Statistical estimation of deltoid subcutaneous fat pad thickness: implications for needle length for vaccination.

Current US Centers for Disease Control and Prevention intramuscular injection needle length guidelines for injection fo the deltoid muscle are based on weight and gender. The aims of this study are (1) to evaluate whether other biometric data (age, gender, height, weight and body mass index (BMI)) are better predictors of the thickness of the deltoid subcutaneous fat pad (DSFP) than weight and gender and (2) to evaluate the performance of the CDC weight-based needle length guidelines. This was a retrospective single center cohort study of 386 patients who underwent surveillance PET/CT between 01/01/2020 and 04/01/2021. Patient age, gender, height, weight, BMI and CT measurements of the DSFP were evaluated. DSFP was positively correlated with weight and BMI in men (r = 0.67, P < 0.001; r = 0.74, P < 0.001) and women (r = 0.69, P < 0.001; r = 0.75, P < 0.001) respectively. DSFP was negatively correlated with age in women (r = - 0.19, P = 0.013). Age and BMI were better predictors of DSFP than weight. The best model to predict the DSFP is: [Formula: see text] A 1-inch needle is expected to reach the deltoid in 85.3% of women less than 200 pounds, and 98.6% of men less than 260 pounds. This rate differed between genders (P < 0.001, odds ratio (OR) 0.08, 95% CI (0.02, 0.29)). A 1.5-inch needle is expected to reach the deltoid in 76.7% of women greater than 200 pounds, and 75.0% of men greater than 260 pounds. Current CDC deltoid intramuscular injection needle length guidelines result in women and obese individuals being more likely to receive subcutaneous injections. Age and BMI based guidelines for needle length selection are more accurate.

Re-examining the Optimal Use of Neuromodulators and the Changing Landscape: A Consensus Panel Update

Since initial US Food and Drug Administration approval of botulinum toxin type A (BoNT-A) for aesthetic use in 2002, clinical evidence and experience with BoNT-A and understanding of facial anatomy have greatly increased, leading to rapid advances in treatment planning and implementation. BoNT-A use has expanded from the upper face to the midface, lower face, and neck, so that BoNT-A injection is the most common cosmetic procedure worldwide. Trends in facial aesthetics reflect growing patient diversity with respect to age, gender, and ethnicity. In October 2019, a multidisciplinary panel of 6 experts in minimally invasive injectable procedures in the specialties of dermatology and plastic surgery convened at the 2019 American Society for Dermatologic Surgery (ASDS) meeting in Chicago, IL. Their goal was to discuss recent advances in BoNT-A use in facial aesthetics, including implications of the introduction of new agents in light of an evolving patient population. J Drugs Dermatol. 2020;19(4 Suppl 1):s5-15 To receive a CME certificate of participation, you should: •Read the entire publication, including the CME information. •Register or log in at www.paradigmmc.com/822 to complete and submit the online posttest and evaluation. Following online completion of the posttest and evaluation, a certificate of participation will be available for download/printing immediately.

Effect of Intranasal vs Intramuscular Naloxone on Opioid Overdose: A Randomized Clinical Trial.

