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Acute Contrast Reaction Management

The reaction management chart below is organized by reaction type. Any time a patient displays a contrast reaction, even a mild one, the best practice is to administer oxygen to the patient as the reaction may progress and could become life-threatening. Always preserve I.V. access and continue to monitor vital signs.

Download a printable copy of the Acute Contrast Reaction Management Poster

This reference correlates to the online continuing education courses Contrast Administration in the Radiology Setting and I.V. Education for the Radiology Professional.








Acute Contrast Reaction Management

Hives (uticaria)
  • Discontinue injection if not completed
  • No treatment needed in most cases - reassure the patient
  • Consider diphenhydramine (Benadryl®) PO/IM/IV 25-50 mg
  • If severe/widely disseminated: Epinephrine SC (1:1,000) 0.1-0.3 ml (=0.1-0.3 mg) (if no cardiac contraindications)
Facial or Laryngeal Edema
  • 0.1-0.3 ml epinephrine SC or IM (1:1,000) (=0.1-0.3 mg) or, if hypotensive, 1 ml epinephrine IV (1:10,000) slowly (=0.1 mg). Repeat as needed up to 1 mg.
  • Give oxygen 6-10 L/min (via mask)
  • If not responsive to therapy or if there is obvious acute laryngeal edema, seek appropriate assistance (e.g., cardiopulmonary arrest response team).
Bronchospasm
  • Give oxygen 6-10 L/min (via mask)
  • Monitor: ECG, O2 saturation (pulse oximeter), and BP
  • Give beta-agonist inhalers, such as metaproterenol (Alupent®), terbutaline (Brethaire®), or albuterol (Proventil®)(Ventolin®) 2-3 puffs; repeat as needed
  • If unresponsive, epinephrine SC or IM (1:1,000) 0.1-0.3 ml (=0.1-0.3 mg) or, if hypotensive, epinephrine (1:10,000) slowly IV 1 ml (=0.1 mg) - Repeat up to 1 mg
  • Alternatively, give aminophylline 6 mg/kg IV in D5W over 10-20 minutes (loading dose), then 0.4-1 mg/kg/hr, as needed (caution: hypotension)
  • Call for assistance for severe bronchospasm or if O2 saturation < 88% persists
Hypotension with Tachycardia
  • Legs elevated 60° or more (preferred) or Trendelenburg position
  • Monitor: ECG, O2 saturation (pulse oximeter), and BP
  • Give oxygen 6-10 L/min (via mask)
  • Rapid large volumes of IV isotonic Ringer’s lactate or normal saline
  • If poorly responsive: Epinephrine (1:10,000) slowly IV 1 ml (=0.1 mg) (if no cardiac contraindications). Repeat as needed up to a maximum of 1 mg
  • If still poorly responsive seek appropriate assistance (e.g., arrest team).
Hypotension with Bradycardia (Vagal Reaction)
  • Monitor: ECG, O2 saturation (pulse oximeter), and BP
  • Legs elevated 60° or more (preferred) or Trendelenburg position
  • Secure airway and give oxygen 6-10 L/min (via mask)
  • Rapid large volumes of IV isotonic Ringer’s lactate or normal saline
  • If unresponsive, atropine 0.6-1 mg IV slowly - repeat up to 2-3 mg in adult
  • Ensure complete resolution of hypotension and bradycardia prior to discharge.
Severe Hypertension
  • Give oxygen 6-10 L/min (via mask)
  • Monitor: ECG, O2 saturation (pulse oximeter), and BP
  • Give nitroglycerine 0.4-mg tablet, sublingual (may repeat x 3)
  • Transfer to intensive care unit or emergency department
  • For pheochromocytoma—phentolamine 5 mg IV
Seizures or Convulsions
  • May be consequence of hypotension, primary treatment should be as indicated
  • Lateral decubitus position, give oxygen, 6-10 L/min by mask
  • Consider diazepam (Valium®) 5 mg or more or midazolam (Versed®) 0.5-1 mg IV
  • If longer effect needed, obtain consultation; consider phenytoin (Dilantin®) infusion – 15-18 mg/kg at 50 mg/min.
  • Careful monitoring of vital signs, particularly of pO2 (respiratory depression)
  • Consider using cardiopulmonary arrest response team for intubation
Pulmonary Edema
  • Elevate torso; rotating tourniquets (venous compression)
  • Give O2 6-10 liters/min (via mask)
  • Give diuretics – furosemide (Lasix®) 20-40 mg IV, slow push
  • Consider giving morphine (1-3 mg IV)
  • Transfer to intensive care unit or emergency department
  • Corticosteroids optional
Unconscious, Unresponsive, Pulseless, or Collapsed Patient
  • CALL CODE
  • Institute Basic Life Support
  1. Establish airway, head tilt, chin lift
  2. Initiate ventilation and external chest compression
  3. Continue uninterrupted until help arrives

References
1. Manual on Contrast Media, Version 10.2, 2016. American College of Radiology. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/Contrast%20Manual/2016_Contrast_Media.pdf

2. CT and X-ray Contrast Guidelines, UCSF Department of Radiology and Biomedical Imaging; Management of Acute Contrast Reactions; accessed 10/24/2016 https://radiology.ucsf.edu/patient-care/patient-safety/contrast/iodinated#accordion-allergies

 

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