Contrast medium reaction

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Author: Mikael Häggström [notes 1]

Intramuscular site of adrenaline.jpg
This page in a nutshell:
In a more severe reaction:[1]
  • Adrenaline shot, 0.3-0.5mg in adults, given intramuscularly.
  • Summon an anesthesiologist

In case of a allergic reaction to contrast media, anaphylaxis is a more severe allergic reaction whose diagnostic criteria generally include low blood pressure and/or respiratory distress.[2] In anaphylaxis, intramuscularly administered adrenaline is the most important initial therapy.[1] Also, an anesthesiologist or corresponding clinician on duty should be summoned. A peripheral venous catheter is needed for the administration of IV fluids.[1] Oxygen saturation, pulse and blood pressure are monitored.[1]

Document the incident to avoid repeat reactions.

Evaluation

Hives

Initial evaluation can be done according to an ABCDE approach:[1]

  • Airway: Stridor? Swollen tongue?
  • Breathing: Cyanosis? Use pulse oximeter if available.
  • Circulation: Palpable pulse over radial, femoral and carotid artery? Heart rate? Blood pressure? Difficulty in taking blood pressure must not delay adrenaline administration.
  • Disability: Altered level of consciousness?
  • Exposure: Hives?

Severity grading

Severity[3] Skin[3] Eyes and nose[3] Mouth and GI tract[3] Skin[3]Airways Circulatory[3] Mental[3]
Non-anaphylactic allergic reaction
  • Itching
  • Flushing
  • Hives
  • Angioedema
  • Conjunctivitis
  • Rhinitis
  • Itching mouth
  • Lip swelling
  • Feeling of swollen mouth and throat
  • Nausea
  • Mild abdominal pain
  • Single vomiting
  • Fatigue
Anaphylaxis, grade 1
  • Increasing abdominal pain
  • Repeated vomiting
  • Diarrhea
  • Hoarseness
  • Mild bronchial constriction
  • Substantial fatigue
  • Restlessness
  • Anxiety
Anaphylaxis, grade 2
  • Barking cough
  • Difficulty swallowing
  • Moderate bronchial constriction
  • Feeling like fainting
  • Sense of impending doom
Anaphylaxis, grade 3
  • Passing urine or feces
  • Hypoxia/cyanosis
  • Severe bronchial constriction
  • Complete airway obstruction
  • Hypotension
  • Bradychardia
  • Arythmia
  • Cardiac arrest
  • Confusion
  • Loss of consciousness

In severe hives and progressive angioedema[1]

Angioedema
  • 0,3-0,5 mg adrenaline intramuscularly on the anterolateral part of the mid-thigh. It is repeated if needed every 3–5 minutes.
  • Corticosteroid (see Table of medications below)
  • Observation at least 30 minutes

Anaphylaxis[1]

  • 0,3-0,5 mg adrenaline intramuscularly on the anterolateral part of the mid-thigh. It is repeated if needed every 3–5 minutes.
  • Summon anesthesiologist or corresponding clinician on duty
  • Oxygen, 10 L/min on mask. Attach a pulse oximeter.
  • In asthma or bronchospasm: Inhalations of bronchodilator (see Table of medications below)
  • In hypotension: Tilt the table to lower the head of the patient and give volume expander
  • Corticosteroid (see Table of medications below)

Cardiac arrest (unconscious and no breathing)[1]

Chest compressions.
  • Start CPR: 100 chest compressions per minute and ventilate x2 every 30 compressions
  • Connect a defibrillator
  • If ventricular fibrillation or tachycardia: defibrillate at 200 Joule
  • If asystole or pulseless electrical activity (PEA): 1 mg adrenaline 0,1 i.v. bolus
  • Continue CPR

Itching hives

If ABCDE is otherwise normal:[1]

  • Antihistamine (see Table of medications below)
  • Observation at least 30 minutes

Table of medications

Symptoms[1] Medication[1] Route[1] Dosage[1] Time to effect[1] Repeat[1]
Class Example Adults Children
  • Severe hives
  • Respiratory distress
  • Hypotension
  • Altered level of consciousness
  • Severe abdominal pains and vomiting
Injection of adrenaline Intramuscular in lateral thigh 0.3 - 0.5 mg
  • 0.01 mg/kg, up to 0.5 mg
    • 10-20kg: 0.15 mg
    • ≥20kg: 0.3 mg
Less than 5 min Every 5-10 min if needed
Asthma Bronchodilator Salbutamol (Ventolin) or own bronchodilator Inhalation
  • 5 mg
  • Usually 4-6 doses
  • 2-6 doses
Less than 5 min Every 10 mins if needed
Hypoxia Oxygen Mask >5 l/min Almost immediate Continuous
Altered level of consciousness or hypotension Volume expander Ringer's IV with pressure 20mg/kg Fast As needed
All anaphylaxis cases Antihistamine Desloratadine (Clarinex/Aerius) Oral 10mg
  • <6 years: 2.5mg
  • 6 - 12 years: 5 mg
Within 30-60 minutes
Chlorphenamine[4] IM or slow IV[4] 10mg[4]
  • <6 months: 250μg/kg
  • 6 months - 6 years: 2.5mg
  • 6 - 12 years: 5mg[4]
All anaphylaxis cases Glucocorticoid Betamethasone Oral or IV 5-8 mg
  • <6 years: 3-4 mg
  • ≥6 years: 5-8 mg
2-3 hours
Hydrocortisone[4] IM or slow IV[4] 200mg[4]
  • <6 months: 25mg
  • 6 months - 6 years: 50mg
  • 6 - 12 years: 100mg[4]

Documentation

All allergic reactions should be documented, and anaphylactic reactions should be documented so that it shows clearly when planning subsequent exams:

  • Brand or type of contrast agent.
  • Symptoms and their severity, or overall severity grading and most worrisome symptoms.
  • Treatment if given (treated symptoms may have become worse without treatment)

Prevention

Main article: Prevention of contrast medium reaction

Before a contrast CT of a patient with known allergic-like or unknown-type of contrast reaction to the same class of contrast medium (such as iodinated), the American College of of Radiology recommends premedication with a glucocorticoid, preferably starting 12 or 13 hours before contrast administration.[5]

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Radlines:Authorship for details.

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 Unless otherwise specified in lists and table: . Hypersensitivity reactions against contrast media - Swedish Society of Uroradiology [Swedish: Överkänslighetsreaktioner mot kontrastmedel – SURFs kontrastmedelsgrupp ], 2014-10-17].
  2. Kim, Harold; Fischer, David (2011). "Anaphylaxis ". Allergy, Asthma & Clinical Immunology 7 (Suppl 1): S6. doi:10.1186/1710-1492-7-S1-S6. ISSN 1710-1492. 
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Anaphylaxis group. Anafylaxi - svårighetsgradering [Anaphyaxis, severity grading] (Table 1). Swedish Association for Allergology. 2015
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Younker, Jackie; Soar, Jasmeet (2010). "Recognition and treatment of anaphylaxis ". Nursing in Critical Care 15 (2): 94–98. doi:10.1111/j.1478-5153.2010.00366.x. ISSN 13621017. , citing Resuscitation Council UK
  5. . Page 9 in: Manual on Contrast Media. American College of Radiology, Committee on Drugs and Contrast Media. Retrieved on 2018-08-25. Version 10.3. 2018. ACR