Importance: Previous unblinded clinical trials suggested that the intranasal route of naloxone hydrochloride was inferior to the widely used intramuscular route for the reversal of opioid overdose. Objective: To test whether a dose of naloxone administered intranasally is as effective as the same dose of intramuscularly administered naloxone in reversing opioid overdose. Design, Setting, and Participants: A double-blind, double-dummy randomized clinical trial was conducted at the Uniting Medically Supervised Injecting Centre in Sydney, Australia. Clients of the center were recruited to participate from February 1, 2012, to January 3, 2017. Eligible clients were aged 18 years or older with a history of injecting drug use (n = 197). Intention-to-treat analysis was performed for all participants who received both intranasal and intramuscular modes of treatment (active or placebo). Interventions: Clients were randomized to receive 1 of 2 treatments: (1) intranasal administration of naloxone hydrochloride 800 µg per 1 mL and intramuscular administration of placebo 1 mL or (2) intramuscular administration of naloxone hydrochloride 800 µg per 1 mL and intranasal administration of placebo 1 mL. Main Outcomes and Measures: The primary outcome measure was the need for a rescue dose of intramuscular naloxone hydrochloride (800 µg) 10 minutes after the initial treatment. Secondary outcome measures included time to adequate respiratory rate greater than or equal to 10 breaths per minute and time to Glasgow Coma Scale score greater than or equal to 13. Results: A total of 197 clients (173 [87.8%] male; mean [SD] age, 34.0 [7.82] years) completed the trial, of whom 93 (47.2%) were randomized to intramuscular naloxone dose and 104 (52.8%) to intranasal naloxone dose. Clients randomized to intramuscular naloxone administration were less likely to require a rescue dose of naloxone compared with clients randomized to intranasal naloxone administration (8 [8.6%] vs 24 [23.1%]; odds ratio, 0.35; 95% CI, 0.15-0.66; P = .002). A 65% increase in hazard (hazard ratio, 1.65; 95% CI, 1.21-2.25; P = .002) for time to respiratory rate of at least 10 and an 81% increase in hazard (hazard ratio, 1.81; 95% CI, 1.28-2.56; P = .001) for time to Glasgow Coma Scale score of at least 13 were observed for the group receiving intranasal naloxone compared with the group receiving intramuscular naloxone. No major adverse events were reported for either group. Conclusions and Relevance: This trial showed that intranasally administered naloxone in a supervised injecting facility can reverse opioid overdose but not as efficiently as intramuscularly administered naloxone can, findings that largely replicate those of previous unblinded clinical trials. These results suggest that determining the optimal dose and concentration of intranasal naloxone to respond to opioid overdose in real-world conditions is an international priority. Trial Registration: anzctr.org.au Identifier: ACTRN12611000852954.

Comparison of antibody titres between intradermal and intramuscular rabies vaccination using inactivated vaccine in cattle in Bhutan.

In developing countries, the cost of vaccination limits the use of prophylactic rabies vaccination, especially in cattle. Intradermal vaccination delivers antigen directly to an area with higher number of antigen-presenting cells. Therefore, it could produce equivalent or higher antibody titres than conventional intramuscular vaccination even when a lower dose is given. This study aimed to compare the antibody response in cattle vaccinated intramuscularly with 1mL of inactivated rabies vaccine (Raksharab, Indian Immunologicals) against intradermally vaccinated cattle with 0.2mL of the same vaccine. The study was conducted in Haa province of Bhutan where rabies is not endemic. One hundred cattle from 27 farms were selected for the study. Virus neutralising antibody (VNA) response was measured using the fluorescent antibody virus neutralisation test on the day of vaccination (day 0) and 14, 30, 60 and 90 days later. Overall, 71% of intradermally vaccinated cattle and 89% of the intramuscularly vaccinated cattle produced an adequate response (≥0.5IU/mL). On days 14 and 30 post vaccination fewer cattle (P<0.02) in the intradermal group had adequate titres with 36% and 58%, respectively, having titres ≥0.5 IU/mL compared to the equivalent figures of 78% and 77% in the intramuscular group. The mean VNA titres were lower for the intradermal group than intramuscular group (p<0.001) with the mean difference being > 0.6 IU/mL. Although low dose intradermal vaccination did produce a detectable antibody response, it was inferior to intramuscular vaccination. Thus, although intradermal vaccination has the potential to reduce the cost of vaccination by reducing the dose required, this study showed that a single dose of 0.2 mL intradermally was inferior to an intramuscular dose of 1 mL. Further research evaluating dose and dose regimen is needed before intradermal vaccination using the Raksharab rabies vaccine can be recommended in cattle.

Consideration of Muscle Depth for Botulinum Toxin Injections: A Three-Dimensional Approach.

Knowledge of variable anatomy is key for excellent outcomes from the administration of botulinum toxin for aesthetic purposes. One must understand the location and function of each facial muscle to predict the patient's desired outcome. One concept often overlooked by injectors is the understanding of the target muscle's depth. In addition, a firm understanding of where each facial muscle originates and attaches can be essential to correctly identifying and injecting the correct muscle with botulinum toxin. Facial muscles often overlap each other and cross various planes. For example, an injector may be unaware that the corrugator supercilii muscle lies in different depths medially and laterally. Novice injectors may miss the variability of this muscle and inject the lower frontalis muscle by mistake. This may lead to a heavy brow look, or it could drop the area between the brows, creating an appearance of anger. This article explores a three-dimensional anatomical approach to achieve excellent outcomes, rather than the two-dimensional approach traditionally discussed. Many of the injection techniques defined in this article are considered off-label by the Food and Drug Administration at the time of this publication but are commonly discussed in peer-reviewed literature and consensus opinion reports. Twelve facial muscles often injected for positive aesthetic outcomes will be outlined as well as seven facial muscles to generally avoid.

