10.3 Integumentary Injuries

IV Infiltration and Extravasation

Children's veins are small, mobile, and often hidden under chubby subcutaneous tissue. Infiltration is leakage of a non-vesicant into soft tissue; extravasation is leakage of a vesicant capable of blistering, necrosis, or compartment-level injury. Both are nursing-sensitive events heavily tested on the Pediatric CCRN because early recognition saves limbs and prevents OR debridement.

High-Risk Infusates

Vesicants and irritants common in the PICU include calcium chloride/gluconate, potassium chloride concentrates, vasopressors (norepinephrine, dopamine, epinephrine), sodium bicarbonate, certain antibiotics, parenteral nutrition with high osmolarity, and chemotherapeutic agents. Peripheral vasoactive infusions raise extravasation risk — prefer central access when infusions will be prolonged or concentrated, and never ignore pump occlusion alarms.

Recognition and Immediate Actions

Warn signs: swelling, blanching or coolness, pain or unexplained agitation (infants cannot localize), damp dressing, slowed drip despite open clamps, and skin that looks taut or mottled distal to the site. Compare limb circumference and color to the opposite side.

Stop the infusion immediately but do not automatically yank the catheter — aspirate residual drug through the cannula if protocol allows, then remove. Elevate the limb, mark the border of erythema/swelling with a pen and time stamp, notify the provider, and photograph per policy. Specific antidotes (for example hyaluronidase for many non-vasoactive extravasations; phentolamine for catecholamine extravasation in some protocols) are time-sensitive — know your unit's kit location. Plastic surgery or wound consult is indicated for progressive blanching, blistering, delayed capillary refill, or concern for compartment syndrome (pain out of proportion, tense compartment, neurovascular change).

Hourly site checks on continuous infusions, transparent dressings, and avoiding joints for high-risk drugs are prevention pillars. Scalp and foot IVs in infants need extra scrutiny.

Pressure Injury in Critically Ill Children

Pediatric pressure injuries frequently form under medical devices, not only on the sacrum. Endotracheal tube tape, nasally applied NIV interfaces, tracheostomy flanges, pulse-oximeter probes, arterial-line boards, cervical collars, EEG leads, and ECMO cannulae all create focal pressure and moisture.

Staging (Never Reverse-Stage)

• Stage 1: Intact skin, non-blanchable erythema.
• Stage 2: Partial-thickness loss; shallow open ulcer or intact serum-filled blister.
• Stage 3: Full-thickness skin loss; subcutaneous fat may be visible; no exposed bone/tendon/muscle.
• Stage 4: Exposed fascia, muscle, tendon, ligament, cartilage, or bone.
• Deep tissue pressure injury: Intact or blistered skin with persistent deep red, maroon, or purple discoloration.
• Unstageable: Base obscured by slough or eschar.

As wounds heal, document improvement but keep the original deepest stage in the record ("healing Stage 3"), never down-stage to Stage 2.

Prevention That Actually Works in PICU

Reposition the child on a schedule appropriate to hemodynamic stability, offload heels, float occiputs in infants (watch positional plagiocephaly versus pressure), rotate pulse-ox sites every few hours, and cushion device edges. Moisture from saliva, sweat, and diarrhea softens skin — barrier creams and timely linen changes matter. Nutrition (protein, calories, micronutrients) and adequate cardiac output are physiologic prevention; the best mattress cannot overcome untreated shock.

Stable, dry heel eschar in a non-infected, adequately perfused child is often left intact as a biologic cover while pressure is removed — do not dig it off "to stage" the wound.

Skin Failure From Hypoperfusion

When cardiac output or SVR collapses, skin becomes an early casualty. Mottling, prolonged capillary refill, cool extremities, and livedo appear before frank ulceration. Hypoperfusion-related skin failure can progress within hours over knees, buttocks, and ears despite turning schedules because the problem is oxygen delivery, not "nurse forgot to turn." Document perfusion status alongside skin findings, escalate vasoactive/volume management, and avoid blaming staging language that implies pure pressure when the physiology is ischemic.

Purpura fulminans and meningococcemia produce rapidly progressive purpuric necrosis — these are infectious/thrombotic emergencies, not ordinary pressure injuries. Differentiate by systemic toxicity, spreading purpura, and coagulopathy.

Wounds: Matching Dressing to Goal

Open surgical wounds, gastrostomy sites, tracheostomy stomas, and traumatic lacerations need moist wound healing unless a specific dry protocol applies (for example some chest-tube sites). Choose dressings that manage exudate without desiccating granulation tissue. Infected wounds show increasing pain, erythema, purulence, fever, or leukocytosis — culture when infection is suspected and remove necrotic burden per wound-team guidance.

For burn-adjacent or friction wounds in restrained children, prevent shearing during turns (lift, do not drag). Keep diapered skin clean; candidal intertrigo needs antifungal barrier strategies, not escalating steroid creams alone.

Documentation and Exam Traps

The exam loves device-related injury and extravasation sequences. If a question describes blanching around a calcium infusion, the first action is stop the infusion, not apply a warm pack and reassess in an hour. If purple intact skin appears over a heel after prolonged boarding, call it deep tissue injury, not Stage 1 erythema. If a child in cold shock develops sacral breakdown overnight, address perfusion while you treat the wound.

Integumentary care is inseparable from renal and perfusion chapters: edema from AKI macerates skin, uremia delays healing, and steroids or immunosuppression after transplant raise infection risk in every open site. Think whole-child, not "just a dressing change."