Management of Acute Contrast Reactions

Management of Acute Contrast Reactions

Guidelines for Initial Emergency Management in the Radiology Suite

Guidelines for Initial Emergency Management in the Radiology Suite

CALL FOR ASSISTANCE IMMEDIATELY
For any signs of significant allergic/contrast reaction
(Code team, rapid response team, surgical airway team, RICU; 911 if off-site)
AND DISCONTINUE CONTRAST INJECTION

Hypotension with Bradycardia (Vagal Reaction):

1. Administer high flow oxygen via face mask. Consider calling code team, rapid response team, RICU/
anesthesia or 911 (off-site). Place on monitor (do not delay therapy).
2. Rapid large volume of Ringer's lactate or normal saline IV (begin with immediate 250-500 mL bolus,
up to 1-2 liters IV).
3. For profound bradycardia, hypotension unresponsive to initial IV fluid bolus, or symptoms of shock:
atropine 0.5-1 mg IV (may repeat up to total adult dose of 2-3mg).

Mild

PEDIATRICS:

(Self-limited without progression.)

High flow oxygen via mask and call for assistance. Rapid IV/10 infusion of normal saline or Ringer's lactate
20 mLlkg. For profound bradycardia, pediatric hypotension (SBP: less than [70 + 2*age in years]) unresponsive to initial IV fluid bolus, or for symptoms of shock: atropine IV 0.02 mg/kg (minimum initial dose
of 0.1 mg; maximum initial dose of 0.5 mg [infant/child] or 1.0 mg [adolescent]).

Limited urticaria

Pallor

Transient nausea

.chills

Emesis

Nasal stuffiness

Dizziness

Anxiety

Tachycardia/bradycardia

Moderate

NOTES:
1. Hypotension in adults often defined as: SBP <80-90 mmHg; clinical evidence of shock can be seen in
altered mental status, chest pain, or other signs of hypoperfusion. Hypotension in children varies by
age (SBP less than: [70 + 2*age in years]).
2. Severe allergic reaction/anaphylaxis requires prompt epinephrine treatment. However, use caution
in administering epinephrine in the elderly and those with ahistory/risk profile for coronary ischemia
(or other relative contraindications); be prepared for side-effects (tachyarrhythmia/
chest pain/ischemia).
3. In the contrast reaction kit: EpiPen = epinephrine (1:1000) 0.3 mg=O.3 mL IM~
EpiPen Junior=epinephrine (1:2000) 0.15 mg=O.3 mL 1M.
4. In the code cart: epinephrine (1 :l,OOO/small ampule [1 mg=l mL]) for manual 1M dosing of
0.3-0.5 mg=0.3-0.5 mL 1M (adults); and 0.01 mg/kg=O.Ol mL/kg 1M (children). May repeat dosing in
3-5 minutes.
5. In the code cart: epinephrine (1 :10,000/code cart emergency syringe [lmg=10mL]) for manual IV
dosing of 0.1 mg=1mL VERY SLOW IV push over 5minutes (for profound hypotension with shock
and/or serious allergic symptoms unresponsive to 1M epinephrine).

Laryngeal edema or dyspnea

Mild hypotension

~~.

Severe
(Life threatening signs/symptoms
require aggressive treatment and often
hospitalization.)

"
Adapted from ACR Manual on (ontrast Media Version 6 E;) 2008 and Joint Task force on Practice Parameters for Allergy and
Immunology; The diagnosis and management of anaphylaxis @ 2005 in consultation with local content expert>.

Bronchospasm, wheezing

(Pronounced signs/symptoms require prompt

treatment. Beware of progression.)

'9

MASSACHUSETTS
GENERAL HOSPITAL
IMAGING

,
r~

Laryngeal edema
Profound hypotension
Unresponsiveness
Cardiopulmonary arrest

MEDICATiON EDUCATiON SAFETY APPROVAL COMMITTEE

Standard Register # CPD) 927)

Management of Acute Contrast Reactions

Management of Acute Contrast Reactions

Guidelines for Initial Emergency Management in the Radiology Suite

GUidelinesfor Initial Emergency Management in the Radiology Suite

Urticaria (Hives):

Bronchospasm (e.g. wheezing):

1. No treatment may be needed in MILO cases.

2. Diphenhydramine (Benadryl) PO/1M/IV 25-50 mg.
3. If generalized or associated with facial or laryngeal edema, bronchospasm, or hypotension/shock:
Treat with EpiPen 1M (may repeat in 3-5 minutes), and proceed with other algorithms (below).

