A Case of Mistaken Identity

This month’s column begins with a case report.

Wound, Ostomy, and Continence Nursing consulted on the case of a 7-month-old male admitted to the pediatric intensive care unit (ICU) secondary to respiratory deterioration. Results of a rhinovirus/enterovirus respiratory viral panel were positive. History was complex due to Down syndrome, repair of a congenital atrioventricular defect, and pulmonary artery banding. Due to a lack of reserve and recovery from cardiac surgery, this viral illness precipitated prolonged respiratory decompensation that required extensive support. Figure 1 shows the wound noted by the bedside nurse on the day of consultation.

Neither the nurse caring for the patient nor the patient’s mother knew when and how this wound originated. The bedside nurse reviewed documentation from the medical and nursing teams from the present to 1 week prior and did not find any entries describing skin breakdown. A wound nurse consulted on further care and the potential etiology of the injury. The only new information she obtained was that there had been a peripheral intravenous line (PIV) on the medial malleolus area that was removed 3 days prior.

DIFFERENTIAL DIAGNOSIS

Untreated or missed extravasation injury. The wound site did not align precisely with the PIV site, but extravasation soft tissue damage does not always happen at the site of PIV entry. It would be unfortunate to miss early signs of extravasation that would lead to such injury. Depending on the scale/classification used, this wound would probably qualify as stage 3 or 4 or severe extravasation. Such wounds typically present with blanching, blisters, swelling, and tightness, as well as likely non-flushing PIV and signs of pain and discomfort. There was no documentation supportive of untimely PIV removal. If the etiology of this injury was extravasation, an opportunity for timely treatment with hyaluronidase and potential wound prevention had been missed.

Pressure injury (PI). The initial inclination of the nursing staff was to label this as a PI. Generally, this was not an unreasonable consideration. However, the PI source was unknown. Staff often place ID bands on young patients’ extremities, and the presence of an ID band could have caused friction from the edge of the band, injuring the skin. Monitoring devices, such as a pulse oximeter, also could have caused prolonged pressure on the area and led to a PI. Injury from a PIV stabilizing board or PIV connecting hub could have contributed as well. However, the most likely scenario, in this case, was the presence of the pulse oximeter. The concerning point was the absence of any documentation on the evolution of the wound. The initial skin changes, whatever they were, were not captured, nor was the wound progression trajectory.

Medical adhesive–related skin injury. Superficial epidermal skin-stripping progressing to a deeper wound was entertained because of the history of PIV, likely tape securement, and use of a pulse oximeter. Removal of any adhesive device has a theoretical risk for epidermal stripping.

Congenital cutaneous disorders (eg, epidermolysis bullosa, ichthyosis variants). In this case, such disorders were unlikely given prior unremarkable skin examination results, including at birth, and presence of one lesion only.

Infectious etiology: viral (herpes simplex virus)/fungal/bacterial. The team did not think that infectious etiology was likely after chart review. There was no documentation of skin swelling, exudate, erythema, warmth, or other findings consistent with preceding cellulitis or abscess. Unfortunately, as we all know, “absence of evidence is not evidence of absence.” I believe this case illustrates the common challenge that many practitioners face with daily documentation misses, reflecting lack of time to chart, excessive workload, and under-recognition of the importance of a thorough cutaneous examination in the ICU.

Trauma. This was unlikely given that the child was non-ambulatory and the physical location of the wound.

Thermal iatrogenic injury. The causes of iatrogenic thermal injuries in patients of this age vary. They include defective transillumination devices, infrared heating lamps placed too close to the child’s surface, certain phototherapy devices (mostly in neonates), tap water burns, and warming compresses. Most of these causes are not pertinent at 7 months of age, with the exception of the transillumination devices and burns from hot compresses.

ETIOLOGY

Another in-depth review of the patient’s daily devices history revealed that a vascular team had difficulty placing the PIV and used a pocket vein-finder flashlight to look for potential sites. The size of the flashlight corresponded closely to the wound. The team remembered looking in the area involved and keeping the light on the skin for at least 2 minutes for continued transillumination. The light in the device was advertised as cold light. However, the flat surface did get warm after 3 continuous minutes of exposure. This could have caused a burn to sensitive pediatric skin.

Wound treatment then consisted of medical-grade honey applied once a day and a silicone atraumatic dressing. Figure 2 shows the wound after 3 days of honey application.

