Aesthetic Medicine: Managing Medical Complications

Introduction

  • The presentation will cover materials, drugs, and practical management of frequent and serious medical complications in aesthetic medicine.
  • Clinical cases, resuscitation, and arrhythmia management will be discussed.
  • The final part will address pain management and anesthesia in aesthetic medicine.

Essential Materials and Equipment

  • Each autonomous community in Spain has its own regulations regarding necessary equipment.
  • Portugal is still defining required materials for aesthetic medicine clinics.
  • The focus should be on being prepared for any complication, beyond legal requirements.

Key Equipment:

  • Stethoscope:
    • Essential for medical professionals; should be used to examine patients.
    • Important reminder that aesthetic medicine is still medicine, and practitioners are doctors.
  • Tensimeter (Blood Pressure Monitor):
    • Digital tensimeters are recommended for easy and reliable blood pressure readings.
    • Used to monitor patient's blood pressure, which is crucial in managing complications.
  • Digital Pulse Oximeter:
    • Measures patient's oxygen saturation.
    • Inexpensive and reliable; can be more reliable than expensive monitors.
  • Glucometer:
    • Important for measuring blood glucose levels in patients with altered consciousness.
    • Low blood sugar can be mistaken for more serious conditions, like a stroke.
  • Masks (Venturi and Nebulization):
    • Necessary for treating patients who experience bronchospasms.
  • Guedel Airways and Ambu Bag:
    • Essential for managing a patient's airway during complications.
    • Indicates quality airway management.
  • Automated External Defibrillator (AED / DESA):
    • Having an AED is seen as morally necessary in a medical clinic.
    • These devices can save lives in cardiac emergencies, and are now commonly found in public places.
    • AEDs are available for around 800 euros.

Essential Medications

Core Medications:

  • Oxygen:
    • Essential drug.
  • Bronchodilators (Salbutamol):
    • Used with inhaler chambers or nebulizers for bronchospasms.
    • Doses of 2.5 to 5 milligrams are recommended for nebulization; can be used with ipratropium bromide.
  • Corticosteroids (Hydrocortisone and Methylprednisolone):
    • Used for various complications.
    • Hydrocortisone acts faster but has a shorter half-life, while methylprednisolone takes longer but lasts longer.
    • In severe allergic reactions, both are used simultaneously.
    • Hydrocortisone dosage: 200 mg IV or IM (adjusting for new ampule concentration of 75mg).
    • Methylprednisolone dosage: 1-2 mg/kg; in severe reactions, prefer 2 mg/kg.
  • Antihistamines (Dexchlorpheniramine):
    • Used for allergic reactions.
    • Standard dose is 5 mg intramuscularly or slow intravenously.
  • Anti-inflammatories (Dexketoprofen):
    • Has analgesic effects and can be administered intravenously.
    • Dosage: 50 mg IV or IM, or 25 mg orally.
  • Alprazolam:
    • Used to manage anxiety; dosage is 0.5 mg orally or subcutaneously.
    • Anxiety is common in modern society and frequently encountered in medical settings.
  • Adrenaline (Epinephrine):
    • Vital for saving lives in anaphylactic reactions, among other things.
    • Should be used correctly and safely, playing a crucial role in emergency situations.
    • The presenter aims to emphasize safe usage and indications during the class.

Other Medications:

  • Atropine:
    • May be used during vasovagal reactions, although often not truly necessary.
    • Often administered more for the professional's insecurity than the patient's need.
  • Antiarrhythmics (Amiodarone, Adenosine):
    • Useful but not strictly necessary in an aesthetic clinic setting.
  • Hyaluronidase:
    • Essential for managing complications related to aesthetic procedures and should always be available in any aesthetic clinic.

Most Prevalent Medical Complication: Vasovagal Reaction

  • Often linked to anxiety, vasovagal reactions are the most common complication in aesthetic medicine.

Definition:

  • Transient loss of consciousness, typically sudden, and short in duration.
  • Can be longer in elderly patients, due to slower regulatory mechanisms.
  • Requires rapid, spontaneous, and complete recovery to the patient’s baseline.
  • Caused by transient global hypoperfusion, explained below.

Mechanism:

  • Mediated by the tenth cranial nerve (vagus nerve).
  • Overstimulation leads to parasympathetic activation, increasing acetylcholine secretion.
  • This results in decreased peripheral vascular resistance, decreased heart rate, and decreased contractility.
  • The combined effects cause a drop in blood pressure, reducing cerebral blood flow and leading to syncope.

Triggering Factors:

  • Postural changes, emotional stress, pain, heat, anxiety, and venipuncture.
  • These factors are common in aesthetic medicine (anxious patients, potential pain, etc.).

Prevention:

  • Managing anxiety, stress, and pain is critical.
  • Address patient discomfort by pausing, offering reassurance, and adjusting the environment.
  • Perception of pain can impact patient satisfaction, with pain negatively affecting their experience regardless of aesthetic outcomes.

Anecdote:

  • A case involving a dentist who administered adrenaline incorrectly due to anxiety and misdiagnosed an allergic reaction, highlighting the importance of staying calm in medical procedures.

