What stage of pressure injury is characterized by a bullae (fluid-filled blister) containing blood?

Blood-Filled Bullae in Pressure Injuries: Staging Classification

A pressure injury with a blood-filled bullae (fluid-filled blister containing blood) is classified as a Stage 2 pressure injury. 1

Understanding Stage 2 Pressure Injuries

Stage 2 pressure injuries are characterized by:

• Partial-thickness loss of dermis
• Present as a shallow open ulcer with a red-pink wound bed without slough
• May also present as an intact or ruptured serum-filled blister 2

When the fluid within the blister contains blood (hemorrhagic bullae), this remains classified as a Stage 2 pressure injury, as the damage is still limited to the dermis and has not extended to deeper tissues.

Distinguishing Features of Stage 2 Pressure Injuries

• Involves only the epidermis and part of the dermis
• Does not extend to subcutaneous fat
• May present as an intact blister or shallow open ulcer
• The wound bed appears red-pink and viable 1

Differential Considerations

It's important to distinguish blood-filled bullae in pressure injuries from other conditions:

• Necrotizing fasciitis: Blood-filled bullae can also be a sign of necrotizing fasciitis, which is a medical emergency requiring immediate surgical intervention 3
• Deep tissue pressure injury (DTPI): These appear as purple or maroon localized areas of discolored intact skin or blood-filled blisters due to damage of underlying soft tissue from pressure and/or shear
• Stage 3 pressure injury: These involve full-thickness tissue loss extending into the subcutaneous fat 1

Clinical Implications

The presence of blood in a pressure injury blister requires careful assessment:

• Blood-filled bullae may indicate trauma to the tissue or capillary damage
• The area should be monitored closely for signs of deterioration
• Blood-filled bullae should not be confused with deep tissue pressure injury, which presents as purple or maroon discoloration of intact skin 2

Management Approach

1. Assessment: Carefully document the size, location, and characteristics of the blood-filled bullae
2. Wound care:
   • Keep the area clean and protected
   • If the blister is intact, consider leaving it in place as a natural barrier
   • If broken, clean the area and apply appropriate dressing 1
3. Pressure redistribution: Implement repositioning schedule and use pressure-redistributing surfaces 1
4. Monitor for infection: Watch for signs of local infection or deeper tissue involvement 2
5. Nutritional support: Ensure adequate protein intake (1.25-1.5 g/kg/day) to support wound healing 1

Prevention of Progression

To prevent progression to deeper stage injuries:

• Implement a turning schedule every 2 hours
• Use specialized pressure-redistributing surfaces
• Maintain optimal nutrition and hydration
• Perform regular skin assessments 1

Common Pitfalls

• Misclassifying blood-filled bullae as deep tissue injury when they are actually Stage 2
• Failing to distinguish between pressure-related blood-filled bullae and those caused by other conditions like necrotizing fasciitis
• Neglecting to assess for biofilm formation and infection, which can hinder healing 1
• Inadequate pressure redistribution leading to worsening of the injury

Remember that accurate staging is essential for appropriate treatment planning and documentation. Blood-filled bullae in pressure injuries should be monitored closely for signs of deterioration to deeper tissue involvement.