1. EPINEPHRINE 2. PREDNISONE 3. BENADRYL 4. HYALURONIDASE 5. BABY ASPIRIN 6. NITROPASTE 7. VIAGRA 8. CANNULAS. Must Haves for Injection Safety

Transcription

1 1. EPINEPHRINE 2. PREDNISONE 3. BENADRYL 4. HYALURONIDASE 5. BABY ASPIRIN 6. NITROPASTE 7. VIAGRA 8. CANNULAS Must Haves for Injection Safety

2 Facial artery: This artery stems from the external carotid artery, follows the inferior border of the mandible, and enters the face. It provides blood to the muscles of the face. Submental artery: This artery starts from the facial artery and supplies blood to the tissues under the chin. Inferior labial artery: Starting from the facial artery at the angle of the mouth, this artery runs medially to the lower lip, where it provides blood flow. Superior labial artery: This artery starts with the inferior labial artery, but it runs medially to the upper lip and provides blood flow there. Lateral nasal artery: Starting at the facial artery alongside the nose and running out to the ala of the nose (part of the nose that flares out around the nostril), this artery provides blood to the skin of the nose. Angular artery: This last branch of the facial artery passes to the medial angle of the eye. It provides blood to the inferior eyelid and the cheek just below. Occipital artery: This artery branches from the external carotid artery and passes to the occipital region. It provides blood flow to the scalp on the back of the head. Posterior auricular artery: This artery also branches from the external carotid artery and runs to the areas around the mastoid process and the ear. It provides blood to the ear and scalp behind the ear. Maxillary artery: This artery also starts from the external carotid artery. It runs deep to the neck of the mandible to supply blood to deeper structures of the face and meninges.

3 Inferior alveolar artery: This artery branches off the maxillary artery and enters the mandible to supply the teeth. Infraorbital artery: This artery branches from the maxillary artery and supplies blood to the maxilla, teeth, lower eyelid, cheek, and nose. Superficial temporal artery: Starting at the termination of the external carotid artery and ascending in front of the ear to the temporal region, this artery supplies blood to the facial muscles and skin in the frontal and temporal areas. Zygomaticoorbital artery: This artery branches off the superficial temporal artery and runs to the orbit (eye socket). Transverse facial artery: This artery stems from the superficial temporal artery and crosses the face to just below the zygomatic arch. It supplies blood to the parotid gland and muscles and skin of the face. Mental artery: The terminal branch of the inferior alveolar artery, this artery emerges from the mental foramen, where it supplies blood to the facial muscles and skin of the chin. Supraorbital artery: This artery branches from the ophthalmic artery and runs upwards to supply blood to the muscles and skin of the forehead and scalp. Supratrochlear artery: Also a branch of the ophthalmic artery, this artery passes from the supratrochlear notch to supply blood to the muscles and skin of the scalp.

4 Brow Ptosis Correction <> 10 Units in areas with an X

5

6 Angular vein: This vein runs obliquely down the side of the nose. Facial vein: The facial vein drains most of the blood from the face. It begins at the angular vein in the medial angle of the eye. The deep facial vein joins the facial vein, which goes on to drain into the internal jugular vein. Maxillary vein: This vein accompanies the maxillary artery and drains blood from the face. Superficial temporal vein: This vein drains the forehead and scalp. Retromandibular vein: This vein is formed by the superficial temporal vein and the maxillary vein. It receives blood from the region of the temple and the face. Posterior auricular vein: This vein is joined by a branch of the retromandibular vein to form the external jugular vein. Supraorbital and supratrochlear veins: These veins descend from the scalp to form the angular vein.

7 Lidocaine Toxicity While generally safe, local anesthetic agents can be toxic if administered inappropriately, and in some cases may cause unintended reactions even when properly administered. The toxicity of local and infiltration anesthetics can be local or systemic. Systemic toxicity of anesthetics most often involves the central nervous system (CNS) or the cardiovascular system. Adverse effects are usually caused by high plasma concentrations of the agent, which may result from one of the following: Inadvertent intravascular injection Excessive dose or rate of injection Delayed drug clearance Administration into vascular tissue Patient factors can also affect toxicity. For example, because lidocaine is hepatically metabolized, liver dysfunction increases the risk of toxicity. Because lidocaine is also protein bound, low protein states may also increase risk. Acidosis increases the risk because it favors dissociation of lidocaine from plasma proteins. Interactions with other drugs (e.g., cimetidine, beta-blockers) can also affect lidocaine drug levels. The toxicity of local and infiltration anesthetics can be localized or systemic. The localized adverse effects of anesthetic agents include neurovascular manifestations such as prolonged anesthesia and paresthesias, which may become irreversible. Systemic toxicity of anesthetics most often involves the central nervous system (CNS) or the cardiovascular system. Concurrent administration of other drugs, such as benzodiazepines, may mask the development of CNS symptoms but not cardiovascular symptoms. Relatively rarely (<1%), local anesthetic agents can affect the immune system, producing an immunoglobulin E (IgE) mediated allergic reaction. Most cases are associated with the use of amino esters. Some anesthetics, particularly benzocaine, are associated with hematologic effects, namely methemoglobinemia. The following factors influence duration of action: Addition of epinephrine to local anesthetic solutions prolongs duration of action by causing vasoconstriction and decreasing systemic absorption Degree of protein binding primarily determines duration of action; high

