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Management of acute Contrast Reactions

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Management of acute Contrast Reactions

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    1. Management of acute Contrast Reactions Fabio Komlos Can you put me as last author? ThanksCan you put me as last author? Thanks

    2. Outline Management of acute contrast reactions Management of IV infiltrations Special contrast related situations that may come up on call Metformin Pregnancy Dialysis Pheocromocytoma

    3. Catergories of reactions Changed wordingChanged wording

    4. Risk factors for a reaction Prior reaction is best predictor. Shellfish allergy NOT a risk factor Multiple other allergies may increase risk but not a contraindication Asthma may increase risk of bronchospasm these patients may already have an inhaler with them. If reaction was minor and patient can tolerate hives, prob OK to proceed with a necessary scan. Bettmann, MA, Heeren T, GreenfieldA, Goudy C. Adverse events with radiographic contrast agents: results of SCVIR Contrast Agent Registry. Radiology 1997; 203 611-620

    5. Risk for Reaction:

    6. Premedication Pre-medication with steroids and anti-histamines Only reduces incidence of minor reactions Must begin 12 hours prior to contrast injection Carries little negative consequences

    7. General approach to reactions Techs 1 - Call radiology on call * 2 - Call Radiology nurse * Consider calling code

    8. General approach to reactions Radiology Resident 1 - ABC (CPR)

    9. General approach to reactions Radiology Resident 1 - ABC (CPR) 2 - Assessment O2 Monitor (BP, pulse) consider cardiac monitor, pulse ox Access (assure venous access)

    10. General approach to reactions Radiology Resident 1 - ABC (CPR) 2 - Assessment O2 Monitor (BP, pulse) consider cardiac monitor, pulse ox Access (assure venous access) 3 Non-pharmacological measures Leg elevation Fluids

    11. General approach to reactions Radiology Resident 1 - ABC (CPR) 2 - Assessment O2 Monitor (BP, pulse) consider cardiac monitor, pulse ox Access (assure venous access) 3 Non-pharmacological measures Leg elevation Fluids 4 - Drugs

    12. General approach to reactions Drugs

    13. General approach to reactions Drugs

    14. Epinephrine

    15. Rash (hives, itching) SOB (wheezing) Hypotension Facil and Laryngeal edema Seizures Most important Situations to deal

    16. Case 1 34y/o female with skin reaction after administration of IV contrast

    17. General approach to reactions Radiology Resident 1 - ABC (CPR) 2 - Assessment O2 Monitor (BP, pulse) consider cardiac monitor, pulse ox Access (assure venous access) 3 - Drugs

    18. Hives No tretament needed most cases Consider Benadryl

    19. Disseminated HIVES Consider epinephrine 1:1000 0.1-0.3cc

    20. Case 2 8 y/o male with SOB after administration of IV contrast

    21. General approach to reactions Radiology Resident 1 - ABC (CPR) 2 - Assessment O2 Monitor (BP, pulse) consider cardiac monitor, pulse ox Access (assure venous access) 3 Non-pharmacological measures Leg elevation Fluids 4 - Drugs

    22. Bronchospasm Initial steps (including O2) Inhaler 2-3 puffs prn If no response: Epinephrine 1:10.000 1cc IV slowly (up to 1mg)

    23. Case 3 65 y/o male feels sick after administration of IV contrast. She is confused

    24. General approach to reactions Radiology Resident 1 - ABC (CPR) 2 - Assessment O2 Monitor (BP, pulse) consider cardiac monitor, pulse ox Access (assure venous access) 3 Non-pharmacological measures Leg elevation Fluids 4 - Drugs

    25. Hypotension Initial steps (including leg elevation and fluids) If no response TACHYCARDIA: Epinephrine 1:10.000 1cc IV slowly (up to 1mg) BRADYCARDIA: Atropine 0.6-2mg IV (up to 3mg) If poor response Call code

    26. Case 1 45y/o male does not look good

    27. General approach to reactions Radiology Resident 1 - ABC (CPR) 2 - Assessment O2 Monitor (BP, pulse) consider cardiac monitor, pulse ox Access (assure venous access) 3 Non-pharmacological measures Leg elevation Fluids 4 - Drugs

    28. Facial or Laryngeal Edema Initial steps (including O2) Epinephrine 1:1000 0.1-0.3cc Consider intubation Call CODE earlier rather than later

    29. Hypotension Initial steps (including leg elevation and fluids) If no response Epinephrine 1:10.000 1cc IV slowly (up to 1mg) If poor response Call code

    30. Case 5 51y/o male with seizure after administration of IV contrast

    31. General approach to reactions Radiology Resident 1 - ABC (CPR) 2 - Assessment O2 Monitor (BP, pulse) consider cardiac monitor, pulse ox Access (assure venous access) 3 Non-pharmacological measures Leg elevation Fluids 4 - Drugs

    32. Seizure Initial steps (including O2, Pulse ox and securing airway Diazepan 5mg IV (may repeat if needed) Get appropriate consultation (may need phenytoin)

    33. Post Reaction Tasks 1 Call referring physician 2 Call nurse in the floor if inpatient 3 Document in the chart 4 Document Allergy in POE if appropriate 5 Inform patient about the future precautions 6 Report the reaction in the dictation

    34. Other situations

    35. Infiltration of IV Elevate Ice Pack If >30cc volume contact plastics monitor for compartment syndrome.

    36. Hypertension Nitroglycerine 0.4mg SL or 1 paste If due to pheochromocytoma phentolamine 5mg IV

    37. Special situations

    38. Metformin (anti-diabetic agent) High levels of Metformin ? lactic acidosis if metformin levels too high (50% mortality) Patients should not be on metformin if their renal function is already compromised Hold metformin after contrast for 48h hours

    39. Pregnancy Only theoretical risks to unborn fetus and to breast feeding infants Use when needed, not for stupid studies or when alternatives are available Pump milk before exam, pump and discard for 24 hours

    40. Dialysis As a rule patients should be dialyzed in the next 24h.

    41. Review What should I do if

    42. Urticaria ABC and Vital signs Consider benadryl If disseminated then consider epinephrine SOB ABC and vital signs Start oxygen Inhaler If no improvement consider epinephrine and CODE Hypotension ABC, vitals, pulse ox, cardiac monitor, IV acces Elevate legs Fluids TACHYCARDIC: Epi BRADYCARDIC: Atropine Laryngeal edema ABC, O2, Pulse ox, cardiac monitor Epinephrine (1:1000) Consider intubation, CODE Seizure Secure airway Diazepan 5mg

    43. Patient is on Metformin Check creatinine. If abnormal contact physician Stop metformin for 48h Patient is lactating Pump before the contrast Pump and discard milk for 12-24h after Patient has allergy to shellfish Nothing Patient has multiple allergies Most times, no premedication recommended Patient has elevated creatine Hydrate Consider mucomyst, bicarb, visipaque

    44. Patient had hives in previous CT scan If possible pre-medicate Prednisone, benadryl, ranitidine Patient has multiple myeloma Try to avoid. Specially if increased Cr Patient had infiltration of contrast in the subcutaneous tissues Elevation and ice Consider evaluation by plastics Patient has asthma Make sure there is b-agonists available Patient complaints of hives ABC Benadryl if necessary Patient on dialysis Advise to dialyse within 24h

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