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Radiology Life Support: Dealing with
Acute Contrast Reactions
William H. Bush, Jr., MD, FACR
University of Washington
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Contrast Use
Test Yourself
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Question # 1
A patient who has had a reaction to
iodinated contrast is at higher risk for
having a reaction to gadolinium agents.
True or False ?
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Question # 2
Your patient is cool, clammy, and has
perspiration on their forehead and upper
lip. The reaction most likely occurring is:
1. Vagal reaction
2. Urticaria
3. Bronchospasm
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Question # 3
Your patient complains of shortness of
breath. The most likely reaction occurring
is:
1. Vagal reaction with bradycardia
2. Urticaria
3. Bronchospasm
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Question # 4
Which of these IMMEDIATE actions by you during
response to a major allergic-like systemic contrast
reaction is the most important ?
1. I.V. access
2. Airway / suction / oxygen
3. Cardiac monitor / pulse oximeter
4. Blood pressure
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Question # 5
Which of these IMMEDIATE actions by you during
response to a major allergic-like systemic contrast
reaction is the least important ?
1. Talk to the patient
2. Take their pulse
3. Take their blood pressure.
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Question # 6
The treatment for severe hypotension
and bradycardia is: (a, b or c)
a. IV fluids and atropine
b. IV fluids and epinephrine
c. Nitroglycerine
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Question # 7
The key finding for diagnosing a vagal
reaction is: (a, b, c, or d)
a. Rapidity of breathing
b. Systolic blood pressure
c. Diastolic blood pressure
d. Pulse rate
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Question # 8
The adult dose of IV atropine for treating
a vagal reaction is: (a, b, or c)
a. 5-10 mg
b. 1.0 mg
c. 0.3 mg
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Question # 9
Initial treatment of laryngeal edema is:
(a, b, c, or d)
a. Atropine
b. Benadryl®
c. Beta-agonist inhaler
d. Epinephrine
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Question # 10
Your patient is hypotensive; the most
effective route for epinephrine
administration is: (a or b)
a. Intravenously
b. Subcutaneously
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Question # 11
Adult dosage of IV epinephrine for
treating a systemic anaphylaxis-like
contrast reaction is: (a or b)
a. 1 cc of 1:1,000
b. 1 cc of 1:10,000
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Anticipate Potential Problems:
Chemotoxic effects of contrast
Anaphylaxis-like reactions
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CONTRAST-INDUCED NEPHROTOXICITY
Gadolinium is not nephrotoxic if
given in usual does for MR imaging, e.g.
0.1 mmol/kg. However, in larger doses,
there is increased risk to the kidneys.
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GADOLINIUM, ADVANCED RENAL FAILURE, and SYSTEMIC TOXICITY
Unresolved question of increased systemic toxicity to patients with advanced renal failure (e.g. GFR < 15cc/min) or on dialysis.
Theory of Nephrogenic Systemic Fibrosis (NSF): Free Gd triggers the process.
Three dialysis treatments removes 99% of
the gadolinium.
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Questions of Your Patient
• Hemodialysis; advanced renal failure
• Previous reaction to contrast *-obtain specifics
• Asthma *• Allergies *
* Allergic reactions are more likely when these patient factors exist.
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ACUTE, ANAPHYLACTIC-LIKE REACTIONS
from iodinated LOCM
Moderate, non-life-threatening:
0.2- 0.4% (1:250 injections)
Severe, life-threatening:
0.04% (1:2500 injections)
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ACUTE, ANAPHYLACTIC-LIKE REACTIONS
with gadolinium agents
Very uncommon
Mayo Clinic: epinephrine was needed to
treat a serious reaction in 1:20,000
injections of a gadolinium agent.
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PREMEDICATION
WHEN IS IT NECESSARY?
