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In general in a contrast medium reaction, '''Document''' the patient should be evaluated for the presence of the following symptoms and be medicated accordinglyincident to avoid repeat reactions.<ref name=SURF/>
→Evaluation: Better
{{AuthorsTop|author1=[[User:Mikael Häggström|Mikael Häggström]]|author2=}}[[File:Injection Sites Intramuscular Thigh Adultsite of adrenaline.pngjpg|300px230px|rightthumb]]
{{Nutshell|In a more severe reaction:<ref name=SURF>Unless otherwise specified in lists and table: {{cite web|url=http://www.mastcellssjukdom.se/wp-content/uploads/2015/12/Nationella_rekommendationer_%C3%B6verk%C3%A4nslighetsreaktioner_kontrastmedel__PDF_2014-10-17.pdf|title=Hypersensitivity reactions against contrast media - Swedish Society of Uroradiology [Swedish: Överkänslighetsreaktioner mot kontrastmedel – SURFs kontrastmedelsgrupp] ], 2014-10-17}}</ref>
*'''Adrenaline''' shot, 0.3-0.5mg in adults, given intramuscularly.
*Summon an '''anesthesiologist'''
}}
In case of a allergic reaction to '''[[contrast medium reactionmedia]]''', anaphylaxis is a more severe allergic reaction whose diagnostic criteria generally include low blood pressure and/or respiratory distress.<ref name="KimFischer2011">{{cite journal|last1=Kim|first1=Harold|last2=Fischer|first2=David|title=Anaphylaxis|journal=Allergy, Asthma & Clinical Immunology|volume=7|issue=Suppl 1|year=2011|pages=S6|issn=1710-1492|doi=10.1186/1710-1492-7-S1-S6}}</ref> In anaphylaxis, intramuscularly administered adrenaline is the most important initial therapy.<ref name=SURF/> Also, an '''anesthesiologist''' or corresponding clinician on duty should be summoned. A '''peripheral venous catheter''' is needed for the administration of IV fluids.<ref name=SURF/> '''Oxygen saturation''', '''pulse''' and '''blood pressure''' are monitored.<ref name=SURF/>
==Evaluation==
[[File:Urticaria near navel.jpg|thumb|180px|Hives]]
Initial evaluation can be done according to an ABCDE approach:<ref name=SURF/>
* Airway: Stridor? Swollen tongue?
* Disability: Altered level of consciousness?
* Exposure: Hives?
===Severity grading===
{|class="wikitable"
! Severity<ref name=sffa>{{cite web|url=http://www.sffa.nu/wp-content/uploads/2015/12/Anafylaxi_sept_2015.pdf|title=Anafylaxi - svårighetsgradering <nowiki>[</nowiki>Anaphyaxis, severity grading<nowiki>]</nowiki> (Table 1)|website=Swedish Association for Allergology|author=Anaphylaxis group}} 2015</ref> !! Skin<ref name=sffa/> !! Eyes and nose<ref name=sffa/> !! Mouth and GI tract<ref name=sffa/> !! Skin<ref name=sffa/>Airways !! Circulatory<ref name=sffa/> !! Mental<ref name=sffa/>
|-
! 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<ref name=SURF/>==
[[File:Angioedema2010Angioedema of the face.JPGjpg|thumb|150px|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 minuterminutes
==Anaphylaxis<ref name=SURF/>==
* Summon anesthesiologist or corresponding clinician on duty
* Oxygen, 10 L/min on mask. Attach a pulse oximeter.
* In asthma or bronchospasm: Salbutamol inhalations 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)
==Table of medications==
{|class="wikitable"
!rowspan=2| Symptoms<ref name=SURF/> !!rowspancolspan=2| Medication<ref name=SURF/> !!rowspan=2| Route<ref name=SURF/> !!colspan=2| Dosage<ref name=SURF/> !!rowspan=2| Time to effect<ref name=SURF/> ||rowspan=2| Repeat<ref name=SURF/>
|-
! Class !! Example !! Adults !! Children
|-
|
*Altered level of consciousness
*Severe abdominal pains and vomiting
|colspan=2| Injection of '''adrenaline'''
| Intramuscular in lateral thigh
| 0.3 - 0.5 mg
|-
| Asthma
| '''Bronchodilator'''
| Salbutamol (Ventolin) or own bronchodilator
| Inhalation
|-
| Hypoxia
| colspan=2| '''Oxygen'''
| Mask
|colspan=2| >5 l/min
|-
| Altered level of consciousness or hypotension
| '''Volume expander such as '''| Ringer's
| IV with pressure
|colspan=2| 20mg/kg
| As needed
|-
|rowspan=2| All anaphylaxis cases| rowspan=2| '''Antihistamine such as desloratadine '''| Desloratadine (Clarinex/Aerius)
| Oral
| 10mg | *<6 years: 2.5mg *6 - 12 years: 5 mg|rowspan=2| Within 30-60 minutes|rowspan=2||-| Chlorphenamine<ref name="YounkerSoar2010">{{cite journal|last1=Younker|first1=Jackie|last2=Soar|first2=Jasmeet|title=Recognition and treatment of desloratadineanaphylaxis|journal=Nursing in Critical Care|volume=15|issue=2|year=2010|pages=94–98|issn=13621017|doi=10.1111/j.1478-5153.2010.00366.x}}, citing Resuscitation Council UK</ref>| IM or slow IV<ref name="YounkerSoar2010"/>| 10mg<ref name="YounkerSoar2010"/>
|
*<6 months: 250μg/kg*6 months - 6 years: 2.5mg desloratadine*6 - 12 years: 5 mg desloratadine| Within 30-60 minutes| Usually not5mg<ref name="YounkerSoar2010"/>
|-
|rowspan=2| All anaphylaxis cases
|rowspan=2| '''Glucocorticoid such as betamethasone'''| Betamethasone
| Oral or IV
|*5-8 mg betamethasone
|
*<6 years: 3-4 mg
*≥6 years: 5-8 mg
|rowspan=2| 2-3 hours
| Usually notrowspan=2|
|-
| Hydrocortisone<ref name="YounkerSoar2010"/>
| IM or slow IV<ref name="YounkerSoar2010"/>
| 200mg<ref name="YounkerSoar2010"/>
|
*<6 months: 25mg
*6 months - 6 years: 50mg
*6 - 12 years: 100mg<ref name="YounkerSoar2010"/>
|}
==ReferencesDocumentation==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|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.<ref>{{cite web|url=https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf#page=11|title=Page 9 in: Manual on Contrast Media|website=American College of Radiology, Committee on Drugs and Contrast Media|accessdate=2018-08-25}} Version 10.3. 2018. ACR </ref> {{reflistBottom}}