1. Administer high flow oxygen via face mask. IMMEDIATELY call code team, rapid response team, RICU/
anesthesia, surgical airway team, or 911 (off-site). Place on monitor (do not delay therapy).
2. Beta-agonist (albuterol) inhaler: 2-3 puffs (with spacer) or albuterol nebulizer (1 pre-mixed ampule);
repeat/continuous pm.
3. Diphenhydramine (Benadryl) 1M/IV 25-50mg.
4. If severe or associated with facial/laryngeal edema or hypotension: EpiPen 1M (may repeat in 3-5 min).
5. If profoundly hypotensive with shock and/or unresponsive to EpiPen: consider epinephrine IV
(1:10,000; code cart emergency syringe) 1mL (=0.1 mg) VERY SLOW IV push over 5minutes.

PEDIATRICS:
Diphenhydramine (Benadryl) PO/1M/IV 1-2 mg/kg (up to 50 mg).
If generalized or associated with facial or laryngeal edema, bronchospasm, or hypotension/shock: Treat
with EpiPen Junior 1M (if child weighs 15-29 kg), or EpiPen 1M (if >30 kg); for child <15 kg, treat with
epinephrine 1M (1:1 ,OOO/small code cart ampule) 0.01 mg/kg (=0.01 mLlkg) 1M.
Facial Edema (e.g. lip/tongue swelling), and/or
Laryngeal Edema (e.g. stridor/hoarse voice):

1. Administer high flow oxygen via face mask. IMMEDIATELY call code team, rapid response team, RICU/
anesthesia, surgical airway team, or 911 (off-site). Place on monitor (do not delay therapy).
2. EpiPen 1M (may repeat in 3-5 minutes).
3. Diphenhydramine (Benadryl) 1M/IV 25-50mg.
4. If profoundly hypotensive with shock and/or unresponsive to EpiPen: consider epinephrine IV
(l:10,000/code cart emergency syringe) 1mL (=0.1 mg) VERY SLOW IV push over 5minutes.

PEDIATRICS:
High flow oxygen via mask and call for assistance. Treat with EpiPen Junior 1M (if child weighs15-29 kg),
or EpiPen 1M (if >30 kg); for child <15 kg, treat with epinephrine 1M (1 :l,OOO/small code cart ampule)
0.01 mg/kg (=0.01 mLlkg) 1M. Give diphenhydramine (Benadryl) 1M/IV 1to 2mg/kg (up to 50 mg).

PEDIATRICS:
High flow oxygen via mask and call for assistance. Albuterol2-3 puffs (with spacer) or albuterol nebulizer;
repeat/continuous pm. Ifsevere/other symptoms: EpiPen Junior 1M (if child weighs15-29 kg), or EpiPen
1M (if>30 kg); for child <15 kg, treat with epinephrine 1M (1 :l,OOO/small code cart ampule) 0.01 mg/kg
(=0.01 mLlkg) 1M. Diphenhydramine (Benadryl) 1M/IV 1-2 mg/kg (up to 50 mg).

Hypotension with Tachycardia:

(Consider if anaphylactoid shock due to allergy/contrast reaction vs. other causes of shock)
1. Administer high flow oxygen via face mask. IMMEDIATELY call code team, rapid response team, RICU/
anesthesia or 911 (off-site). Place on monitor (do not delay therapy).
2. Rapid large volume of Ringer's lactate or normal saline IV (begin with immediate 250-500 mL bolus,
up to 1-2 liters IV).
3. For allergic contrast reactions with hypotension unresponsive to initial IV fluid bolus, or for associated
facial/laryngeal edema or bronchospasm: EpiPen 1M (may repeat in 3-5 minutes) and administer
Diphenhydramine (Benadryl) 1M/IV 25-50 mg.
4. If allergic contrast reaction: For profound hypotension with shock and/or unresponsive to EpiPen:
consider epinephrine IV (1 :10,000; code cart emergency syringe) 1mL (=0.1 mg) VERY SLOW IV
push over 5minutes.

PEDIATRICS:
High flow oxygen via mask and call for assistance. Rapid IV/10 infusion of normal saline or Ringer's lactate
20 mL/kg. For allergic contrast reactions unresponsive to initial IV fluid bolus or associated with facial!
laryngeal edema or bronchospasm: EpiPen Junior 1M (if child weighs15-29 kg), or EpiPen 1M (if>30 kg);
for child <15 kg, treat with epinephrine 1M (l:l,OOO/small code cart ampule) 0.01 mg/kg (=0.01 mLlkg)
1M. Diphenhydramine (Benadryl) 1M/IV 1-2 mg/kg (up to 50 mg).