IV and blood under the skin

[the_alchemist]

I was orienting with a nurse who was to start IV hydration to one patient. After preparing everything, I came closer to her to observe the insertion. When she hit the vein, there was blood return, i thought to myself wow that was pretty easy! as soon as she started flushing it though, there was a bulge. The patient did not complain of pain or anything. The nurse said it needed to be reinserted. She pulled it out, applied pressure and covered with a piece of gauze. I watched her opened the second needle (which was at the table right next to her), and as soon as we turned to the patient's hand, it was bleeding under her skin and it was fast! she got a tourniquet above the site, apparently to prevent further spreading.

my question is, why did it bleed under her skin? that was a huge hematoma (like the size of my hand and the patient was skinny).. what could have been done to prevent it? any comments?

[mamamerlee, LPN]

If a site is bleeding, APPLY PRESSURE UNTIL YOU ARE CERTAIN THE BLEEDING HAS STOPPED. Where's your basic first aid training? Simply putting a dressing on an infiltrated spot does not stop the bleeding.

If the pt is elderly, or on anticoags, you should monitor the site for a few minutes before trying again.

[Emergency RN]

application of a tourniquet above (or proximal to) the site, which increases venous pressure, will actually force blood to come out faster. you need to lower pressure in the vein by elevation of the wound and removal of the tourniquet and (like stated) apply direct pressure to the wound until hemostasis is achieved.

why the bleeding happened so fast could also be because of a variety of reasons; clot time, pressure in the surrounding subcutaneous tissue, the caliber of the vein, and the mass size of tissue that it drains from. that is, if she had been on an anticoagulant, the vein was very large, returns (drains) blood from a significant amount of tissue, and the patient is so dehydrated that her skin is "tenting" (retains the shape of traction applied to it); then her likely bleeding into a hematoma would be indeed rapid.

[Christy1019, ASN, RN]

If a site is bleeding, APPLY PRESSURE UNTIL YOU ARE CERTAIN THE BLEEDING HAS STOPPED. Where's your basic first aid training? Simply putting a dressing on an infiltrated spot does not stop the bleeding.

If the pt is elderly, or on anticoags, you should monitor the site for a few minutes before trying again.

Excuse me but I believe she posted her question because she wasn't sure and expected us to be respectful and help her to understand the situation. I'm sorry but if I notice another nurse is restarting an IV d/t infiltration, I'm not gonna jump on top of the pt and say "watch out i know basic first aid training, I need to apply pressure to stop the bleeding!" It aggravates me when we forget that we were new nurses at some point too.

Alchemist, I agree with everything emergency RN said.. you won't see that type of reaction with every patient so don't worry but regardless of her age or any other history it has been my experience many times that with dehydrated pts their veins will be flatter and harder to feel (not as bouncy when you feel them), and when you DO find a vein, many times they will blow. Good luck with your orientation, hope your questions were answered.

[marissa795]

This actually happened to me during a routine blood draw... The nurse took out the needle and applied the little gauze but never told me to unclench my fist. The result was pretty much what you described... a huge hematoma that popped out like 5 inches. the bruising lasted for like 2 weeks. Im assuming it is mostly due to the increased venous pressure (from clenching your fist or applying the tourniquet) Maybe she was short-cutting and left the tourniquet on longer than she should have? Personally i would have chosen a different vein altogether.

[the_alchemist]

thank you for your responses... like u said, it couldve been the tourniquet. the pt was really skinny and dehydrated. in fairness to the nurse, she did apply direct pressure. guess it was just the way it was.

and i agree, let's not forget that we were once new nurses. and even with an already admirable amt of experience, we still learn new things along the way. :)

[Lunah, MSN, RN]

Whenever I am removing an IV, I ask the patient (if they're not on something like Coumadin, aspirin, Plavix, etc.) if they tend to bleed a lot. If yes, I hold pressure longer (or ask them to do so). And if they're meds that make them bleedy, we hold pressure even longer than that. :) The vein has to have a chance to close the hole, or you will get bleeding under the skin, and sometimes outside of the skin as well. The hematomas can develop quickly and look mighty ugly.