ContrastRx

Premedication Strategy Acute Reaction

* * * UPDATED 6/2015 * * *
Content summarized from the ACR Manual on Contrast Media v9 (2013)

Medical Disclaimer

dsk 2015

Premedication

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Elective Protocols

  • Prednisone 50mg PO 13h, 7h, and 1h before exam.
    PLUS Benadryl 50mg PO, IV, or IM 1h before exam.
  • Medrol (methylprednisolone) 32mg PO 12h and 2h before exam.
  • IV Hydrocortisone 200mg 13h, 7h, and 1h before exam.
    PLUS Benadryl 50mg PO, IV, or IM 1h before exam.

Emergency Protocols

  • Solu-Medrol (methylprednisolone) 40mg or hydrocortisone 200mg IV q4h until exam
    PLUS Benadryl 50mg IV 1h before exam.
  • Decadron 7.5mg or Betamethasone 6mg IV q4h until exam in patient with known allergy to medrol, aspirin, NSAIDS, especially if asthmatic.
    Also Benadryl 50mg IV 1h before exam.
  • Omit steroids entirely and give Benadryl 50 mg IV

NOTE: IV steroids have not been shown to be effective when given less than 4-6 hours prior to contrast injection

Acute Reaction

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Acute Reaction

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  1. Diffuse Erythema
  2. Preserve IV access; Monitor vitals; Pulse oximeter; 6-10 L/min O2 by mask
  3. No treatment needed if normotensive
  4. If hypotensive:
  5. Normal saline or Lactated Ringers rapid infusion (1,000 mL)
  6. Consider epinephrine (IV) 1-3 ml of 1:10,000 slowly (=0.1-0.3 mg). Can repeat every 5-10 min up to 10 mL total
  7. If no IV access, consider epinephrine (IM) 0.3 mg 1:1,000. Can repeat up to 1 mg total (IM EpiPen® or equivalent up to 3 times)
  8. Consider calling emergency response team or 911

Acute Reaction

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  1. Laryngeal Edema
  2. Preserve IV access; Monitor vitals; Pulse oximeter; 6-10 L/min O2 by mask
  3. Epinephrine (IV) 1-3 ml of 1:10,000 slowly (=0.1-0.3 mg). Can repeat every 5-10 min up to 10 mL total
  4. OR Epinephrine (IM) 0.3 mg 1:1,000. Can repeat up to 1 mg total (IM EpiPen® or equivalent up to 3 times)
  5. Consider calling emergency response team or 911 based upon completeness of response

Acute Reaction

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  1. Bronchospasm
  2. Preserve IV access; Monitor vitals; Pulse oximeter; 6-10 L/min O2 by mask
  3. Give 2 puffs beta-agonist inhaler (Albuterol®) repeat up to 3 times
  4. Consider sending to ED, calling emergency response team or 911 based upon completeness of response
  5. Moderate Bronchospasm
  6. Consider epinephrine (IM) 0.3 mg 1:1,000. Can repeat up to 1 mg total (IM EpiPen® or equivalent up to 3 times)
  7. Consider epinephrine (IV) 1-3 ml of 1:10,000 slowly (=0.1-0.3 mg). Can repeat every 5-10 min up to 10 mL total
  8. Consider calling emergency response team or 911 based upon completeness of response
  9. Severe Bronchospasm
  10. Epinephrine (IV) 1-3 ml of 1:10,000 slowly (=0.1-0.3 mg). Can repeat every 5-10 min up to 10 mL total
  11. OR Epinephrine (IM) 0.3 mg 1:1,000. Can repeat up to 1 mg total (IM EpiPen® or equivalent up to 3 times)
  12. Call emergency response team or 911

Acute Reaction

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  1. Hypotension with Tachycardia (Anaphylactoid reaction)
  2. Preserve IV access; Monitor vitals; Pulse oximeter; 6-10 L/min O2 by mask
  3. Elevate legs at least 60 degrees
  4. Consider Normal saline or Lactated Ringers rapid infusion (1,000 mL)
  5. If hypotension persists
  6. Epinephrine (IV) 1-3 ml of 1:10,000 slowly (=0.1-0.3 mg). Can repeat every 5-10 min up to 10 mL total
  7. OR Epinephrine (IM) 0.3 mg 1:1,000. Can repeat up to 1 mg total (IM EpiPen® or equivalent up to 3 times)
  8. Consider calling emergency response team or 911 based upon severity of reaction and completeness of response

