Extravasation Injury
Emergency Mx = SLAP
Danger (?Hazardous drug ie purple PPE)
Stop
Leave vascular access device in
Aspirate
Plan
Staging an extravasation injury
Stage 1: PIVC will be difficult to flush.
?swelling and pain at the site.
Stage 2: Slight/mild swelling and leakage around the site may be present
Pain at the site
Intact skin
? hardened area, mild blanching, redness and/or discolouration of the skin.
Stage 3: Moderate swelling and/or hardened area around the site
Cool to touch
?blanching of the skin, redness and/or discolouration which could be purple or black.
?Pulses weak
Stage 4: Severe swelling, blistering and hardening around the site may be present.
Stage 3 +
Blanching, redness and/or discolouration which may be purple or black.
Pulses will be weak or absent on the affected limb
Capillary refill time may be >4 seconds.
(This is a medical emergency)
Danger (?Hazardous drug ie purple PPE)
Stop
Leave vascular access device in
Aspirate
Plan
- Analgesia
- Examine and Photograph
- Location
- Size
- Swelling
- Oedema
- Erythema (mark)
- Pain
- Drug (Irritant v Vesicant v Neutral)
- Dose + Volume + rate
- Notify TL, Consultant, Plastics, Parents
- ? extravasation kit from pharmacy / after hours cupboard /
- ? cold (wrapped in light towel) or warm (vinc alkaloids) compress (not for infants)
- for 20 mins, q6h for 48hrs
- ? antidote if listed in appendix
- ? contact pharmacist if drug not listed in appendix
- Remove VAD post antidote or if no antidote
- ? dressing as per plastics
- Elevate
- Hourly neurovascular obs
- Document, IIMS
- Resite if necessary
Staging an extravasation injury
Stage 1: PIVC will be difficult to flush.
?swelling and pain at the site.
Stage 2: Slight/mild swelling and leakage around the site may be present
Pain at the site
Intact skin
? hardened area, mild blanching, redness and/or discolouration of the skin.
Stage 3: Moderate swelling and/or hardened area around the site
Cool to touch
?blanching of the skin, redness and/or discolouration which could be purple or black.
?Pulses weak
Stage 4: Severe swelling, blistering and hardening around the site may be present.
Stage 3 +
Blanching, redness and/or discolouration which may be purple or black.
Pulses will be weak or absent on the affected limb
Capillary refill time may be >4 seconds.
(This is a medical emergency)