Emergencies in aesthetic medicine: how to recognize them, act, and protect the patient's life

When we talk about aesthetic medicine, we tend to think of natural-looking results, facial rejuvenation, laser treatments, botulinum toxin, or dermal fillers.

However, there is a far more important aspect: patient safety.

Aesthetic medicine is a medical specialty. Although the vast majority of procedures are carried out without serious complications, situations can arise that demand knowledge of anatomy, pharmacology, clinical diagnosis, life support, and emergency medicine.

An anaphylactic reaction, a sudden loss of vision, a seizure, or a cardiorespiratory arrest cannot be resolved simply by stopping the treatment or applying a cream.

In certain circumstances, the difference between a favorable outcome and an irreversible complication depends on what is done during the first few minutes.

In this article we will explain the main emergencies that can occur in an aesthetic medicine practice, how to recognize their symptoms, what the principles of immediate treatment are, and why it is essential to consult legally qualified doctors and authorized medical facilities.

The goal is not to generate fear, but to promote responsible aesthetic medicine, grounded in prevention and the capacity to respond.

1. Why can emergencies occur in aesthetic medicine?

An aesthetic treatment may involve needles, local anesthetics, injectable substances, thermal energy, laser devices, or medications with systemic effects.

Even though the goal is to improve appearance, the procedure may interact with important anatomical structures.

Among the mechanisms of complication we find:

• Hypersensitivity reactions to medications or substances.

• Alterations in blood circulation.

• Accidental injection into a blood vessel.

• Toxicity from local anesthetics.

• Vasovagal responses.

• Respiratory or cardiovascular complications.

• Thermal injuries.

• Infections.

• Hemorrhages.

• Ocular accidents.

Emergencies not directly caused by the procedure may also occur, such as hypoglycemia or a coincidental cardiovascular event.

This is why the physician must assess the patient as a whole, and not only the area to be treated.

2. The main emergencies: a quick-reference table

Part One: recognising the emergency

3. The ABCDE principle: the assessment that can save a life

In the face of any acute deterioration, healthcare professionals use a systematic evaluation.

A — Airway. Is it patent? Is there tongue swelling, stridor, or obstruction?

B — Breathing. Is the patient breathing adequately? Is there respiratory distress, cyanosis, or altered oxygen saturation?

C — Circulation. Is there a pulse, adequate perfusion, hemorrhage, or signs of shock?

D — Disability: neurological status. Is the patient conscious? Are there seizures, confusion, or neurological deficits? What is the blood glucose level when it is indicated?

E — Exposure: exposure and physical examination. Are there skin lesions, oedema, bleeding, burns, or signs of infection?

The assessment must be accompanied by a response proportionate to the severity of the situation.

4. Vasovagal syncope: one of the most common incidents

Vasovagal syncope can be triggered by pain, anxiety, the sight of needles, or emotional stress.

The patient may present with:

• Pallor.

• Cold sweating.

• Nausea.

• Dizziness.

• Blurred vision.

• Bradycardia.

• Hypotension.

• Brief loss of consciousness.

How should you respond?

• Stop the procedure and safely remove any instruments.

• Position the patient lying down, generally in the supine position, and consider elevating the legs if there is no contraindication.

• Check breathing, pulse, blood pressure and level of consciousness.

• Do not sit the patient up abruptly.

If the patient does not quickly regain consciousness, or presents with chest pain, dyspnoea, trauma, neurological signs or persistent alterations, a more serious underlying cause must be ruled out.

An unconscious patient who is not breathing normally must be treated as a possible cardiac arrest, not as a simple fainting episode.

Part Two: anaphylaxis and respiratory emergencies

5. Anaphylaxis: an allergic reaction that can be life-threatening

Anaphylaxis is a severe systemic reaction, generally of rapid onset.

It can produce respiratory complications, cardiovascular complications, or both.

In aesthetic medicine it may occur following exposure to certain medications, antiseptics, latex or other substances.

Although skin manifestations are common, they are not always present.

Main symptoms

• Urticaria or generalised redness.

• Swelling of the lips, tongue or throat.

• Hoarseness or stridor.

• Difficulty breathing.

• Wheezing.

• Hypotension.

• Severe dizziness or loss of consciousness.

• Digestive symptoms in certain cases.

What should be done immediately?

1. Stop exposure to the possible trigger.

2. Activate emergency assistance.

3. Administer intramuscular adrenaline without delay when anaphylaxis is suspected.

4. Place the patient in a position appropriate to their clinical condition, preventing them from standing up or walking.

5. Maintain continuous assessment of the airway, breathing, and circulation.

6. Administer oxygen and fluid therapy when indicated and when trained personnel are available.

Protocol for healthcare professionals: adrenaline

In adults, a recommended regimen for anaphylaxis is:

Adrenaline 0.5 mg intramuscularly, into the anterolateral aspect of the thigh, using a solution of 1 mg/mL (1:1000).

