baby with strange bruising from tourniquet

[stunner127]

The other day I saw something strange and I was wondering if anyone here has seen anything like this before and can give me any info.

The patient was a baby in the ER. A nurse had placed an IV on the previous shift and IV fluids were infusing. I went in to assess the patient, unwrapped the arm to check the IV site and noticed the entire arm where the IV was was a purplish red color and there was a ring of petechiae on the upper arm where I assume the tourniquet had been placed. The discoloration went all the way down the arm and there was definitely a really defined line between the normally colored skin and the discolored skin. There was no infiltrate and no tourniquet was left on the arm. There was good capillary refill, a strong radial pulse and his hand was warm. It looked awful and the mom was really upset. The entire arm looked like one big bruise.

Of course I had the doc come in and check it out and he had never seen anything like that either. Does this happen when the tourniquet is left on too long or is applied too tightly? Are babies particularly vulnerable? I have never seen this before even on patients who have mistakenly had tourniquets left on them for an hour or more. Does elevating the arm or applying cold or heat help in this type of situation? Should I have d/c'd the IV (it was flushing fine and the doc said it was ok to leave it). Any info would be appreciated especially on how to prevent this!

[morte, LPN, LVN]

hm... dont do babes myself, but i wonder about a Vit K def?

[Jolie, BSN]

How old was the baby, how fat, and how much did he weigh?

I worked in NICU and quickly got out of the habit of using tourniquets at all because they caused more problems than they solved. A standard tourniquet is far too wide, and capable of producing too much pressure on the baby's arm or leg, which can injure the skin (bruising, petechiae). I also personally found that veins tend to "blow" when a tourniquet is used.

My suggestion is to have a second person (You need a helper to hold the baby anyway.) restrain the extremity, and apply gentle pressure in lieu of a tourniquet. In my experience, this prevents skin injury and lessens the chance of "blowing" the vein. If a tourniquet is needed, tie a couple of rubberbands together, and don't apply it too tightly.

If the baby shows no other signs of a bleeding disorder, I would probably attribute the discoloration to trauma from the IV start. As long as the site is monitored closely, I believe it is OK to use it for the short term. But be aware that discoloration that may signal an infiltrate will be difficult to observe, so the IV will have to be pulled at the first sign of trouble.

[iluvivt, BSN, RN]

I absolutely would have discontinued that site immediately. Babies are at increased risk for infiltration and extravasation injuries. Any extravastion in an infant or small child needs immediate intervention. It sounds like an adult tourniquet was used and it was too tight-----then when the vein was accessed blood escaped and or subsequently leaked from the hole made to get into the vein. The other thing that could have happened is that there was a through and through puncture of the vein and the nurse was able to get back into the vein. Or maybe multiple attempts were made near the insertion site causing leakage from the vein. The collection of blood in that tissue in some cases could be enough to cause nerve injury and compartment syndrome. When in doubt take it out no matter what the doctor says. You asked the doctor----but did he write his or her assessment and the time checked in the medical record---I bet not----and they probably will not remember in court that they said it was OK to use

[kt82]

i have an alderly patient who has an unexplained bruise, i found her vest arm was too tight and was around the area where the bruise was she also leaens upon this arm, is this similar situation?

[Rob72, ASN, RN]

Could be any of the above. Nursing school doesn't "waste time" on such "mundane" skills as venipuncture.:icon_roll A tourniquet should lightly compress the skin, and never requires the slingshot-pulling motions frequently seen. Extravasation is also possible (I sincerely hope not!).

Me- an old NICU/PICU phleb...