Nurses' Use of Appropriate Needle Sizes When Administering Intramuscular Injections.

BACKGROUND: In cases where patients are overweight or obese, administration of intramuscular medications can be ineffective due to inappropriate sizes of needles used. This study investigated whether the size of needles used to administer intramuscular injections is appropriate for patients on the basis of their weight or body mass index. METHOD: This retrospective review examined 100 instances of intramuscular injection on a 50-bed ward. RESULTS: In most instances, intramuscular medication was inappropriately administered. Needle sizes were not determined based on body mass index, and the possibility of true intramuscular penetration was minimal. Appropriate needle sizes were more likely to be chosen when instructions were provided with medications. CONCLUSION: Current available needle sizes may be inappropriate for certain patients. Nursing staff require further education to assist them in making correct needle choices. It is also important that health care settings have evidence-based policies in place and the necessary resources provided to ensure safe and correct administration of medication. J Contin Educ Nurs. 2018;49(11):519-525.

Adrenaline in the Acute Treatment of Anaphylaxis.

BACKGROUND: Anaphylaxis is the most serious manifestation of an immediate allergic reaction and the most common emergency event in allergology. Adrenaline (epi- nephrine) is the mainstay of acute pharmacotherapy for this complication. Although epinephrine has been in use for more than a century, physicians and patients are often unsure and inadequately informed about its proper administration and dosing in everyday situations. METHODS: This review is based on pertinent publications from the period 1 January 2012 to 30 September 2017 that were retrieved, on the basis of the existing guide- lines of 2007 and 2014, by a PubMed search employing the keywords "anaphylaxis treatment," "allergic shock," "adrenaline," and "epinephrine," as well as on further ar- ticles from the literature. RESULTS: Adrenaline/epinephrine administration often eliminates all manifestations of anaphylaxis. The method of choice for administering it (except in intensive-care medicine) is by intramuscular injection with an autoinjector; this is mainly done to treat reactions of intermediate severity. The injection is given in the lateral portion of the thigh and can be repeated every 10-15 minutes until there is a response. The dose to be administered is 300-600 µg for an adult or 10 µg/kg for a child. The risk of a serious cardiac adverse effect is lower than with intravenous administration. There have not been any randomized controlled trials on the clinical efficacy of ephi- nephrine in emergency situations. The use of an autoinjector should be specially practiced in advance. CONCLUSION: The immediate treatment of patients with anaphylaxis is held to be ad- equate, yet major deficiencies remain in their further diagnostic evaluation, in the prescribing of emergency medications, and in patient education. Further research is needed on cardiovascular involvement in anaphylaxis and on potential new thera- peutic approaches.

Intramuscular injection CLIMAT pathway: a clinical practice guideline.

The intramuscular (IM) injection has been part of nursing practice since the 1960s. Over the past 60 years, the practice of aspiration during IM injection has been controversial and understudied. In 2016, a study by Thomas et al identified that blood aspiration does occur during injection. This article introduces a clinical practice guideline for safe and effective aspiration during IM injection, as a follow-up to the findings of that study. The proposed guideline acknowledges the correct practice of aspiration and identifies considerations that may make aspiration unnecessary. These practices and considerations are presented to the reader using a visual clinical pathway and a narrative clinical practice guideline.

Treatment of Gastrocnemius Muscle Hypertrophy with Botulinum Toxin Injection Followed by Magnetic Resonance Imaging Assessment and 3-Dimensional Evaluation.

BACKGROUND: Hypertrophy of the gastrocnemius muscle is considered to be a hindrance to lower leg beauty in the Asian aesthetic market. A noninvasive technique that has been gaining recognition involves botulinum toxin A injection; however, there are no proper guidelines or standardized protocols for the administration of botulinum toxin to correct gastrocnemius hypertrophy. OBJECTIVES: This study sought to determine the most effective botulinum toxin injection method for correcting the contour of the lower leg calf, as well as to determine the dose that can produce the maximum effect in meeting the demands of the physician and patient. METHODS: Eighteen female patients aged between 18 and 35 years were enrolled in this study from January 2015 to July 2015. Two injection methods were compared: (I) 48 injection points with a distance of 2 cm between every point; and (II) 10 injection points. Magnetic resonance imaging examinations were conducted at baseline prior to treatment and at one month and 6 months after treatment. A 3-dimensional study was performed to analyze the volumetric changes. RESULTS: The most effective and significant treatment method for hypertrophic gastrocnemius muscle was the 48-point method (scattering injection). Following injection, this method exhibited a significant level of satisfaction with outcome. CONCLUSIONS: Our study reveals that injection dosage and method have a strong relationship with achieving a better contouring result. LEVEL OF EVIDENCE: 3.

