Contrast medium reaction

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Author: Mikael Häggström [notes 1]

Injection Sites Intramuscular Thigh Adult.png
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 contrast medium reaction, 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]

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?

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[3] IM or slow IV[3] 10mg[3]
  • <6 months: 250μg/kg
  • 6 months - 6 years: 2.5mg
  • 6 - 12 years: 5mg[3]
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[3] IM or slow IV[3] 200mg[3]
  • <6 months: 25mg
  • 6 months - 6 years: 50mg
  • 6 - 12 years: 100mg[3]

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 3.7 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


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