sharp’s in when the injection has been given.
3. Take the Solu-Cortef vial and check the expiry date on the side of the vial. If the date has expired or the contents appear discolored do not use. If all is well then apply pressure to the yellow cap with thumbs on either side until the rubber bung moves and the fluid and hydrocortisone powder contents are mixed together. Shake the contents until they are well mixed and appear clear.
4. Take the syringe out of the sealed packaging and remove the cap from the needle.
5. Pull back the plunger on the syringe. Draw in the same volume of air as the dose you intend to give in cc/ml’s. Do not touch the plunger or the needle.
6. Push the needle into the rubber stop on the vial and push the air into the vial and without removing the needle. Invert the vial so that the plunger is at the bottom and underneath the vial. Be sure to support the syringe so that the needle is not bent.
7. Pulling on the plunger, fill the syringe to the required measurement on the side of the syringe that is to be administered. Check the syringe for air bubbles and if these are present, gently tap the syringe barrel until the bubbles move to the top of the syringe then push the plunger slightly to remove them. After this draw on the plunger again to re-draw the required measured dose. If there are still bubbles in the syringe, repeat the above processes until they have disappeared.
8. Remove the needle and replace the cap carefully onto the needle temporarily and place on the table close to hand.
9. Clean the site or area where you intend to give the injection with a sterile alcohol wipe thoroughly by rubbing in a circular motion.
10. Now remove the needle cap from the syringe and hold it like you would a pencil.
11. Pinch the muscle between thumb and forefinger and bunch slightly as illustrated above.
12. Still holding the barrel of the syringe, push the needle quickly and efficiently into the muscle, but not right up to the hilt of the syringe. Do this in a dart-like fashion.
13. Depress the plunger until the whole dose has been administered.
14. Withdraw the needle and using sterile gauze padding apply light pressure on the site of the injection briefly if there is slight bleeding.
15. Place all the sharps and wipes into the plastic container and tighten the lid. Dispose of this immediately to avoid injuries and spread of infections to other’s.
Adrenal crisis and severe acute adrenocortical insufficiency in Congenital Adrenal Hyperplasia can be caused by illness or injury or any stress that makes demands upon the adrenals to produce large amounts of cortisol. People who have Congenital Adrenal Hyperplasia or parent’s with children who have Congenital Adrenal Hyperplasia should be taught to recognize signs of potential stress that may cause an acute adrenal crisis to occur suddenly and unexpectedly. Most people with CAH or parent’s who have children with CAH are advised to give administer an emergency shot of solu-cortef or increase their dose of oral steroid in times of stress. It is important for the individual with Congenital Adrenal Hyperplasia to always carry a medical identification card that states the type of medication and the proper dose needed in case of an emergency. Never delay the increase in oral steroid if Adrenal Crisis occurs. If unable to retain medication or administer such due to vomiting give the injection and notify the health care provider immediately.
When someone with CAH has an adrenal crisis, an intravenous or intramuscular injection of hydrocortisone (an injectable corticosteroid) must be given immediately. The patient will also need the following:
1: Supportive treatment of low blood pressure
2: Hospitalization is required for adequate treatment and monitoring.
3: Low blood pressure may be treated with intravenous fluids.
4: If infection is the cause of the crisis, antibiotic therapy is indicated.
Death may occur due to overwhelming shock if early treatment is not provided. Go to the ER or A & E or call the local emergency services if symptoms of acute adrenal crisis develop.
We can reduce the likelihood of Adrenal Crisis in Congenital Adrenal Hyperplasia by doing the following:
At times where illness is obvious increase the steroid to the recommended double or triple dose immediately. If you have taken a normal dose some hours earlier and become or start to feel ill, immediately take the next dose in double or triple quantity, whichever you feel is appropriate at the time. Then space the other three to four doses equally apart and at the same quantity until the condition improves.
Should the increased dose be vomited back within half an hour of being taken, then this will need to be repeated immediately in the same increased quantity. You cannot overdose when ill, and it is important to increase in such cases. If this is vomited back a second time then you must not delay and an emergency shot of cortisol should be administered immediately. This is generally 50mg in a child under 5 years and 100mg in a child over 5 years. In adults this may be 100-200mg of hydrocortisone or possibly more in the form of Dexamethasone. In ALL cases as soon as the injection has been given, you will need to take the patient to ER or A & E immediately after the shot. In the case of Solu-Cortef this is provided in 100mg per vial. So this means 50ml for an under five yr old and the whole 100ml for an over five year old when drawing off into a syringe.
Always have on hand a letter from yours or your child’s Doctor that gives precise details about what treatment you or your child should be given in an Adrenal Crisis. This will help staff in the Emergency Room to treat immediately without delay. This can be delayed if the staff are trying to obtain second or perhaps third opinions or to reach yours or your child’s Doctor for advice. Time is of the essence.
Wear an ID bracelet such as a Medic Alert bracelet which gives the following information:
It is advisable to have the emblem engraved with the words Adrenal Insufficiency in addition to Congenital Adrenal Hyperplasia because the term Adrenal Insuffiency is far more likely to be recognised in an emergency as someone needing urgent medical attention. It is important to avoid delay in treatment wherever possible.
Treatment recommended and doses in an emergency should also be engraved on such an emblem as this ensures less likelihood of a delay also.
Ensure that you have an emergency kit prepared with the following items in it so that you can have all that you need to hand in any emergency:
It is recommended that you have at least two of all the above items due to breakage or being unsuccessful in giving the shot in the first attempt. I.e. in instances where the vial shatters or other such incident. Keep all of the above in a suitable dark cool place away from direct heat and light and out of the reach of small children. This can also be placed in a small plastic container for when travelling any distance from home or your local Hospital. When any of the supplies are used, always ask for eplacement prescriptions and replenish them. Check the "Use By" dates for the vials and wipes and always replace them just before these dates are up. If you keep an inventory of your medicine cabinet or first aid kit you will be able to check this list 6 monthly for medicines or drugs that have become outdated. This will ensure that you are always well prepared for anything in advance.