Prodromal Symptoms:

  • Yawning, warmth, pallor, dizziness, generalized weakness, hyperventilation, palpitations, diaphoresis, and tinnitus.
  • These symptoms indicate an impending vasovagal reaction.

Symptoms of a Vasovagal Reaction:

  • Pallor, profuse sweating, cold skin, dilated pupils, urinary and fecal incontinence, tonic-clonic movements, hypotension, and bradycardia.

Management of Tonic-Clonic Movements

  • If there's uncertainty about whether the patient had a vasovagal reaction or a seizure, take them to the emergency room.

Treatment:

  • Patient should lie in supine position and elevate the lower extremities.
  • IV fluids may be needed in the elderly.

Most Serious Medical Complication: Anaphylaxis

  • A severe allergic reaction with rapid onset and potential for fatality.

Pathophysiology:

  • Mediated by mast cells and basophils which release histamine and heparin.
    • Histamine and heparin cause vasodilation and increase vascular permeability.
    • Complex process involving leukotrienes, prostaglandins, complement, and other substances.

Cellular Distribution:

  • Mast cells are concentrated in the skin, blood vessels, respiratory mucosa, and gastrointestinal mucosa.
  • This distribution leads to cutaneous, respiratory, cardiovascular, and gastrointestinal symptoms during anaphylaxis.

Specific Symptoms Include:

  • Cutaneous: Erythema, pruritus, urticaria, angioedema.
  • Respiratory: Bronchospasm, wheezing, dyspnea, hoarseness, stridor.
    • Cardiovascular: Chest pain, arrhythmias, Kounis syndrome (acute ischemic heart disease due to coronary artery spasm caused by inflammatory mediators).
  • Gastrointestinal: Nausea, vomiting, abdominal pain, incontinence.

Syndrome of Kounis:

-Underdiagnosed syndrome involving acute ischemic heart disease that happens during anaphylaxis.

  • Caused by vasoconstriction of coronary arteries.

Presentation:

  • Can manifest as angina or acute coronary syndrome with or without ST elevation.
  • Three types:
    • Type 1: Normal coronary arteries.
    • Type 2: Atheroma plaque-related.
    • Type 3: Stent thrombosis.

Symptom Presentation

  • In 80% of cases, anaphylaxis presents traditionally with skin symptoms.
  • However, 20% of reactions do not have these skin symptoms and manifest as abdominal pain.

Symptoms of Shock Anaphylaxis:

 * Inability to stand. 
  * Low blood pressure (below 90 systolic).

Common Causes:

  • Medications (47-62%): Beta-lactams, NSAIDs.
  • Foods (around 30%): Nuts, seafood.
  • Insect stings (9-15%).
  • Latex (2-26%).

Importance of Clinical History:

-Always ask if the patient has any history with allergy or anesthetic complications.

Severity of the Anaphylactic:

  • Moderate: Respiratory distress, chest pain, vomiting.
  • Severe: Cyanosis, low oxygen (below 92%), altered mental status, hypotension.

Important Consideration:

-It is cutaneous symptoms, no matter how severe, are never by themselves a criteria for a severe reaction.

Treatment of Anaphylaxis

*** Early and aggressive treatment is crucial due to the rapid onset of potentially fatal issues.

  • Adrenaline (Epinephrine):

    • Dose: 0.5 mg intramuscularly in the quadriceps or deltoid.
    • Repeat every 5-15 minutes up to 1.5 mg total.

    Adrenaline

  • In a desert island, always pick adrenaline before anything else.

The main question:

When should you put adrenaline on an anaphylactic patient?

  • Obstructed upper air-waves.

When it is needed, any other consideration is secondary, because adrenaline does not have contra-indications.

  • If it's necessary to survive to survive, then inject the adrenaline because there isn't absolute counter indications.

How does Adrenaline work?

It works on the Alpha 1, Beta 1, and Beta 2 agonists.

  • In Alphy 1, it raises vasoconstriction and peripheral resistance. It avoids mucousal odema.
  • In Beta 1, it has inotropic and chronotropic effects on the heart.
  • In Beta 2, it is bronchodilator and avoid the release of inflammatory mediators on mass cells.

What are the potentially harmful effects?

  • Those with higher doses, tend to arrythmia and eschimia of the Miocardio.

This is the safety rule: be bold on the adrelanine dosage.

Other respiratory diseases to consider

*Albutamol: 2.5 or 5 miligrams.
*Antistaminic, such a Dexclorfeniramina, 5 miligrams.

  • Corticoids, hidrocoortisona.
    What about glucagone?
  • In patients which take Beta Blookers the effects of Adrenaline can be incompleted. So, the glucagone comes to be used at this point.
  • Use Atropine when bradycardia.
    Use Raaitidine because it has excellent antihistamines effects.
    *Use Oxygen always!

Clinical Cases:

Clinical Case 1. Patient 1. 65-year-old female. Medical History. Allergies to medicines. Hypertension, Dislipidemia, Cardiopaty, Previous Aesthetic Treatments.

