Pulse oximeters have been widely used since the 1980s as they are considered to provide a safe, convenient, noninvasive method of estimating blood oxygen saturation. Initially used in the operating room by anesthesiologists, pulse oximetry has become ubiquitous in the healthcare setting. Although rare, serious burn injuries secondary to pulse oximetry have been reported. These include blistering or full-thickness burns of distal phalanges, in some cases requiring amputation and/or grafting;2–4
thermal burns in the setting of poor peripheral circulation;5,6
and extremity burns on infants with cases of gangrene and digit loss.7–13
We present a case of a full-thickness burn arising in a 17-month-old child, which required further therapy for resolution.