History of a few scattered hives: No
History of treatment for prior reaction: Yes
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PREMEDICATION
Prednisone
50 mg, PO, q 6 h x 3 (e.g. 13, 7, 1 hr)
Diphenhydramine
50 mg, PO 1 hour before contrast
Greenberger and Patterson
J Allergy Clin Immunol
87:867-872, 1991
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PREMEDICATION
Methylprednisolone (Medrol ®)
32 mg, PO, 12 and 2 hours before contrast
Diphenhydramine
50 mg, PO 1 hour before contrast
E. Lasser, et al
N.Engl.J.Med 1987; 317:845-9
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PREMEDICATION
Corticosteroids: necessary to decrease
risk of contrast reactions needing
treatment
Antihistamines: alone are not adequate
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PREMEDICATION
Corticosteroids are essential
Need minimum of 6 hours before contrast
(preferably longer)
** Reduces risk but does not eliminate it
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Recognition & Treatment of
Systemic Reactions
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Patient Presentations
• Uncomfortable
• Calm, poorly responsive to commands
• Anxious, agitated
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Responding to a Possible Reaction
• Quickly assess the situation
• Call for help
• Remove the patient from the MR suite
(much of the emergency equipment
is not MR- compatible)
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Responding to a Possible Reaction
• Take their pulse
• Talk with them
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Responding to a Possible Reaction
• Taking their pulse:
1. Palpable: systolic is 80-90 mmHg
2. Rate: rapid or slow
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Responding to a Possible Reaction
• Talking with the patient:
1. Assess for laryngeal edema
2. Assess degree of SOB
3. Assess responsiveness
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Uncomfortable
• Skin reaction: Redness, itching,
hives
• Nausea & vomiting
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Uncomfortable
• Skin reaction: Redness, itching,
hives
• Nausea & vomiting
• Plan: observation (may be first signs of a more serious reaction)
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SERIOUS, LIFE-THREATENING REACTIONS
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RESPONDING TO A SERIOUS REACTION
• Multiple tasks to accomplish
1. Airway / suction / oxygen2. Obtain pulse; I.V. access3. Leg elevation4. Provide medications5. Cardiac monitor / pulse
oximeter6. Obtain Blood pressure
• Take “ownership” of a task
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Calm, Unresponsive
• Hypotension
• Hypoglycemia
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HYPOTENSION
• With Tachycardia
• With Bradycardia
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HYPOTENSION WITH TACHYCARDIA
• Leg elevation (approx. 60°)
• Oxygen by mask ( 6-10 L/min )
• IV fluids (normal saline or Ringer’s lactate)
Treatment includes:
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HYPOTENSION WITH BRADYCARDIA
• Leg elevation (approx. 60°)
• Oxygen by mask ( 6-10 L/min )
• IV fluids ( normal saline or Ringer’s solution)
• Atropine IV
Treatment includes:
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VAGAL REACTION
• Key finding = decreased pulse rate
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ATROPINE
• Give if bradycardia is symptomatic
• Recommended dose:
• Adult IV dose range: 0.6-1.0 mg
• My preference: 1.0 mg as initial dose
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Anxious, Agitated
• HYPOXIA (lack of oxygen)
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ACUTE BRONCHOSPASM
Recommended treatment:
Beta-2 agonist inhaler
(2 - 3 puffs)
• Supplementary treatment:
Epinephrine
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LARYNGEAL EDEMA
Goals: Oxygenation
Reduce edema of upper airway
Treatment: Oxygen by mask
Epinephrine, 1:10,000 IV
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EPINEPHRINE: Route of Administration
• If hypotension is not significant –
can use I.M. or subcutaneous route
With significant Hypotension – Use IV
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Epinephrine for I.V. use
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EPINEPHRINE (Adrenalin)
INTRAVENOUS:
1:10,000 (1 mg in 10 ml)
10 ml = 1000 mcg
1 ml = 100 mcg
Start with 1 ml given slowly
(deliver the 100 mcg over 2-5 minutes)
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EPINEPHRINE: Route of Administration
• If hypotension is not significant –
can use I.M. or subcutaneous route
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EPINEPHRINE (Adrenalin)
SUBCUTANEOUS OR I.M. ( * if not
hypotensive )
1:1000 (1 mg in 1 ml)
1 ml = 1000 mcg
0.5 ml = 500 mcg
0.1 ml = 100 mcg
Start with 0.1 or 0.2 ml
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EPINEPHRINE
PROBLEMS:
1. Not giving it
2. Giving it too late
3. Giving too much
4. Giving it so that it is not absorbed effectively
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EPINEPHRINE
Recommended initial I.V. Dose:
1 ml of 1:10,000 epinephrine (100 mcgm) given slowly over 2 – 5 minutes
Additional amounts can be given if the
patient does not respond adequately
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LARYNGEAL EDEMA
Beta-2 agonist inhaler: may make edema worse
Benadryl®: thickens secretions;
may cause hypotension
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AD BEN RYL
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PEDIATRIC REACTIONS
Children have good hearts
If a problem develops,
think AIRWAY
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RESUSCITATION
Airway:
– clear, suction
– jaw lift
– oral airway
Ventilation:
– mouth-valve-mask
– bag-valve-mask (Ambu®)
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OXYGEN IS GOOD !
