Management of acute contrast reactions

  

“Hives” (urticaria)	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.
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/ collapsed patient	CALL CODE. Institute Basic Life Support Establish airway, head tilt, chin lift Initiate ventilation and external chest compression Continue uninterrupted until help arrives.

Ref; 

1.http://radiology.ucsf.edu/patient-care/patient-safety/contrast/iodinated/acute-contrast-reactions.

2.Guidelines for the Management of Reactions to Intravenous Contrast Media. Royal College of Radiologists, London.