Recognize: blanching (white/dusky skin) · severe pain out of proportion · mottled/livedo pattern · delayed cap refill · (late: dusky purple, coolness)

DO NOW: 1) STOP injecting · 2) Get the NP into the room immediately (no provider on site = call 911) · 3) CALL DR. V NOW — she directs treatment by phone if she's not on site · 4) Grab the BLACK BOX VO KIT + HYLENEX from the FRIDGE · 5) Warm compress on the area · 6) NP floods area with hyaluronidase (high-dose pulse, repeat until reperfusion) · 7) Massage area · 8) Reassess cap refill every few minutes

ANY vision change/eye pain = 911 + tell them "possible retinal artery occlusion from facial filler" — minutes matter for sight.

Document: time of onset, signs, hyaluronidase doses+times+lot, response, photos, all provider communications, patient instructions given. Do not discharge until provider clears; arrange next-day follow-up.

Recognize: pale, sweaty, "I feel weird/hot," tunnel vision, slow pulse — most common right after needles.

DO NOW: 1) Stop procedure, protect from falling · 2) Lay flat, LEGS UP · 3) Cold compress to neck/forehead · 4) Call provider in · 5) Vitals when able · 6) Small sips of juice/water when fully alert · 7) Recover 15+ min, no driving until fully normal

Unresponsive >1 minute, chest pain, irregular breathing, or seizure activity = 911.

Document: time down/up, vitals, recovery, provider assessment. Flag chart "vasovagal hx — premedicate with recline + distraction next visit."

Recognize: hives spreading · face/lip/throat swelling · wheeze/trouble breathing · dizziness/collapse — usually within minutes of product.

DO NOW: 1) CALL 911 · 2) NP administers EPINEPHRINE — it's INSIDE the BLACK BOX VO KIT (if no provider on site, tell the 911 dispatcher you have epinephrine on hand and follow their instructions) · 3) Lay flat, legs raised (sitting up if breathing is hard) · 4) Second epi in 5-15 min if no improvement · 5) Nothing by mouth · 6) Stay with patient, note times · 7) CALL DR. V — immediately, phone is fine

After: ER transport even if improved (biphasic reactions). Document product/lot, timeline, doses, EMS handoff.

Mild allergic (localized hives/itch, NO breathing/face involvement): provider assesses → antihistamine per provider order → observe 30+ min → document.

FD — patient calls about a lump: never dismiss it, never diagnose it. Ask: When did it appear? Which treatment/filler? Painful? Red/warm? Fever? Growing? Then notify the provider SAME DAY and log the call verbatim in AR. Your only job is triage + booking — the clinical part below is for the NP + Dr. V.

Say: "I'm so glad you called — this is something our provider will want to look at directly. Let me get you in [this week]."

RED FLAGS → same-week visit + Dr. V notified immediately (phone OK): red + warm + painful · fever · rapidly growing · skin breakdown

NP — classify first (the timeline tells you the cause):

① Early, NOT inflamed (weeks 1–4): usually superficial placement, maldistribution, or product clumping — a placement problem, not an immune problem. → Vigorous massage first; if it persists: saline or lidocaine displacement, or needle subcision to break it up.

② HA filler + INFLAMED (red/warm/painful, any timing): treat as immune reaction or biofilm. → High-dose PULSE hyaluronidase (Hylenex — fridge), repeated until full resolution · add doxycycline if biofilm is suspected.

③ Delayed 3+ months / biostimulators (Sculptra, Radiesse): true granuloma — foreign-body immune reaction or biofilm; hyaluronidase won't dissolve these products. → Intralesional 5-FU combined with LOW-dose corticosteroid (triamcinolone or dexamethasone) — the combo suppresses the fibroblast overgrowth without causing skin atrophy · oral support per Dr. V · refractory cases: refer for ultrasound-guided precision injection.

Every case: Dr. V is looped in before treatment — phone is fine. Document filler type + lot if known, onset timeline, inflammatory signs, classification, treatment + doses, photos.

Recognize: immediate excessive pain, white/grey patches, blistering, epidermal sliding during or after energy treatment.

DO NOW: 1) Stop treatment · 2) Cool (not ice) compresses / cool saline 10-15 min · 3) Provider assesses depth · 4) Per provider: topical care, dressing, possible Rx · 5) Photos NOW (documentation + monitoring baseline)

After: written aftercare (no picking, strict SPF, signs of infection) · 24-48h follow-up call SCHEDULED before they leave · PIH protocol applies to healing (see Training tab) · document settings used, area, immediate response, all care given.

Normal & expected (reassure + monitor): bruising, mild swelling, tenderness, pinpoint bleeding, redness 24-48h post-MN/laser, mild headache post-tox, small lumps that settle ~2 weeks post-filler.

Concerning → provider TODAY: worsening after day 3 · spreading redness/warmth (infection) · fever · severe/one-sided swelling · dusky color change · vision anything · blistering/cold sores post-lip work.

FD rule: NEVER say "that's normal" — say: "Thanks for telling us — I'm flagging this to the provider who treated you and they'll follow up shortly." Then actually flag it, same hour, and log it in AR.

1) Chart everything same day (times, meds+lots, response, photos, instructions)

2) Add the patient to next week's FOLLOW-UP LIST on the huddle with a note of what happened — they get a personal reassurance call, not the standard script

3) Dr. V reviews every event at the weekly huddle build

4) Do NOT ask an event patient for a Google review — the follow-up call is about care, full stop.