*Procedure.
*Biestimulators of Collagen in the left part of the face.
*5 minutes later Patient refers that is not feeling well and is hard to breath.
*What to do. Check the patient. You can go faster!!
*Explore the taquirrenia. What to check? The blood pressure.
*Saturatation. The glycemic levels.
*The most probable diagnosis is anxiety.
*Many patients have it. It is important to lower the tension and the pulse! 180 or more beats can be the level of tachycardia.
*Many patients have anxiety, so pay attention:
*To anxiety
*To pressure
Explored if everything id well to assure the patient.

Clinical Case 2. Patient 2. Man, 45 years old. No Allergy. No Disease. Athletic Man. Previous aesthetic treatments. But now has to do the Auto Clinic Toxin.

*Does procedure. Man refers that he has the Nauseas, that it is Hard to breath after the process after the process . Has DOMINAL TENSION. What to do.
Check pulse, blood, etc.
Check the broncoespasms, the arterial stress and the saturation.
The patient says he has an allergy, and the body and body ache.
*What to do: Apply anti inflammatory etc.
*After 2 hours, the patient returns with Thoracic Tension. What to do? Make him an ecg right now!!
*This type of complications implies that is a allergic reaction which is critical.
Why has this clinic case. Does anyone has allergy to BOTOX? Yes; it can.
*Allergic response to face and tongue etc. . is critical.
*Rashes Inflamation in the tong, Tracheal Compriming.

The product itself may say not.But the truth; is that it can cause allergy. so watchout
*What are the possible side effects: Sincopes, miocardio and cardiorespiratory arrest.

Clinical Case 3. Woman -77 YO - Dislipidiemia

*Anesty with Lorazepam

  • Goes to do the filling with alueronic, But feel Heat Pruritus and disnea at that very moment.
    If she get worse…. She shows the saliorrea, the stridor, and an obfuscation of the brain. You have to administer Adrenaline.
    *What if the situation gets wrose? Just keep the adrenaline..
  • What about Beta Blockers patients.
    Is there allergy to elueronic acid? The main culprity is the bdd
  • Allergy can cause type 1 reaction. But isn`t really to the elueronic asid. But with that that acid.
    *To finish a good allergy history.
    *And pay attention about
    *There there is
    *Is important too in the filler aloueronic asid with lidocaine..

Realitazion Cardiopulmonar

What you have todo basicall is:

Give to patient a respire adequate with the less time as possible

Why to think about this:

The resuscitation cardiopulmonary is not that important
Important : Keep calm and always the best quality possible for the patient to give a excellent help.
The only important factor to save a live; will be to de fibriliate soon as possible. So it's important to have an aedes in the clinics and you know how and when to use him!!

Anestesia Topica en Medician Estética .

What anestesic must choose
*Technical analgetic
*Doses
*The more accurate technical history
Cryo analysis. Is clearly been underestimate.
Do not use Ice directly in the skin.
*Use always cryo pack to protect it.
*Cooling the skin in about ten/ fifteen degrees
*Ten minutes until start tech .
Benefits are : To low speed nerves, not hemathomas and it does vasoconstriction.

The great enemie of anestesic action is Corneo Extrato.

*Clear skin before start, clean skin before start.

  • Ocusivity increase the absorption. Leave the anestesia.
  • Use some time until start to poke or to fill.
  • EMLA - THE most common anestesic cream
  • Lidocaine 2,5 % + Pyri Caine + Tetracaíne = More Potential effects

BLT = VERY POWERFUL

*BenzOcaine 20 % + LidoCaine + TetraCaine = The Most Powerfull anestesic cream for the most aggressive clinic.
Be cautious : More power is more toxic and risk of side effects.
*Anestesic inflitrative. Use lidocaine.
*The most clear effect of having way much is to have metallic sabor on the mouth , vomits and even commas.
*Maximum recomendation : 0.5ml mililiters.
*Use or not adrenaline? Think in ischimy and try to avoid in the areas which are more sensitive.
*One 1000 per milimiters is the standard value.
The way to do the anestesia is inflitrative: Intranasal or Intracutanea??

Never Poke directly the nerves . Do damage and Hurt

How to get the nerves from the face?
It is the trigémino, which is the 5th nerve.
The super ofthalmic > is the Frontal
*supru orbital

  • Supra Troclear
    Maxilar > Infra orbital
    Mandibular > Mentonian.
    You must anestesiar the 4 important nerds now!
    Where does the super orbital pass t? And which function does he have?> to find those points is crucial
    And to know how to block it
    *Try to point on the left to avoid diffuser the
    Anesteic, always near it or close to in. 50 mililiters as maximun and is enough.
    In case of hurting or extreme pain. Stop and never poke the nerd.
    Does the infra orbital leave? To know the point is crucial.
    It innervates a lot more. You can put it in this side or in the inside.
    Use finger and follow your target.
    Mentonian nerd. To know the point is crucial.
    Try to follow the instructions.
    And done.Thank you all guys .
    Any doubt: is it ok to direct cube ice?