Ask Kara RDH: PSA Block Injection Complication

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I recently administered a right PSA block on a patient. Seconds after, my patient expressed that it hurt more than when I had numbed the left side a week prior. She kept expressing that her cheek felt puffy and hard. I attempted to massage the anesthetic into the nerve, but the patient continued to tell me that it felt strange. I retrieved the doctor in my office, and she continued to massage the patient’s cheek. Long story short, I performed SRPs, but the patient was still feeling “puffy” and strange. There was no trace of a hematoma, no observant facial paralysis. What could have happened?

It sounds like you inadvertently nicked or punctured a blood vessel. According to Dr. Stanley Malamed, this doesn’t always lead to a hematoma with a visually-apparent “bruise,” like if you perforated an artery. A “bruise” doesn’t always appear either because of the density of the tissue around the certain blood vessel. The best treatment here may have been for the patient to ice the area immediately and then to continue icing for the next 24 hours or so at 20-minute intervals every couple hours. Heat should not be applied for the first 24 because it is a vasodilator. The patient’s symptoms should heal in 10-14 days. If it doesn’t get better in that time frame, they should contact the office. There is a risk of secondary infection, so the patient should be aware and possibly monitored for that.

I do want to mention that the PSA block is a high-risk injection for complications due to the highly vascular area you are injecting into, and sometimes this just happens. All patients are different anatomically, and we don’t have X-ray vision, so we have to do our best using the training we have. My point is, don’t feel like you were necessarily wrong or had poor technique with your injection!

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Kara Vavrosky, RDHEP
Kara Vavrosky, RDHEP, is a co-founder and the chief content officer of Today’s RDH, an independent educational publishing company for dental hygienists, encompassing articles, a podcast, virtual continuing education events, and self-study continuing education. Today’s RDH was launched in 2018 after Kara built her social media presence with her largest following on her Facebook page, Dental Hygiene with Kara RDH, which was created in 2013. An Oregon Institute of Technology graduate, Kara has a deep passion for spreading knowledge about the importance of oral health and its association with systemic health. Kara’s passion extends to helping other hygienists understand current protocols and evidence-based research – all with the goal of lifting dental hygienists and the dental hygiene profession. Kara was recognized in 2020 as one of the Top 100 Women in Media for her entrepreneurship as a co-founder of Today’s RDH. In 2022, she was recognized by the American Dental Hygienists’ Association for their Standout Seven Award in the Entrepreneur category. Kara lives in Vancouver, Washington, just outside Portland, Oregon, with her husband, Ben, and their four Chihuahuas. When she’s not working, Kara loves riding the Oregon Dunes on her quad, spoiling her Chihuahuas, and spending time with her close-knit family.