DISCUSSION

Transillumination is an effective means of localizing arteries and veins for blood sampling and has been used in pediatrics for more than 50 years. Transillumination can be performed using high-intensity fiberoptic light, a light-emitting diode (LED) device, or white and yellow incandescent light, all incorporated into specific vein-finders or pocket-based flashlights. Many thermal burns caused by transilluminators were reported in the 20th century.¹ However, numerous safety precautions now make these burns uncommon.

Safety issues have been attributed to prolonged surface contact with the skin, excessive brightness of the light, incorrect placement of filters on the transilluminator (in the OFF position), non-replacement of heat-absorbing glass, and use of pocket flashlights that become hot very fast and to a much higher temperature.^2-4 Uy et al⁵ demonstrated the importance of light filtration in reducing thermal burns during transillumination almost 50 years ago. They postulated that specific wavelengths of photoelectric energy are converted to heat energy in the skin and may be responsible for thermal damage. This work demonstrated that peak absorbency of transilluminator light was consistent among skin types and was located at around 410 nm. A filter that eliminated light with wavelengths less than 570 nm only mildly decreased the transillumination effect clinically but markedly decreased skin heating and the risk of burn. Contemporary models use cold light, but there are still reports of burns if there is prolonged contact with the skin. The literature cautions against prolonged skin contact (longer than 30 seconds of continuous application) and recommends self-testing the device for at least 30 seconds.^3,4

Characteristically, thermal burn lesions present as discrete vesicles with necrotic bases, found in acral locations adjacent to common venous access locations such as the proximal palm, olecranon, and lateral malleoli. Others appear as erythematous papules with erosions, progressing to denuded areas, often with a necrotic base.³

In the author’s experience, transillumination with cold light flashlights can cause significant injuries. Three (3) years ago, many of our neonatal ICU providers bought 3 different models of flashlights, all advertised as safe for transillumination cold light with surface glass that does not heat up. Three (3) separate burns were sustained when using these devices. The first was in a 25-week premature infant after a 1-minute encounter. The other burns were in a full-term neonate who had prolonged skin contact with the device, and a 35-week-old infant with moderate edema and a 2-minute encounter with the device. Our experiences have led us to ban the use of the flashlight in our unit. LED vein-finder devices have been purchased. They are less bright and bulkier, and therefore less convenient, but they have a better safety record.³

In conclusion, clinicians should always consider iatrogenic injuries in hospitalized patients. The challenge of finding the etiology is in the history and proper documentation. This case highlights how lack of documentation could have led to an erroneous diagnosis of a PI, which is a reportable event that could have been counted against the unit/hospital quality metric. More importantly, PI, extravasation, burn, or any other hospital-acquired condition has a high risk of litigation, where lack of proper documentation leads to an assumption of poor care. This injury was discovered late. We do not know if medical and nursing teams were aware of early skin changes and did not document them, did not do “the expected” skin examination every shift, or performed just a cursory examination without looking under the devices or clothing (eg, socks). Regardless, what was not documented was never done in the eyes of a court of law.

My learning points from this case are, “document, document, and document thoroughly.” Understand that every device applied to the skin has a risk. Use approved devices and recognize that any device has a potential for failure and iatrogenic injury if used incorrectly, especially on sensitive skin or for longer-than-suggested times.

REFERENCES

1. Van der Walt JH, Gassmanis K. Skin burns from a cold light source. Anesth Intensive Care. 1990;18(1)113–115. doi:10.1177/0310057X9001800119

2. Sumpelmann R, Osthaus W, Irmler H, Hernandez C. Prevention of burns caused by transillumination for peripheral venous access in neonates. Pediatr Anesthesia. 2006;16(10);1097–1098. doi:10.1111/j.1460-9592.2006.01962.x

3. Perman ML, Kauls LS. Transilluminator burns in the neonatal intensive care unit: a mimicker of more serious disease. Pediatr Dermatol. 2007;24(2);168–171. doi:10.1111/j.1525-1470.2007.00368.x

4. Lamperti M, Pittiruti M. Difficult peripheral veins: turn on the lights. Br J Anesthesia. 2013.110(6);888-891.

5. Uy J, Kuhns LR, Wall PM, Stein RT, Heidelberger K. Light filtration during transillumination of the neonate: a method to reduce heat buildup in the skin. Pediatrics. 1977;60:308–312.

Dr Boyar is director of Neonatal Wound Services, Cohen Children’s Medical Center of New York, New Hyde Park, and associate professor of Pediatrics, Zucker School of Medicine, Hofstra/Northwell, Hempstead, NY. All photos provided are with the consent of the patients’ parents. This article was not subject to the Wound Management & Prevention peer-review process.