Investigation of suitability of ventrogluteal site for intramuscular injections in children aged 36 months and under.

PURPOSE: This study was performed to determine suitability of ventrogluteal (VG) site for intramuscular (IM) injections in children aged 36 months and under. DESIGN AND METHODS: The present study was designed as a prospective descriptive study and performed between 2016 January and June. The study included a total of 120 children aged 36 months and under that met the study criteria. The subcutaneous tissue thickness and muscle thickness of anterolateral, deltoid, and VG sites were measured and assessed by ultrasound. RESULT: A strong and powerful correlation was identified between the measurements of subcutaneous tissue and muscle thicknesses in the injection site by the age groups. The thickness of subcutaneous tissue was deltoid < anterolateral < VG by age groups. The muscle thickness of anterolateral and VG sites was significantly higher than that of deltoid site. PRACTICE IMPLICATIONS: This study established that skin thickness of VG site was suitable for IM injection in children aged 36 months and under.

Taking the alternative route: Women's experience of intranasal fentanyl, subcutaneous fentanyl or intramuscular pethidine for labour analgesia.

OBJECTIVE: To compare women's experience of receiving either intranasal fentanyl, subcutaneous fentanyl or intramuscular pethidine for labour analgesia. DESIGN: A content analysis was undertaken as part of the third phase of a larger randomised controlled trial, using the per-protocol dataset to examine women's experiences of treatment received. Healthy women birthing at term, who received intranasal fentanyl (n=41), subcutaneous fentanyl (n=37) and/or intramuscular pethidine (n=38) for labour analgesia, were contacted at 6 weeks postpartum to complete a phone questionnaire. SETTING: A tertiary and regional maternity unit in South Australia. FINDINGS: Over 80% of women who received intranasal or subcutaneous fentanyl reported that they would use the treatment again compared to 44.8% of women who had received pethidine (self-administered intranasal fentanyl provided more expressive responses emphasising the route provided a strong sense of control and enablement. KEY CONCLUSIONS: Route of administration influenced the women's experience, more women who self-administered intranasal fentanyl reported positive emotional responses, with women reporting increased autonomy and satisfaction. Whereas, women who relied on the midwife to administer subcutaneous fentanyl or intramuscular pethidine, were more often focused on the physical effect of the drug. Pethidine was the least preferred option due to adverse effects. IMPLICATIONS FOR PRACTICE: For women requesting parenteral analgesia, fentanyl administered by less invasive routes offers women additional options that may better meet their emotional, cognitive and physical needs than the current practice of administering intramuscular pethidine.

The Practical Use of AbobotulinumtoxinA in Aesthetics.

Botulinum toxin (BoNT) has been approved for aesthetic use since 2002. Since then, clinical studies and expert use have informed our understanding of how BoNT exerts its clinical effect and the practical use of this product across a number of aesthetic applications. This review discusses the clinical properties and characteristics of abobotulinumtoxinA, which patients are suitable for its use, and how it can be utilized to treat facial rhytides.

Insights into the Functional Anatomy Behind the PREEMPT Injection Paradigm: Guidance on Achieving Optimal Outcomes.

