Management Of Contrast Reactions

Front 1

Name the different types of contrast reactions in order of increasing severity:

Back 1

-Urticaria
-Facial or Laryngeal Edema
-Bronchospasm
-Hypotension with tachycardia
-Hypotension with bradycardia (vasovagal)
-Hypertension (severe)
-Seizures or Convulsions
-Pulmonary Edema

Front 2

Describe the management of urticaria:

Back 2

1. Discontinue injection if not completed
2. No treatment needed in most cases
3. Give H1-receptor blocker: diphenhydramine (Benadryl®) PO/IM/IV 25 to 50 mg.

-If severe or widely disseminated: give alpha agonist (arteriolar and venous constriction): epinephrine SC
(1:1,000) 0.1 to 0.3 ml (=0.1 to 0.3 mg) (if no cardiac contraindications).

Front 3

Describe the management of facial or laryngeal edema:

Back 3

1. Give O2 6 to 10 liters/min (via mask).
2. Give alpha agonist (arteriolar and venous constriction): epinephrine SC or IM (1:1,000) 0.1 to 0.3 ml (=0.1 to
0.3 mg) or, especially if hypotension evident, epinephrine (1:10,000) slowly IV 1 to 3 ml (=0.1 to 0.3 mg).

-Repeat as needed up to a maximum of 1 mg.
-If not responsive to therapy or if there is obvious acute laryngeal edema, seek appropriate assistance
(e.g., cardiopulmonary arrest response team).

Front 4

Describe the management of facial or bronchospasm:

Back 4

1. Give O2 6 to 10 liters/min (via mask). Monitor: electrocardiogram, O2 saturation (pulse oximeter), and blood pressure.
2. Give beta-agonist inhalers (bronchiolar dilators, such as metaproterenol [Alupent®], terbutaline [Brethaire®],
or albuterol [Proventil® or Ventolin®]) 2 to 3 puffs; repeat as necessary. If unresponsive to inhalers, use SC,
IM, or IV epinephrine.
3. Give epinephrine SC or IM (1:1,000) 0.1 to 0.3 ml (=0.1 to 0.3 mg) or, especially if hypotension evident,
epinephrine (1:10,000) slowly IV 1 to 3 ml (=0.1 to 0.3 mg).

-Repeat as needed up to a maximum of 1 mg.
-Call for assistance (e.g., cardiopulmonary arrest response team) for severe bronchospasm or if O2 saturation <88% persists.

Front 5

Describe the management of hypotension with tachycardia:

Back 5

1. Legs elevated 60 degrees or more (preferred) or Trendelenburg position.
2. Monitor: electrocardiogram, pulse oximeter, blood pressure.
3. Give O2 6 to 10 liters/min (via mask).
4. Rapid intravenous administration of large volumes of Ringer’s lactate or normal saline.

-If poorly responsive: epinephrine (1:10,000) slowly IV 1 ml (=0.1 mg)
-Repeat as needed up to a maximum of 1 mg

-If still poorly responsive seek appropriate assistance (e.g., cardiopulmonary arrest response team).

Front 6

Describe management of hypotension with bradycardia (vasovagal reaction):

Back 6

1. Secure airway: give O2 6 to 10 liters/min (via mask)
2. Monitor vital signs.
3. Legs elevated 60 degrees or more (preferred) or Trendelenburg position.
4. Secure IV access: rapid administration of Ringer’s lactate or normal saline.
5. Give atropine 0.6 to 1 mg IV slowly if patient does not respond quickly to steps 2 to 4.
6. Repeat atropine up to a total dose of 0.04 mg/kg (2 to 3 mg) in adult.
7. Ensure complete resolution of hypotension and bradycardia prior to discharge.

Front 7

Describe management of severe hypertension:

Back 7

1. Give O2 6 to 10 liters/min (via mask).
2. Monitor electrocardiogram, pulse oximeter, blood pressure.
3. Give nitroglycerine 0.4 mg tablet, sublingual (may repeat × 3); or, topical 2% ointment, apply 1 inch strip.
4. If no response, consider labetalol 20 mg IV, then 20 to 80 mg IV every 10 minutes up to 300 mg.
5. Transfer to intensive care unit or emergency department.
6. For pheochromocytoma: phentolamine 5 mg IV. (may use labetalol if phentolamine is not available)

Front 8

Describe management of seizures or convulsions:

Back 8

1. Give O2 6 to 10 liters/min (via mask).
2. Consider diazepam (Valium®) 5 mg IV (or more, as appropriate) or midazolam (Versed®) 0.5 to 1 mg IV.
3. If longer effect needed, obtain consultation; consider phenytoin (Dilantin®) infusion – 15 to 18 mg/kg at 50 mg/min.
4. Careful monitoring of vital signs required, particularly of pO2 because of risk to respiratory depression with
benzodiazepine administration.
5. Consider using cardiopulmonary arrest response team for intubation if needed.

Front 9

Describe management of flash pulmonary edema:

Back 9

1. Give O2 6 to 10 liters/min (via mask).
2. Elevate torso.
3. Give diuretics: furosemide (Lasix®) 20 to 40 mg IV, slow push.
4. Consider giving morphine (1 to 3 mg IV).
5. Transfer to intensive care unit or emergency department.

Front 10

What is the pediatric dose of IM/IV benadryl?

Back 10

1to 2 mg/kg, up to 50 mg.

Front 11

What is the pediatric IV epinephrine dose?

Back 11

Epinephrine IV (1:10,000) 0.1 mL/kg slow push over 2 to 5 minutes, up to 3 mL/dose.
Repeat in 5 to 30 minutes as needed.

Front 12

What's the pediatric dose of albuterol for bronchospasm?

Back 12

-It's the same as the adult dose
-2 to 3 puffs from metered dose inhaler.
-Repeat as necessary.

Front 13

What is the pediatric Lasix dose?

Back 13

furosemide (Lasix®) IV 1 to 2 mg/kg.

Front 14

What is the pediatric atropine dose?

Back 14

-Atropine IV 0.02 mg/kg
-Minimum initial dose of
0.1 mg.
-Maximum initial dose of 0.5 mg (infant/child), 1.0 mg (adolescent).
-May repeat every 3–5 minutes
up to maximum dose up to 1.0 mg (infant/child), 2.0 mg (adolescent).

Front 15

How long does it take for the body to clear contrast material?

Back 15

Both iodinated contrast material and gadolinium are cleared from the bloodstream in 24 hours.

Front 16

What should you tell breastfeeding mothers who need to get a contrast enhanced scan?

Back 16

-The literature on the excretion into breast milk of
iodinated and gadolinium-based contrast media and
the gastrointestinal absorption of these agents from
breast milk is very limited however, several studies
have shown that:
1) less than 1% of the administered
maternal dose of contrast medium is excreted into
breast milk; and
2) less than 1% of the contrast medium in breast milk ingested by an infant is absorbed from the gastrointestinal tract.

-Therefore, the expected dose of contrast medium absorbed by an infant from ingested breast milk is extremely low.

-If the mother remains concerned about any potential ill effects to the infant, she may abstain from breast-feeding for 24 hours with active expression and discarding of breast milk from both breasts during that period.