Aesthetic Crash Cart

Enzymatic dissolution of hyaluronic acid filler. Diffuses transvascularly after perivascular injection — no direct intra-arterial injection required. The goal is to flood occluded tissue with sufficient enzyme concentration to dissolve the HA embolus.

High-dose pulsed protocol (DeLorenzi / CMAC): 1,500 units per angiosome, every 20–60 min, repeated until capillary refill normalizes. Mix with plain lidocaine 2% (without epinephrine) for vasodilation and patient comfort. Stock minimum 20–30 vials in the USA (Hylenex = 150 units/mL, requiring 10 vials per 1,500-unit pulse).

Normal capillary refill, return of skin color, resolution of pain, and — if ultrasound available — confirmed arterial flow on Doppler.

Severe acute anaphylactic reaction — including reactions to hyaluronidase, filler components, or lidocaine. First-line agent for anaphylaxis and anaphylactic shock. Also required on hand for biphasic anaphylactic reactions.

0.3–0.5 mg (0.3–0.5 mL of 1:1000) IM into the outer mid-thigh. May repeat every 5–15 minutes as needed. Have a prefilled syringe (EpiRite or equivalent) for rapid administration.

Topical nitric oxide donor that promotes smooth muscle relaxation and local vasodilation. Applied to the ischemic skin territory to support perfusion alongside hyaluronidase.

CMAC does not recommend nitroglycerin paste for cross-linked HA filler occlusion, citing theoretical risk of propagating filler into smaller arterioles with vasodilation. It remains recommended for particulate filler vascular compromise. Many experienced injectors continue to use it. Clinical judgment applies.

Prevents further platelet aggregation in filler-induced vascular occlusion. Based on extrapolation from acute coronary syndrome evidence. Thrombus formation begins early after intra-arterial HA injection — aspirin supports antiplatelet therapy alongside hyaluronidase.

300 mg stat (loading dose) given immediately. If aspirin-allergic, substitute clopidogrel 300 mg. Continue 75 mg daily until occlusion resolved and tissue perfusion confirmed.

Rapid-deployment backup for anaphylaxis — particularly if the patient develops hypersensitivity to hyaluronidase. The CMAC protocol does not recommend allergy skin testing before emergency hyaluronidase administration as time is critical. The theoretical risk of allergy is manageable with epinephrine on hand.

Auto-injectors (0.3 mg adult dose) are preferable for non-physician staff to administer rapidly. Keep at least two devices in the kit. Check expiration dates every 6 months.

Adjunct antihistamine for anaphylaxis management alongside epinephrine. Also useful for milder allergic reactions (urticaria, angioedema) that do not require epinephrine. Important: diphenhydramine is an adjunct — it does not replace epinephrine in true anaphylaxis.

Stock both injectable (IM, 25–50 mg) and oral forms. IM form allows faster onset in acute reactions. Oral form useful for milder post-procedure reactions or continued dosing after resolution of acute event.

Filler-induced ophthalmic or central retinal artery occlusion presenting with vision changes. A beta-blocker that reduces intraocular pressure by decreasing aqueous humor production, thereby improving retinal perfusion pressure while awaiting emergency ophthalmology transfer.

Any filler procedure presenting with sudden vision loss, eye pain, or diplopia is an ocular emergency. Call 911 immediately. Instill timolol drops and 500 mg IV/oral acetazolamide (Diamox) if available while transfer is arranged. Do not delay transfer. Clinic-based retrobulbar hyaluronidase remains controversial and should not delay specialist management.

Plain lidocaine (without epinephrine) serves two functions simultaneously: it reduces pain from repeated hyaluronidase injections — improving patient tolerance during the high-dose pulsed protocol — and produces dermal vasodilation by relaxing smooth muscle, supporting local perfusion.

Mix 1 mL of 2% lidocaine plain (no epinephrine) per 1,500-unit vial of hyaluronidase before injection. CMAC and the THIS and FAT protocol both endorse this mixing approach. Never use lidocaine with epinephrine — epinephrine is a vasoconstrictor and will worsen ischemia.