OBJECTIVE: To provide clinically relevant insights on the identification of the muscles and techniques involved in the safe and effective use of onabotulinumtoxinA for chronic migraine prophylaxis. BACKGROUND: Although guidance on the use of onabotulinumtoxinA for chronic migraine is available, based on the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) clinical program, clinical experience has shown that insufficient understanding of the anatomy and function of the head and neck muscles may lead to undesirable outcomes and suboptimal efficacy. DESIGN/METHODS: Each muscle involved in the standardized PREEMPT injection paradigm is reviewed with a thorough description of each muscle's anatomy (ie, muscle description and location, innervation, vascular supply) and function. Key insights based on clinical experience are also provided to help improve outcomes. RESULTS: The identification of the muscles in the PREEMPT injection paradigm should be based on each patient's unique anatomy and injections should be administered using the advised techniques. A thorough examination of the patient prior to treatment is also critical to determine if any preexisting conditions may increase the risk for unwanted outcomes and appropriate expectations should be communicated. CONCLUSIONS: Thorough knowledge of the functional anatomy of the muscles involved in the standardized PREEMPT injection paradigm is critical to achieve the efficacy and safety observed in clinical trials. In addition, it is important to assess a patient's baseline condition to anticipate the risk for unwanted outcomes that may result from treatment.

A systematic review of patients', parents' and healthcare professionals' adrenaline auto-injector administration techniques.

INTRODUCTION: In order to enable fast treatment response to anaphylactic reactions, adrenaline auto-injectors (AAI) have been developed and manufactured. It has been reported in several studies that administration technique is suboptimal. The primary purpose of this study was to review the nature and extent of the deficiencies in administration technique among patients, parents/caregivers and healthcare professionals. METHODS: Relevant publications were identified between 1998 and 2015 using two search methods: a keyword search in Embase, PubMed, British Nursing Index and Cumulative Index to Nursing and Allied Health Literature and a search of reference lists of relevant articles. RESULTS: Twenty-three studies met the inclusion criteria. Overall, 37% of patients, 32% of parents/caregivers and 21% of healthcare professionals demonstrated correct administration technique. For studies which employed a before-and-after training study design, correct technique was achieved in 77% of patients, 79% of caregivers and 65% of healthcare professionals. The most consistently observed error was the failure to hold the device in place for the recommended time. For patients, factors associated with good technique were being aged over 18 years, trained in AAI administration by an allergist, prescribed an AAI for more than 30 months, having a history of severe anaphylaxis and membership of a support group. For parents/caregivers in addition to those mentioned, being given a training device with which to practice, improved technique. DISCUSSION: There was wide variation in administration techniques reported. However, studies designed using before-and-after training show that even a brief demonstration and educational intervention can improve technique. Further studies are required to design and pilot acceptable and cost-effective educational materials.

Inyección ecoguiada del músculo piriforme. Un nuevo abordaje / Ultrasound-guided piriformis muscle injection. A new approach

El síndrome piriforme es una causa poco frecuente de dolor de espalda y miembros inferiores. Algunas de las opciones de tratamiento incluyen la inyección del músculo piriforme con anestésicos locales y corticoides. Se han descrito varias técnicas de inyección. Las técnicas ecoguiadas permiten la visualización directa del músculo y la inyección en tiempo real. Se presenta una serie de 5 pacientes cuya clínica es compatible con síndrome piriforme, que no han mejorado tras tratamiento farmacológico. Se optó por la inyección del músculo piriforme con anestésicos locales y corticoides mediante un nuevo abordaje ecoguiado más sencillo técnicamente, basado en la técnica estándar. En los 5 pacientes se apreció una mejoría del dolor medido por la escala verbal numérica tras la inyección. Solo en un caso se presentó como complicación una ciatalgia que mejoró espontáneamente en 10 días. En los demás pacientes no se observaron complicaciones tras la inyección. Se describe una variante de la técnica ecoguiada recomendada en la inyección del músculo piriforme, más sencilla de realizar, con un buen perfil de seguridad y con buenos resultados clínicos (AU)

Piriformis syndrome is an uncommon cause of buttock and leg pain. Some treatment options include the injection of piriformis muscle with local anesthetic and steroids. Various techniques for piriformis muscle injection have been described. Ultrasound allows direct visualization and real time injection of the piriformis muscle. We describe 5 consecutive patients, diagnosed of piriformis syndrome with no improvement after pharmacological treatment. Piriformis muscle injection with local anesthetics and steroids was performed using an ultrasound technique based on a standard technique. All 5 patients have improved their pain measured by numeric verbal scale. One patient had a sciatic after injection that improved in 10 days spontaneously. We describe an ultrasound-guided piriformis muscle injection that has the advantages of being effective, simple, and safe (AU)

WHO guideline on the use of safety-engineered syringes for intramuscular, intradermal and subcutaneous injections in health care settings / Lignes directrices de l'OMS sur l'utilisation de seringues sécurisées pour les injections intramusculaires, intradermiques et sous-cutanées dans les structures de soins