Acute Reaction

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  1. Hypotension with Bradycardia (Vasovagal Reaction)
  2. Preserve IV access; Monitor vitals; Pulse oximeter; 6-10 L/min O2 by mask
  3. Elevate legs at least 60 degrees
  4. Consider Normal saline or Lactated Ringers rapid infusion (1,000 mL)
  5. If mild, no other treatment necessary
  6. If severe (remains symptomatic)
  7. Atropine (IV) 0.6 to 1 mg IV slowly followed by saline flush; can repeat up to 3 mg total
  8. Consider calling emergency response team or 911

Acute Reaction

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  1. Hypertensive Crisis (DBP > 120, SBP > 200 and symptoms of end organ compromise)
  2. Preserve IV access; Monitor vitals; Pulse oximeter; 6-10 L/min O2 by mask
  3. Labetalol 20 mg IV slowly over 2 minutes (can double the dose every 10 minutes)
  4. if labetalol unavailable
  5. Nitroglycerine 0.4 mg tablet, sublingual (can repeat every 5 minutes)
  6. AND Furosemide (Lasix®) 20-40 mg IV over 2 minutes
  7. Call emergency response team or 911

Acute Reaction

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  1. Seizures or Convulsions
  2. Observe and protect the patient
  3. Turn patient on side to avoid aspiration
  4. Suction airway as needed
  5. Preserve IV access; Monitor vitals; Pulse oximeter; 6-10 L/min O2 by mask
  6. If unremitting
  7. Call emergency response team or 911
  8. Lorazepam 2-4 mg IV (administer slowly, maximum dose 4 mg)

Acute Reaction

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  1. Pulmonary Edema
  2. Preserve IV access; Monitor vitals; Pulse oximeter; 6-10 L/min O2 by mask
  3. Elevate head of bed, if possible
  4. Furosemide (Lasix ®) 20-40 mg IV, slow push
  5. Morphine 1-3 mg IV (repeat every 5-10 min as needed)
  6. Call emergency response team or 911

Acute Reaction

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Acute Reaction

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  1. Unresponsive/Pulseless
  2. Check for responsiveness
  3. Activate emergency response team (call 911)
  4. CPR (30 compressions at 100/min, then 2 respirations)
  5. Get defibrillator or AED, apply ASAP and shock as indicated
  6. Epinephrine (IV) 10 ml of 1:10,000 between cycles (administer entire ampule quickly)
  7. Note: Please also see BLS and ACLS booklets published by the AHA

Acute Reaction

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  1. Anxiety (Panic Attack)
  2. Diagnosis of exclusion
  3. Assess patient for signs/symptoms of developing reaction
  4. Preserve IV access; Monitor vitals; Pulse oximeter
  5. If no identifiable manifestations and normal oxygenation, consider this diagnosis
  6. Reassure the patient

Acute Reaction

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  1. Hives: Mild (scattered and/or transient)
  2. No treatment often needed.
  3. Consider diphenhydramine (Benadryl®) 25-50 mg PO or fexofenadine (Allegra®) 180 mg PO
  4. Hives: Moderate (more numerous or bothersome)
  5. Monitor vitals; Preserve IV access
  6. Consider diphenhydramine (Benadryl®) 25-50 mg PO or fexofenadine (Allegra®) 180 mg PO
  7. Consider diphenhydramine (Benadryl®) 25-50 mg IM or IV (IV slowly over 1-2 minutes)
  8. Hives: Severe (widespread and/or progressive)
  9. Monitor vitals; Preserve IV access
  10. Consider diphenhydramine (Benadryl®) 25-50 mg IM or IV (IV slowly over 1-2 minutes)
  11. Consider epinephrine (IM) 0.3 mg 1:1,000. (IM EpiPen® or equivalent)
  12. Consider epinephrine (IV) 1-3 ml of 1:10,000 slowly (=0.1-0.3 mg).

Medical Disclaimer

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Content is provided for educational purposes only, and is provided for use by medical professionals. It is not intended as, nor should it be, a substitute for independent professional medical care.

This application should in no way be seen as a replacement for consultation with colleagues and/or other sources. By using this application, you agree to use the information solely for your own educational purposes.