8 protein binding increases duration Increasing ph (using sodium bicarbonate) also prolongs duration of action Do not use large amounts of lidocaine topical, or cover treated skin areas with a bandage or plastic wrap. Local anesthetic toxicity can occur because of inadvertent intravascular injection or dosing error. Intravascular injection can cause toxicity even if the anesthetic was administered within the recommended dose range. Signs and symptoms Manifestations of local anesthetic toxicity typically appear 1 to 5 minutes after the injection, but onset may range from 30 seconds to as long as 60 minutes. Toxicity manifestations can be categorized as follows: CNS Cardiovascular Hematologic Allergic Local tissue CNS manifestations Classically, systemic toxicity begins with symptoms of CNS excitement such as the following: Tongue numbness Metallic taste Lightheadedness Dizziness Visual and auditory disturbances (difficulty focusing and tinnitus) Disorientation Drowsiness With higher doses, initial CNS excitation is often followed by a rapid CNS depression, with the following features: Muscle twitching Convulsions Unconsciousness Coma Respiratory depression and arrest Cardiovascular depression and collapse Cardiovascular manifestations Chest pain Shortness of breath

9 Palpitations Lightheadedness Diaphoresis Hypotension Syncope Hematologic manifestations Methemoglobinemia has been frequently reported in association with benzocaine use; however, lidocaine and prilocaine have also been implicated. At low levels (1-3%), methemoglobinemia can be asymptomatic, but higher levels (10-40%) may be accompanied by any of the following complaints: Cyanosis Cutaneous discoloration (gray) Tachypnea Dyspnea Exercise intolerance Fatigue Dizziness and syncope Weakness Allergic manifestations Rash Urticaria Anaphylaxis (very rare) Management Attention to impending airway compromise, significant hypotension, dysrhythmias, and seizures takes precedence. Once other possible etiologies of the patient's new symptoms have been excluded, management of the specific symptoms can begin. Maximum dosing for lidocaine: Calculating the maximum dose of local anesthetic agent Maximum dose of lidocaine without adrenaline is 4.5 mg/kg. Maximum dose of lidocaine with adrenaline is 7 mg/kg. Why? Lidocaine = sodium channel blocker and if you block enough sodium channels within axon to temporarily stop conduction, thus no pain signal Onset 2-5 min, duration min QUICK MATH:

10 Lidocaine 1% (10mg/ml) max dose 4.5mg/kg for the average 70kg patient: 70kg * 4.5mg/kg = 315mg 315mg / 10mg/ml = 31.5 ml max BOTTOM LINE: max dose 1% lidocaine is ~30 ml for average 70kg person Thus, in a 70-kg patient do not use more than: 20 ml 1% plain lidocaine or 10 ml 2% plain lidocaine 48 ml 1% lidocaine with adrenaline or 24 ml 2% lidocaine with adrenaline Treatment of local anesthetic toxicity may include the following [1] : Get Help Administer 100% Oxygen Airway management Notify medical director Transport to nearest emergency room Medical directive: Notify medical director and monitor patient s vital signs. Be prepared to call 911 and transport to nearest ER James Apesos MD Approved

11 TREATMENT OF VASCULAR COMPROMISE 1. WARM COMPRESSES, 10 MINUTES EVERY 1-2 HOURS 2. VIGOROUS MASSAGE, NERVE BLOCK IF NECESSARY, NO EPINEPHRINE 3. HYALURONIDASE IF FILLER IS HA FILLER 4. TOPICAL NITROGLYCERIN PASTE 2%. CAN BE APPLIED AS FREQUENTLY AS EVERY 1-2 HOURS INITIALLY. ONCE AT HOME, PATIENT CAN APPLY UP TO 3 TIMES A DAY TO THE AFFECTED AREA PROVIDED HE/SHE DOES NOT DEVELOP SYMPTOMS OF DIZZINESS 5. VIAGRA 25 MG QD 6. HYPERBARIC CHAMBER QD UNTIL RESOLUTION OF AREA