View source for Contrast medium reaction

{{Top
|author1=[[User:Mikael Häggström|Mikael Häggström]]
|author2=
}}
[[File:Intramuscular site of adrenaline.jpg|230px|thumb]]
{{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 media]]''', 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/> 

'''Document''' the incident to avoid repeat reactions.

==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?
* 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===
{|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:Angioedema of the face.jpg|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 minutes

==Anaphylaxis<ref name=SURF/>==
* 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)<ref name=SURF/>==
[[File:Chest compressions.gif|thumb|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:<ref name=SURF/>
* Antihistamine (see Table of medications below)
* Observation at least 30 minutes

==Table of medications==
{|class="wikitable"
!rowspan=2| Symptoms<ref name=SURF/> !!colspan=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
|-
|
*Severe hives
*Respiratory distress
*Hypotension
*Altered level of consciousness
*Severe abdominal pains and vomiting
|colspan=2| 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
|colspan=2| '''Oxygen'''
| Mask
|colspan=2| >5 l/min
| Almost immediate
| Continuous
|-
| Altered level of consciousness or hypotension
| '''Volume expander'''
| Ringer's
| IV with pressure
|colspan=2| 20mg/kg
| Fast
| As needed
|-
|rowspan=2| All anaphylaxis cases
|rowspan=2| '''Antihistamine'''
| 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 anaphylaxis|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
*6 - 12 years: 5mg<ref name="YounkerSoar2010"/>
|-
|rowspan=2| All anaphylaxis cases
|rowspan=2| '''Glucocorticoid'''
| Betamethasone
| Oral or IV
| 5-8 mg
| 
*<6 years: 3-4 mg
*≥6 years: 5-8 mg
|rowspan=2| 2-3 hours
|rowspan=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"/>
|}

==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|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>

{{Bottom}}