This is equivalent to 0.5 mL of the 1 mg/mL solution.

If respiratory or circulatory problems persist, the dose may be repeated after 5 minutes, following the anaphylaxis algorithm.

In children, the dose must be adjusted according to weight and paediatric recommendations.

Antihistamines and corticosteroids do not replace adrenaline and must not delay its administration.

Anaphylaxis requires observation and subsequent medical evaluation due to the risk of recurrence and other complications.

6. Bronchospasm and asthmatic crisis

A patient may develop respiratory distress due to bronchospasm.

Signs include wheezing, tachypnoea, difficulty speaking and increased work of breathing.

The procedure must be stopped and the severity assessed.

Initial treatment may include a rapid-acting inhaled bronchodilator, such as salbutamol, administered according to acute asthma protocols.

In severe cases, oxygen, systemic treatment and hospital care may be required.

If bronchospasm occurs together with hypotension, angioedema or other systemic signs following an exposure, anaphylaxis must be considered.

7. Airway obstruction

It may arise from angioedema, aspiration or other causes.

Warning signs include:

• Stridor.

• Inability to speak.

• Progressive respiratory distress.

• Tongue swelling.

• Altered level of consciousness.

The priority is to maintain oxygenation, activate emergency services, and request advanced airway assistance.

Invasive rescue procedures are the responsibility of specifically trained personnel.

Part Three: cardiac arrest and arrhythmias

8. Cardiorespiratory arrest: what to do in the first few minutes

Cardiac arrest is suspected when a person is unconscious and not breathing normally.

Agonal breathing must not be confused with effective breathing.

Immediate action

• Confirm that the environment is safe.

• Check for responsiveness and breathing.

• Call 112 and request an automated external defibrillator (AED).

• Begin chest compressions immediately.

• Use the AED as soon as it is available.

• Continue resuscitation following their instructions and the emergency services' guidance.

Adult cardiopulmonary resuscitation

General recommendations include:

• Compression rate of 100 to 120 per minute.

• Approximate depth of 5 to 6 cm.

• Allow full chest recoil.

• Minimize interruptions.

• Alternate 30 compressions and 2 ventilations when the rescuer is trained and can perform them safely.

When training or means to provide ventilation are unavailable, continuous chest compressions should be started following the instructions of the emergency services.

9. What is ventricular fibrillation?

Ventricular fibrillation is a serious arrhythmia in which ventricular electrical activity is disorganized.

The heart does not generate effective circulation.

The person loses consciousness and goes into cardiac arrest.

Ventricular fibrillation is a shockable rhythm.

This means that defibrillation can interrupt the chaotic electrical activity and allow the heart to recover an organized rhythm.

10. Which rhythms require defibrillation?

The AED identifies whether the rhythm is shockable.

Defibrillation should never be attempted in asystole.

Advanced rhythm interpretation, manual defibrillation, and pharmacological treatments are the responsibility of professionals trained in advanced life support.

11. What happens after a shock?

The shock does not guarantee that the heart will immediately recover effective circulation.

For this reason, after defibrillation, compressions are resumed following the resuscitation algorithm.

Pauses should be kept to a minimum.

Advanced healthcare personnel may perform monitoring, airway management, vascular access, and pharmacological treatment according to the rhythm and the corresponding algorithm.

12. Pharmacological treatment during advanced resuscitation

In advanced life support for adults, adrenaline is administered intravenously or intraosseously following the cardiac arrest algorithm.

A common regimen is 1 mg IV/IO, at intervals of approximately 3 to 5 minutes during resuscitation, but the timing of the first dose depends on the rhythm.

In non-shockable rhythms, it is administered as soon as possible.

In shockable rhythms, it is introduced after the initial shocks, in accordance with the current algorithm.

In refractory ventricular fibrillation or pulseless ventricular tachycardia, antiarrhythmic agents such as amiodarone may be used, in accordance with the advanced life support protocol.

These treatments do not replace CPR or defibrillation and should not be applied outside the context of adequate training and equipment.

13. Tachycardia or bradycardia with a pulse: not the same as cardiac arrest

A patient may present with a serious arrhythmia and still have a pulse.

In that case, management depends primarily on their haemodynamic stability.

Signs of instability include:

• Hypotension.

• Ischaemic chest pain.

• Altered level of consciousness.

• Signs of shock.