( for all reactions )
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OXYGEN
Nasal cannula:
2 – 6 L/min
provides only 25 – 40% concentration
Simple mask:
6 – 10 L/min
provides 35 – 60 % concentration
(Flow rate at least 6 L/min to prevent
carbon dioxide build-up in mask)
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OXYGEN
• Via mask
• High flow rate
( 6 – 10 L / min. )
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RESPONDING TO A SERIOUS REACTION
• Multiple tasks to accomplish
1. Airway / suction / oxygen2. Obtain pulse; I.V. access3. Leg elevation4. Provide medications5. Cardiac monitor / pulse
oximeter6. Obtain Blood pressure
• Take “ownership” of a task
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QUIZ REVIEW
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Answer to Question # 1
A patient who has had a reaction to
iodinated contrast is at higher risk for
having a reaction to gadolinium agents.
True or False ?
(depending on the prior reaction, consider premedication for the gadolinium study)
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Answer to Question # 2
Your patient is cool, clammy, and has
perspiration on their forehead and upper
lip. The most likely reaction occurring is:
1. Vagal reaction
2. Urticaria
3. Bronchospasm
Treatment: I.V. fluids + atropine
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Answer to Question # 3
Your patient complains of shortness of
breath. The reaction most likely occurring
is:
1. Vagal reaction with bradycardia
2. Urticaria
3. Bronchospasm
Treatment: Beta-2 agonist inhaler; epinephrine
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Answer to Question # 4
Which of these IMMEDIATE actions by you during
response to a major allergic-like systemic contrast
reaction is the most important ?
1. I.V. access
2. Airway / suction / oxygen
3. Cardiac monitor / pulse oximeter
4. Blood pressure
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Answer to Question # 5
Which of these IMMEDIATE actions by you during
response to a major allergic-like systemic contrast
reaction is the least important ?
1. Talk to the patient
2. Take their pulse
3. Take their blood pressure.
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Answer to Question # 6
The treatment for severe hypotension andbradycardia is: (a, b, or c)
a. IV fluids and atropineb. IV fluids and epinephrinec. Nitroglycerine
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Answer to Question # 7
The key finding for diagnosing a vagal
reaction is: (a, b, c, or d)
a. Rapidity of breathing
b. Systolic blood pressure
c. Diastolic blood pressure
d. Pulse rate
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Answer to Question # 8
The adult dose of IV atropine for treating a
vagal reaction is: (a, b, or c)
a. 5-10 mg
b. 1.0 mg
c. 0.3 mg
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Answer to Question # 9
Initial treatment of laryngeal edema is:
(a, b, c, or d)
a. Atropine
b. Benadryl®
c. Beta-agonist inhaler
d. Epinephrine
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Answer to Question # 10
Your patient is hypotensive; the most
effective route for epinephrine
administration is: (a or b)
a. Intravenously
b. Subcutaneously
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Answer to Question # 11
Adult dosage of IV epinephrine for
treating a systemic anaphylaxis-like
contrast reaction is: (a or b)
a. 1 cc of 1:1,000
b. 1 cc of 1:10,000
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THANK YOU