Emergence Teleradiology Recommendations

For Contrast Reactions

 

Policy: For all contrast reactions the Supervising Physician is to be notified as soon as possible by radiology personnel.

 

_____________________________________________________________________________

Mild

Signs and symptoms appear self-limited without evidence of progression (e.g., limited urticaria with mild pruritis, transient nausea, one episode of emesis) and include:

 

• Nausea, vomiting                        • Altered taste                                    • Sweats

• Cough                                               • Itching                                                • Rash, hives

• Warmth                                            • Pallor                                                  • Nasal stuffiness

• Headache                                        • Flushing                                              • Swelling: eyes, face

• Dizziness                                          • Chills                                                    • Anxiety

• Shaking

 

Treatment: Requires observation to confirm resolution and/or lack of progression. Patient reassurance is usually helpful.

_____________________________________________________________________________

Moderate- Activate EMS

Signs and symptoms are more pronounced. Moderate degree of clinically evident focal or systemic signs or symptoms, including:

 

• Tachycardia/bradycardia                              • Bronchospasm, wheezing

• Hypertension                                                       • Laryngeal edema

• Generalized or diffuse erythema                  • Mild hypotension

• Dyspnea

 

Treatment: Clinical findings in moderate reactions frequently require prompt treatment. These situations require close, careful observation for possible progression to a life-threatening event.

_____________________________________________________________________________

Severe-Activate EMS

Signs and symptoms are often life-threatening, including:

 

• Laryngeal edema (severe or rapidly progressing)                 • Convulsions

• Profound hypotension                                                                      • Unresponsiveness

• Clinically manifest arrhythmias                                                   • Cardiopulmonary arrest

 

Treatment: Requires prompt recognition and aggressive treatment; manifestations and treatment frequently require hospitalization.

For all cases:

  • Always follow BLS/ACLS Guidelines as indicated
  • Remember your ABCDs (airway, breathing, circulation, drug therapy)
  • Call another radiology personnel for assistance immediately with all contrast reactions
  • If more than mild reaction then activate  911 EMS for emergency response
  • For pediatric patients remember appropriate medication dosing , below are adult doses unless otherwise stated
  • If administer any form of Epinephrine activate EMS and put patient on monitor, have AED device ready.

 

Urticaria:

Mild to Moderate Reaction

  • Benadryl 25-50 mg PO/IM/IV–Adult dose

   1mg/kg up to 50mg–Pediatric dose

  • Discontinue contrast administration
  • Observe 1 hour
  • Discharge home with driver if asymptomatic

Severe Reaction:

  • Benadryl 25-50 mg PO/IM/IV–Adult dose

   1mg/kg up to 50mg–Pediatric dose

  • Epinephrine SC (1:1000) 0.1mg, may repeat q 5 min up to 3 times
  • Contact Primary Care Physician
  • Discharge with driver, patient to follow up with primary care provider that day.

Facial or Laryngeal Edema:

  • Activate EMS
  • Oxygen (6-10L/min)
  • Epinephrine SC (1:1000)  0.1mg, may repeat q 5 min up to 3 times
  • Benadryl 50mg IVP
  • Solu-Medrol 125mg IVP                                                       

Bronchospasm:

  • Activate EMS
  • Oxygen (6-10L/min)
  • Give Albuterol Inhaler 2-3 puffs (beta agonist)
  • Epinephrine SC (1:1000) 0.1mg, may repeat q 5 min up to 3 times
  • Solu-Medrol 125mg IVP                 

Hypotension with Tachycardia:

  • Activate EMS
  • Trendelenberg position or elevate legs
  • Monitor and EKG
  • Oxygen (6-10L/min)
  • Rapid bolus of large volumes of normal saline
  • If poorly responsive and patient unstable consider Epinephrine (1:10,000) 0.1 mg slowly IV, may repeat q 5 min up to 3 times
  • Solu-Medrol 125mg IVP      

Hypotension with Bradycardia (Vasovagal Reaction):

  • Activate EMS
  • Trendelenberg position or elevate legs
  • Monitor and EKG
  • Oxygen (6-10L/min)
  • Rapid bolus of large volumes of normal saline
  • Atropine 1mg IV slowly; Repeat atropine up to 2-3 mg in adult
  • Solu-Medrol 125mg IVP

Hypertension, Severe

  • Activate EMS
  • Monitor and EKG
  • Nitroglycerine 0.4mg tablet, sublingual, ensure have functioning IV give IV NS fluid bolus.        
  • For pheochromocytoma—phentolamine 5.0mg (1.0mg in children) IV
  • Solu-Medrol 125mg IVP

Seizures or Convulsions:

  • Activate EMS
  • Oxygen (6-10L/min)
  • Valium 5mg or Versed 0.5mg IV
  • Solu-Medrol 125mg IVP

Pulmonary Edema:

  • Activate EMS
  • Elevate torso
  • Oxygen (6-10L/min)
  • Administer  Lasix 40mg IV slowly pushed
  • Consider morphine 1-2 mg
  • Solu-Medrol 125mg IVP

 

Equipment and Drugs for Emergency Cart

 

Equipment:

• Oxygen cylinders, flow valve, nasal prongs, tubing, partial non-rebreather oxygen masks (adult and pediatric sizes).

• Suction: wall-mounted or portable; tubing and catheters.

• Oral airways: rubber/plastic; and/or protective breathing barriers.

• “Ambu bag – valve mask and mouth mask (adult and pediatric sizes) with protective barrier.

• Endotracheal tubes: laryngoscopes (adult and pediatric sizes).

• Stethoscope; sphygmomanometer, tourniquets, tongue depressor.

• Intravenous solutions and tubing.

• Normal saline, Ringer’s lactate.

• Syringes: variety of sizes.

• Tracheostomy set, cut-down trays with sterile instruments.

 

The following items should be on the emergency cart or immediately available:

• Defibrillator.

• Electrocardiogram.

• Blood pressure/pulse monitor.

• Pulse oximeter (optional).

 

Medications:

  • Epinephrine 1:10,000, (for IV injection).
  • Epinephrine 1:1000, (for SC/IM injection) or
  • Epinephrine IM auto-injector (injects 0.15 mg or 0.3 ml of 1:2000 [EpiPen Jr] or 0.3 mg or 0.3 ml of 1:1000 [EpiPen] – optional
  • Atropine
  • Albuterol Beta-agonist inhaler.
  • Benadryl for PO/IV injection.
  • Nitroglycerin (NTG) – 0.4 mg tabs, sublingual.
  • Aspirin 325 mg.
  • Solu-Medrol
  • Morphine
  • Lasix
  • Valium or Versed