Injections are one of the most common health care procedures. Every year at least 16 billion injections are administered worldwide. The vast majority around 90% are given in curative care. Immunization injections account for around 5% of all injections, with the remaining covering other indications, including transfusion of blood and blood products, intravenous administration of drugs and fluids and the administration of injectable contraceptives. This guideline provides global, evidence-based recommendations on the use of safety-engineered injection devices to prevent the re-use of syringes and/or prevent needle-stick injuries in health care workers (HCWs). The ultimate aim is to make injection practices safer for patients and HCWs, and to prevent the injection-related transmission of deadly viruses, particularly HIV, hepatitis C and hepatitis B. The procedures covered are intramuscular (IM), intradermal (ID) and subcutaneous (SC) injections, including the syringes needed for the reconstitution of medication or vaccines when required.

Les injections font partie des procédures de soins les plus courantes. Chaque année, au moins 16 milliards d'injections sont administrées dans le monde, dont la grande majorité (environ 90 %) à des fins thérapeutiques. La vaccination représente environ 5 % des injections et les 5 % restants concernent la transfusion de sang et de produits sanguins, l'administration de médicaments et de liquides par voie intraveineuse et l'administration de contraceptifs injectables. Ces lignes directrices présentent des recommandations générales s'appuyant sur des preuves relatives à l'utilisation de matériel d'injection sécurisé afin d'empêcher la réutilisation des seringues et/ou de prévenir les accidents dus à des piqûres d'aiguille chez les agents de santé. L'objectif ultime est de réduire le plus possible les risques associés aux pratiques d'injection, tant pour les patients que pour les agents de santé, et d'éviter la transmission de virus mortels, en particulier le VIH, l'hépatite C et l'hépatite B. Ces lignes directrices couvrent les procédures suivantes : injections intramusculaires (IM), intradermiques (ID) et sous-cutanées (SC), y compris les seringues utilisées pour la reconstitution de médicaments ou de vaccins.

Administering intramuscular injections: how does research translate into practice over time in the mental health setting?

BACKGROUND: Increasingly, mental health nurses are expected to base their clinical practice on evidence based knowledge and many of the practice traditions that have passed between generations of nurses must now be examined within this scientific context. Since 2000, there has been an increasing debate on what is best practice for the administration of intramuscular injections particularly in relation to site selection, needle size and technique. Weight gain associated with second generation long acting antipsychotics influences the site and needle size for effective medication delivery. AIM: To determine intramuscular injecting practice choices made by nurses working in the mental health setting in 2006 compared to those made by a similar group of nurses in 2012. METHODS: A descriptive cross sectional study conducted across two time points: 2006 (93 participants) and 2012 (245 participants) utilising the same questionnaire designed to measure nurses' intramuscular injecting practice choices. RESULTS: Data were analysed using SPSS version 20 package. Six statistically significant practice changes were recorded related to needle size, site selection and the use of the Z-tracking technique. A continued higher usage of the dorsogluteal site was also reported in 2012 contrary to the recommendations in the current research for the ventrogluteal site. CONCLUSION: Whilst some practice changes occurred, translation of research into evidenced based practice is challenging and definitive best practice in the administration of intramuscular injections remains unclear. Education and randomised controlled trials are needed to provide the evidence to ensure the delivery of safe and effective intramuscular injecting practice.

Guiding intramuscular diaphragm injections using real-time ultrasound and electromyography.

INTRODUCTION: We describe a unique method that combines ultrasound and electromyography to guide intramuscular diaphragm injections in anesthetized large animals. METHODS: Ultrasound was used to visualize the diaphragm on each side of spontaneously breathing, anesthetized beagle dogs and cynomolgus macaques. An electromyography (EMG) needle was introduced and directed by ultrasound to confirm that the needle entered the muscular portion of the diaphragm, and methylene blue was injected. Injection accuracy was confirmed upon necropsy by tracking the spread of methylene blue. RESULTS: All methylene blue injections were confirmed to have been placed appropriately into the diaphragm. CONCLUSIONS: This study demonstrates the feasibility and accuracy of using ultrasound and EMG to guide injections and to reduce complications associated with conventional blind techniques. Ultrasound guidance can be used for clinical EMG of the diaphragm. Future applications may include targeted diaphragm injections with gene replacement therapy in neuromuscular diseases.