Difference between revisions of "Contrast medium reaction"
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− | {{ | + | {{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:Hives on back.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" | {|class="wikitable" | ||
− | !rowspan=2| Symptoms<ref name=SURF/> !! | + | !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/> |
|- | |- | ||
− | ! Adults !! Children | + | ! Class !! Example !! Adults !! Children |
|- | |- | ||
| | | | ||
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*Altered level of consciousness | *Altered level of consciousness | ||
*Severe abdominal pains and vomiting | *Severe abdominal pains and vomiting | ||
− | | Injection of '''adrenaline''' | + | |colspan=2| Injection of '''adrenaline''' |
| Intramuscular in lateral thigh | | Intramuscular in lateral thigh | ||
| 0.3 - 0.5 mg | | 0.3 - 0.5 mg | ||
Line 32: | Line 133: | ||
|- | |- | ||
| Asthma | | Asthma | ||
+ | | '''Bronchodilator''' | ||
| Salbutamol (Ventolin) or own bronchodilator | | Salbutamol (Ventolin) or own bronchodilator | ||
| Inhalation | | Inhalation | ||
Line 43: | Line 145: | ||
|- | |- | ||
| Hypoxia | | Hypoxia | ||
− | | Oxygen | + | |colspan=2| '''Oxygen''' |
| Mask | | Mask | ||
|colspan=2| >5 l/min | |colspan=2| >5 l/min | ||
Line 50: | Line 152: | ||
|- | |- | ||
| Altered level of consciousness or hypotension | | Altered level of consciousness or hypotension | ||
− | | Volume expander | + | | '''Volume expander''' |
+ | | Ringer's | ||
| IV with pressure | | IV with pressure | ||
|colspan=2| 20mg/kg | |colspan=2| 20mg/kg | ||
Line 56: | Line 159: | ||
| As needed | | As needed | ||
|- | |- | ||
− | | All anaphylaxis cases | + | |rowspan=2| All anaphylaxis cases |
− | | Antihistamine | + | |rowspan=2| '''Antihistamine''' |
+ | | Desloratadine (Clarinex/Aerius) | ||
| Oral | | Oral | ||
− | | 10mg of | + | | 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 years: 2.5mg | + | *<6 months: 250μg/kg |
− | *6 - 12 years: | + | *6 months - 6 years: 2.5mg |
− | + | *6 - 12 years: 5mg<ref name="YounkerSoar2010"/> | |
− | |||
|- | |- | ||
|rowspan=2| All anaphylaxis cases | |rowspan=2| All anaphylaxis cases | ||
− | |rowspan=2| Glucocorticoid | + | |rowspan=2| '''Glucocorticoid''' |
+ | | Betamethasone | ||
| Oral or IV | | Oral or IV | ||
− | | | + | | 5-8 mg |
− | |||
| | | | ||
*<6 years: 3-4 mg | *<6 years: 3-4 mg | ||
*≥6 years: 5-8 mg | *≥6 years: 5-8 mg | ||
|rowspan=2| 2-3 hours | |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}} |
Revision as of 20:05, 5 February 2019
Author:
Mikael Häggström [notes 1]
This page in a nutshell: In a more severe reaction:[1]
|
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.
Contents
Evaluation
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 |
|
|
|
| ||
Anaphylaxis, grade 1 |
|
|
| |||
Anaphylaxis, grade 2 |
|
| ||||
Anaphylaxis, grade 3 |
|
|
|
|
In severe hives and progressive angioedema[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.
- 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]
- 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 | ||||
|
Injection of adrenaline | Intramuscular in lateral thigh | 0.3 - 0.5 mg |
|
Less than 5 min | Every 5-10 min if needed | |
Asthma | Bronchodilator | Salbutamol (Ventolin) or own bronchodilator | Inhalation |
|
|
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 |
|
Within 30-60 minutes | |
Chlorphenamine[4] | IM or slow IV[4] | 10mg[4] |
| ||||
All anaphylaxis cases | Glucocorticoid | Betamethasone | Oral or IV | 5-8 mg |
|
2-3 hours | |
Hydrocortisone[4] | IM or slow IV[4] | 200mg[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
- ↑ 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
- ↑ 1.00 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].
- ↑ Kim, Harold; Fischer, David (2011). "Anaphylaxis ". Allergy, Asthma & Clinical Immunology 7 (Suppl 1): S6. doi: . ISSN 1710-1492.
- ↑ 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
- ↑ 4.0 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: . ISSN 13621017., citing Resuscitation Council UK
- ↑ . 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