• Acute heart failure.

Unstable tachyarrhythmias with a pulse may require synchronised cardioversion performed by trained personnel.

Certain symptomatic bradyarrhythmias may require pharmacological treatment or cardiac pacing.

Unsynchronised defibrillation, synchronised cardioversion, and cardiac pacing are distinct interventions.

Part Four: specific complications of injectable treatments

14. Vascular occlusion from hyaluronic acid

It is one of the most serious complications of facial fillers.

It can occur when the injected material compromises the circulation of a blood vessel.

The result can be ischemia and, if perfusion is not restored, tissue necrosis.

Warning signs

• Intense or disproportionate pain.

• Pallor or blanching of the skin.

• Reticular pattern or livedo.

• Alteration of skin temperature.

• Abnormal capillary refill.

• Progressive changes in coloration.

Pain may be absent or barely noticeable in certain circumstances, for example, following local anesthesia.

What should the physician do?

• Immediately stop the injection.

• Assess the distribution of the vascular alteration and cutaneous perfusion.

• Activate a specific vascular occlusion protocol.

When the responsible material is hyaluronic acid, hyaluronidase can be used to promote its degradation.

Treatment must be initiated promptly and may require repeated infiltrations, continuous reassessment, and specialized follow-up.

There is no single universal protocol suitable for all cases.

Concentrations, doses and techniques must be adjusted to the product, the area affected, the clinical presentation and the updated professional protocol.

Hyaluronidase does not equivalently reverse complications caused by all types of filler.

15. Vision loss after facial filler

It is a rare but potentially devastating complication.

It can occur when filler material reaches the arterial circulation supplying the eye.

Warning signs

• Sudden vision loss.

• Sudden blurred vision.

• Eye pain, although it may not be present.

• Pupillary changes.

• Associated neurological symptoms.

What should be done?

• Immediately discontinue the procedure.

• Activate the emergency system and arrange urgent ophthalmological evaluation.

• Record the exact time of symptom onset.

• Assess for possible signs of stroke.

Transfer should not be delayed in order to perform local maneuvers of unproven efficacy.

Retrobulbar injections of hyaluronidase should not be presented as a routine solution, as their benefit has not been established and they may carry additional risks.

16. Stroke associated with a vascular complication

Although very rare, a vascular complication from fillers can be associated with neurological symptoms.

We must recognize:

• Weakness on one side of the body.

• Facial asymmetry.

• Difficulty speaking.

• Sudden vision disturbances.

• Loss of coordination.

• Abrupt alteration in the level of consciousness.

These signs require immediate activation of emergency services.

They should not be confused with a simple vasovagal reaction.

17. Expanding hematoma and hemorrhage

Small hematomas are relatively common after needle-based procedures.

However, a hematoma that grows rapidly, causes intense pain, or compromises important structures can become a medical emergency.

The management includes stopping the procedure, assessing the hemodynamic situation, and applying compression where appropriate.

If there is airway compromise, visual disturbance, significant bleeding, or rapid expansion, urgent assistance is required.

Part Five: local anaesthetics and neurological complications

18. Local Anesthetic Systemic Toxicity (LAST)

Local anesthetics, such as lidocaine or bupivacaine, can cause systemic toxicity when they reach dangerous blood concentrations.

This can occur through accidental intravascular injection, excessive systemic absorption, or other factors.

Early neurological symptoms

These may include:

• Metallic taste.

• Perioral tingling.

• Ringing in the ears.

• Dizziness.

• Agitation.

• Confusion.

• Seizures.

However, these symptoms may be absent, and some patients present directly with cardiovascular disturbances.

Cardiovascular manifestations

• Hypotension.

• Conduction disorders.

• Arrhythmias.

• Circulatory collapse.

• Cardiac arrest.

Immediate treatment

• Discontinue administration of the anesthetic.

• Call for help and activate emergency services.

• Maintain adequate oxygenation and ventilation.

• Treat seizures and cardiovascular disturbances according to the specific protocol.

Intravenous 20% lipid emulsion is an important rescue treatment in cases of severe systemic toxicity.

Protocol for professionals: lipid emulsion

The ASRA checklist provides, for patients weighing less than 70 kg, for an initial bolus of approximately 1.5 mL/kg of 20% lipid emulsion, followed by an infusion of approximately 0.25 mL/kg/min.

For patients weighing more than 70 kg, the checklist provides a simplified bolus and infusion regimen.

If instability persists, the algorithm includes repeating the bolus and adjusting the infusion.

The management of cardiac arrest due to anesthetic toxicity has specific features and is not identical to the conventional advanced life support algorithm.

