Continuing medical education
Dermatologic surgery emergencies: Complications caused by systemic reactions, high-energy systems, and trauma

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While the overall incidence of emergencies in dermatologic surgery is low, emergent situations can occasionally pose a risk to patients undergoing such procedures. The clinical importance of several types of emergences related to systemic reactions, high energy systems, and trauma are reviewed, and relevant epidemiology, clinical manifestations, diagnosis, work-up, management, and prevention are discussed. Early detection of surgical emergencies can mitigate any associated adverse outcomes, thereby allowing the outstanding record of safety of dermatologic surgery to continue.

Section snippets

Anaphylaxis

Key points

  1. Anaphylaxis is the most dramatic and potentially catastrophic manifestation of immediate hypersensitivity

  2. Severity of reactions can vary widely from mild pruritus and urticaria to shock and death

  3. The key to anaphylaxis management is prompt recognition

  4. Intramuscular epinephrine is the first-line treatment of patients with suspected anaphylaxis

Cardiac arrhythmia

Key points

  1. Cardiac arrhythmias are associated with multiple etiologies, some of which can occur during dermatologic interventions

  2. Instances of cardiac arrhythmias during phenol chemical peels have been described

  3. Ventricular arrhythmias, especially ventricular fibrillation, herald a life-threatening emergency and must be managed promptly

  4. Clinical features of ventricular fibrillation include faintness, loss of consciousness, seizures, and apnea

  5. Successful management of cardiac arrest is based on adequate

Fire

Key points

  1. Each year in the United States there are approximately 50 to 650 surgical fires, the majority of which involve electrosurgical or laser devices

  2. Three elements are commonly required to initiate and maintain a fire: an ignition source, a fuel, and an oxidizer

  3. Specific steps can be taken pre- and perioperatively to help prevent surgical fires

Laser eye injury

Key points

  1. Eye safety is of the utmost importance during laser therapy

  2. When an eye injury does occur, wavelength, exposure duration, and laser intensity are all primary factors in determining the extent of the injury

  3. Injury to the eye may be temporary, but it also has the potential to result in permanent vision loss

  4. Laser eye injury should motivate emergent ophthalmologic referral

  5. Management of laser-mediated retinal injury is designed to reduce the inflammatory response

  6. While eye protective measures like

Local anesthetic and lidocaine toxicity

Key points

  1. Lidocaine toxicity, although rare, is a reported complication of dermatologic surgery

  2. Symptoms of lidocaine toxicity vary based on serum lidocaine concentrations

  3. The maximum safe dose of lidocaine in an adult is 5 mg/kg without epinephrine and 7 mg/kg with epinephrine. If dilute tumescent anesthesia is being used for large procedures, the known safe dose of lidocaine with epinephrine is 55 mg/kg

  4. If patients experience any of the signs and symptoms associated with excess serum lidocaine, vital

Motor nerve transection

Key points

  1. The nerves at greatest risk for injury during cutaneous surgery are the temporal and marginal mandibular branches of the facial nerve and the spinal accessory nerve

  2. The temporal nerve is most susceptible to transection superior to the zygomatic arch and lateral to the lateral eyebrow

  3. Clinical presentation of temporal nerve transection is a flattened forehead, eyebrow ptosis, and an inability to raise the ipsilateral eyebrow

  4. The marginal mandibular nerve is at greatest risk in the neck because of

Retrobulbar hematoma

Key points

  1. Retrobulbar hematoma can present as a complication of eyelid surgery

  2. Risk factors that increase the risk for postoperative hematoma formation are those associated with bleeding

  3. Pathophysiologic similarity to compartment syndrome, in which pressure causes ischemia and neural damage, has been suggested as a mechanism

  4. Common presentations of retrobulbar hematoma may occur ≤24 hours of surgery, but delayed presentations have been observed more than several days later

  5. The management of retrobulbar

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    Funding sources: None.

    Conflicts of interest: None declared.

    Date of release: August 2016

    Expiration date: August 2019

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