Immediate Clinical Assessment for Ischemia is the First Step
The first step to diagnose epinephrine-induced vasospasm after injecting lidocaine with epinephrine is to assess the hand for signs of ischemia through direct clinical examination—evaluating color, temperature, capillary refill, and pulse. This clinical assessment establishes the diagnosis before considering pharmacologic reversal.
Clinical Assessment Protocol
Immediately evaluate the affected hand for the following ischemic signs:
- Pallor or blanching of the skin indicating severe vasoconstriction 1, 2
- Coldness to touch compared to the contralateral hand 1, 2
- Pain that is disproportionate or sudden in onset 2
- Capillary refill time that is delayed or absent 1
- Pulse assessment via palpation or Doppler if available 1
The combination of a pale, cold, painful hand following lidocaine with epinephrine injection is pathognomonic for epinephrine-induced vasospasm 1, 2.
Why Assessment Precedes Treatment
Clinical examination establishes the diagnosis and severity before initiating reversal therapy. The diagnosis of epinephrine-induced digital vasospasm is primarily clinical, based on the temporal relationship between injection and symptom onset, combined with the characteristic physical findings 1, 2.
Once ischemia is confirmed clinically, phentolamine should be administered without delay to reverse the alpha-adrenergic vasoconstriction 3, 1, 2. The FDA label for epinephrine specifically recommends phentolamine as the antidote for epinephrine-induced vasospasm and extreme pallor 3.
Phentolamine Administration After Diagnosis
After clinical assessment confirms ischemia:
- Administer phentolamine 5-10 mg diluted in 10-15 mL of saline via local infiltration or digital block at the affected site 3, 2
- Alternative dosing: 2 mg phentolamine mixed with 2% lidocaine as a digital block has been successfully used 2
- Expect reversal within 30 minutes, with return of pink color, warmth, and pain relief 2
Critical Timing Considerations
Do not delay assessment or treatment. Epinephrine-induced vasospasm can progress to tissue necrosis and amputation if not reversed promptly 1. The case literature demonstrates successful reversal when phentolamine is administered within 1 hour of symptom onset 2.
Common Pitfall to Avoid
Do not wait for advanced imaging or vascular studies before initiating treatment. The diagnosis is clinical, and delaying phentolamine administration while pursuing unnecessary diagnostic tests increases the risk of irreversible tissue damage 1, 2. The physical examination findings of pallor, coldness, and pain in the temporal context of epinephrine injection are sufficient to establish the diagnosis and proceed with reversal therapy 1, 2.