For this reason, professionals who use local anesthetics must have access to the updated ASRA protocol, appropriate training, and immediate access to rescue treatment when indicated.

19. Seizures during an aesthetic procedure

A seizure can occur due to different causes, including metabolic disorders, neurological conditions, or pharmacological toxicity.

Initial management

• Discontinue the procedure.

• Remove objects that may cause injury.

• Protect the head.

• Do not forcibly restrain the patient.

• Do not place objects in the mouth.

• Assess breathing and circulation.

• Record the duration of the episode.

A prolonged seizure, one that repeats without recovery, or one accompanied by respiratory compromise requires urgent medical attention.

Rescue anticonvulsant treatments must be administered in accordance with clinical protocols by trained professionals.

Part Six: metabolic and cardiovascular emergencies

20. Hypoglycemia

It may occur in patients with diabetes, especially if they use insulin or certain hypoglycemic medications.

It may also be triggered by prolonged fasting.

Symptoms

• Sweating.

• Tremor.

• Intense hunger.

• Palpitations.

• Confusion.

• Behavioral disturbance.

• Seizures or loss of consciousness in severe cases.

Initial treatment

• Check capillary blood glucose when possible, without delaying treatment of an obvious severe hypoglycemic episode.

• If the patient is conscious and able to swallow safely, administer glucose or fast-absorbing carbohydrates and reassess.

• If there is altered consciousness or inability to swallow, do not administer liquids or food by mouth.

• Trained personnel may use intravenous glucose or glucagon in accordance with the protocol and available resources.

21. Hypertensive crisis

A very high blood pressure reading does not always constitute a hypertensive emergency.

The fundamental difference is the presence of acute organ damage.

Among the concerning symptoms we find:

• Chest pain.

• Respiratory distress.

• Neurological deficit.

• Confusion.

• Acute visual disturbances.

• Signs of heart failure.

If a hypertensive emergency is suspected, urgent care must be activated.

It is not advisable to abruptly lower blood pressure with improvised medication without identifying the clinical context.

22. Chest Pain and Acute Coronary Syndrome

Although it is not a complication inherent to aesthetic treatment, a patient may present with chest pain during a consultation.

Possible symptoms include tightness, radiation to the arm or jaw, dyspnea, sweating, or nausea.

The priority is to stop the procedure, activate emergency services, monitor if possible, and follow acute coronary syndrome protocols.

Chest pain should not automatically be attributed to anxiety.

Part Seven: complications from lasers and energy-based devices

23. Laser Burns

Laser devices can cause thermal injuries when there is inadequate exposure or an excessive tissue response.

Signs include:

• Intense pain.

• Disproportionate erythema.

• Blistering.

• Erosions.

• Pigmentation changes.

• Deep injuries in severe cases.

Immediate Management

• Stop the energy emission.

• Remove the thermal source.

• Cool the area with fresh running water when appropriate, avoiding direct ice and excessive cooling.

• Assess depth, extent, and location.

• Protect the injury and determine the need for specialist evaluation.

Extensive, deep, significant facial burns or those involving ocular damage require special attention.

24. Ocular injury from laser

Accidental ocular exposure can cause injuries of varying severity depending on the wavelength, energy, and structures affected.

Symptoms may include pain, photophobia, blurred vision, or loss of vision.

The procedure must be stopped immediately.

The onset of visual symptoms requires urgent ophthalmological evaluation.

Prevention through eye protection specific to each device and wavelength is essential.

Part Eight: infections and late complications

25. Infection following an aesthetic treatment

An infection can appear hours or days after a procedure, depending on the microorganism and the type of intervention.

Signs include:

• Progressive pain.

• Spreading erythema.

• Local heat.

• Purulent discharge.

• Fever.

• General malaise.

Not all inflammation after a procedure is an infection.

It is necessary to distinguish the expected inflammatory response from an infectious complication.

26. Cellulitis, abscess and necrotising fasciitis

Bacterial cellulitis can produce redness, warmth, pain and oedema.

An abscess may require drainage in addition to antimicrobial treatment.

Necrotising fasciitis is a rare and serious infection.

Its warning signs include disproportionate pain, rapid progression, general deterioration and severe skin changes.

When a necrotising infection is suspected, an urgent surgical and hospital evaluation must be activated.

27. Sepsis

Sepsis is a potentially life-threatening organ dysfunction caused by a dysregulated response to an infection.

It may present with:

• Altered consciousness.

• Hypotension.

• Rapid breathing.

• General deterioration.

• Signs of poor perfusion.

One should not wait for all signs to be present.

Suspicion of sepsis requires urgent hospital care.

