Hi, this is Dan Moon. I'm an attending physician at Moss Rehab, and for this talk we'll be reviewing procedural considerations for botulinum toxin injections. I do not have any relevant financial relationships to disclose. The objectives of this talk will be to learn how to obtain proper consent and perform a procedure timeout before injecting, review methods for safe handling of medication and the needle, and demonstrate understanding of proper patient positioning during the procedure to ensure patient comfort and safety. When obtaining consent for injections, discuss the indication, risks, benefits, and what to expect from these injections. For botulinum toxin injections, it's also important to mention the black box warning and what is done to prevent serious complications. Answer any questions, address concerns that that may have. Obtain consent from the patient, guardian, or power of attorney. For patients unable to provide consent who are coming from facilities, it may be better to obtain signed consent from the guardian or power of attorney prior to the appointment. Verbal consent over phone should be done as a last resort, and you should check with state regulations before proceeding with this. The black box warning applies to all brands of botulinum toxin and highlight the distant spread of toxin effect. These symptoms have been reported hours to weeks after injection, and include swallowing and breathing difficulties, which can be life-threatening, and there have been reports of death. The risk of symptoms is probably greatest in children treated for spasticity, but they can occur in adults, particularly those who have underlying conditions that would predispose them to these symptoms. It's important to also note that these are very rare, and measures are in place to prevent this from occurring. It is important to perform a procedure timeout immediately before injections. Review indication and what to expect following injections. Note that the patient may feel immediate effect from needling, but assure them that it may take days to weeks to notice effects of toxin. In layman's terms, review the treatment plan with the patient and their guardian, state which toxin brand you will be using, confirm the extremities being treated and why to ensure treatment goals are aligned, confirm patient and guardian consent before proceeding. Question 1. Which of the following should not be part of the procedural timeout? A. Confirmation of limb being treated B. Stating which botulinum toxin brand is being used C. Obtaining consent D. Reviewing indications for treatment The correct answer is C, obtaining consent. Consent should have already been obtained at a prior appointment or before preparation for procedure begins, but not at timeout. However, it is a good practice to confirm consent at timeout in addition to reviewing with the patient indications for treatment, limbs to be treated, expectations of treatment, and the brand of toxin being used. Botox or onobotulinum toxin A, Dysport, abobotulinum toxin A, and zeomin, incobotulinum toxin A are available as vacuum or partial vacuum dried powders. Reconstitute only with sterile non-preserved 0.9% sodium chloride injection, USP. Sterilize the top of the vial with alcohol and use gloves, sterilized needles, and syringes when reconstituting to avoid contamination. Be aware that the vial is under vacuum and should suck in the diluent once the seal is broken. If this does not occur, please do not use that vial. Concentric EMG needles are most commonly used for injections. They vary in length from 25 to 75 millimeters. They're very thin, oftentimes 24 to 30 gauge. A lead wire is offset to minimize signal interference and connects to an EMG electrical stem device. The tip is also a sharpened bevel and can easily go through clothing, even leather. Therefore, it's important to avoid resheathing of the needle during procedure to reduce risk of needle stick. Have at least one assistant available to support in order to operate guidance and assist with limb positioning. Alcohol swabs and gauze should be nearby. If you need to resheathe, use a one-handed technique to reduce risk of needle stick to the other hand, as shown in the figure to your right. It is important to hold the needle by the hub during localization, not with the thumb on the plunger. Stabilize the needle against the surface of the patient to minimize movement once the muscle has been localized and in case the limb moves during the injection. Once the needle is stabilized, use your other hand to push the plunger while providing counterpressure to further minimize needle incursion. This is especially important for small, thin muscles such as in the forearm. The patient should be positioned as comfortably as possible prior to performing injections. The limb to be injected should be supported against a firm surface or held by an assistant. The patient can be seated for upper limb injections, but ideally supine for lower limb injections. If possible, prone or side-lying for posterior lower limb muscles such as the hamstrings and gastrocnemius. The injector should also be comfortable. Raise the patient's bed or chair whenever possible to minimize strain on lower back and neck muscles. Some patients are willing to tolerate some discomfort with positioning if this allows the injector to quickly localize and treat to minimize needle localization time. Question 2. These are all acceptable methods of minimizing inadvertent needle sticks except A. Resheath needle using one-handed technique. B. Holding sheath with control at hand while resheathing the needle. C. Avoidance of resheathing needle during procedure. D. Have assistance readily available to operate guidance and for limb positioning. The correct answer is B. Holding sheath with control at hand while resheathing the needle. The risk of needle stick injury is highest when the needle is pointed at the injector, such as when the sheath is held in one hand while resheathing the needle with the other hand. In summary, discuss indication, risk including black box warning, benefits and what to expect prior to obtaining consent, confirm the treatment plan including indication, limbs treated, brand of toxin, at procedure timeout. Ideally, an assistant should be present during procedure to help with limb positioning and operation of guidance technique. Minimize resheathing of the needle or use a one-handed technique to reduce risk of needle stick injury. Thank you for your attention. Please do not hesitate to email if you have any questions or concerns.

botulinum toxin injections

procedural considerations

patient safety

black box warning

needle stick injury prevention