Part Nine: how an aesthetic medicine practice should be prepared

28. Prevention begins before the procedure

Safe care requires an adequate clinical history.

The physician must know:

• Previous illnesses.

• Allergies and adverse reactions.

• Regular medications.

• Anticoagulant treatments.

• History of syncope.

• Diabetes and other metabolic diseases.

• Cardiovascular diseases.

• History of anesthetic complications.

• Previous aesthetic procedures.

• Specific risk factors of the treatment.

The indication must also be verified, the risks explained, and appropriate informed consent obtained.

29. What emergency equipment should be available?

The equipment will depend on the authorized activity, the risks of the procedures, and the applicable regulations.

Among the elements that should be considered are:

Having the equipment stored is not enough.

Its availability, expiry dates, storage conditions, and accessibility must be checked.

Staff must know how to use it.

30. The importance of training in life support

A professional who performs medical procedures must know the limits of their training and have adequate preparation for foreseeable emergencies.

Training may include:

• Basic life support.

• Use of the AED.

• Recognition of anaphylaxis.

• ABCDE assessment.

• Initial airway management.

• Identification of vascular complications.

• Emergency drills.

• Coordination with emergency services.

Regular practical training is just as important as theoretical knowledge.

31. Why is it important to see legally qualified doctors?

Because aesthetic medicine does not consist solely of handling a needle or a device.

It requires assessing indications and contraindications, understanding anatomy, selecting treatments, recognising complications, and responding to an emergency.

A qualified healthcare professional must act within their scope of competence, with the appropriate training and resources.

The centre must hold the healthcare authorisations required for its activity.

A satisfactory aesthetic outcome must never be achieved at the cost of compromising medical safety.

Part Ten: frequently asked questions

32. Is it common to experience a serious emergency during an aesthetic treatment?

Serious complications are uncommon in many correctly indicated and performed procedures, but their frequency depends on the treatment, the technique, the product, and the patient.

A low frequency does not eliminate the obligation to be prepared.

33. Can a person suffer anaphylaxis with no prior history of allergy?

Yes.

The absence of any known prior history does not guarantee that a severe reaction is impossible.

34. What is the difference between fainting and cardiac arrest?

In syncope, there is usually a transient loss of consciousness with preserved circulation and breathing.

In cardiac arrest, there is no effective circulation.

The absence of response and normal breathing requires initiating the cardiac arrest algorithm.

35. Are all cardiac arrests treated with an electric shock?

No.

Defibrillation is used in shockable rhythms, such as ventricular fibrillation and pulseless ventricular tachycardia.

Asystole and pulseless electrical activity require CPR and treatment of reversible causes, not a shock.

36. Can hyaluronidase resolve any complication caused by fillers?

No.

It can be used in complications related to hyaluronic acid, but it does not act equivalently on other materials.

Furthermore, vision loss or a neurological event require immediate specialized care.

37. What should a patient do if they notice intense pain or color changes after a filler?

Contact the doctor who performed the procedure immediately and request an urgent evaluation.

You should not wait several days to see if it goes away.

If there are visual disturbances or neurological symptoms, you must go to the emergency room immediately.

38. Can laser treatment damage the eyes?

Yes, if dangerous ocular exposure occurs.

That is why it is essential to use appropriate protection for the device and the procedure.

39. Can a non-medical aesthetic centre perform any procedure?

No.

Authorization and requirements depend on the nature of the procedure and the applicable regulations.

Medical acts must be performed by qualified professionals and under the required health conditions.

40. What should I ask before undergoing a treatment?

It is reasonable to ask who will perform the procedure, what their professional qualifications are, what product or device will be used, what the risks are, what alternatives exist, and how a complication would be managed.

Transparency is part of good medical practice.

Conclusion: safety is the true foundation of aesthetic medicine

Aesthetic medicine has advanced considerably in techniques, products, and devices.

But no technological advance replaces medical knowledge.

A complication can occur even when the procedure is carried out with care.

The important thing is to prevent it whenever possible, recognize it quickly, and act correctly.

An anaphylactic reaction requires adrenaline.

A cardiac arrest demands resuscitation and, when the rhythm indicates it, defibrillation.

A vascular occlusion caused by hyaluronic acid requires immediate recognition and specialized treatment.

A sudden loss of vision cannot wait.

Systemic toxicity from local anesthetics requires a specific rescue protocol.

That is why the choice of an aesthetic treatment should not be based solely on price, advertising, or before-and-after images.

Before choosing a treatment, choose a qualified medical professional who is legally authorized, and a healthcare center that is accredited and prepared to handle complications.

Safety is not an add-on to aesthetic medicine.

Safety is part of the treatment.