Contrast Reaction

Acute Reaction

Sign & Symptoms

Allergic-like Physiologic
Mild
  • Limited urticaria / pruritis
  • Cutaneous Edema
  • Limited “itchy”/“scratchy” throat
  • Nasal congestion
  • Sneezing / conjunctivitis / rhinorrhea
  • Limited N/V
  • Transient flushing / warmth / chills
  • Headache / dizziness / anxiety / altered taste
  • Mild hypertension
  • Vasovagal reaction (resolves spontaneously)
Moderate
  • Diffuse urticaria / pruritis
  • Diffuse erythema (V/S stable)
  • Facial edema (w/o dyspnea)
  • Wheezing / bronchospasm (mild/no hypoxia)
  • Throat tightness or hoarseness (w/o dyspnea)
  • Protracted N/V
  • Hypertensive urgency
  • Isolated chest pain
  • Vasovagal reaction (response to Tx)
Severe
  • Diffuse edema / facial edema + dyspnea
  • Diffuse erythema + hypotension
  • Laryngeal edema + (stridor and/or hypoxia)
  • Wheezing / bronchospasm (significant hypoxia)
  • Anaphylactic shock (hypotension + tachycardia)
  • Arrhythmia
  • Hypertensive emergency
  • Convulsions, seizures
  • Vasovagal reaction (resistant to Tx)
Adapted from Table 1 of ACR Manual On Contrast Media (2022)

Treatment

Treatment Disposition
N/V
  • Stop exam
  • Sit to avoid aspiration

Observe 30 min
Urticaria
  • Usually self-limited
  • Moderate: CPM 4 mg PO q 6-8 hr
  • Severe: CPM 10 - 20 mg IV

Possible admission
Facial or laryngeal edema
  • O2 mask 6 - 10 LPM
  • Epinephrine SC or IM (1:1000) 0.1-0.3 mL (= 0.1 - 0.3 mg) (maximum 1 mg)
  • If Hypotension, Epinephrine (1:10,000) slow IV 1-3 mL (= 0.1 - 0.3 mg)

Possible admission
Bronchospasm
  • O2 mask 6 - 10 LPM
  • B2 agonist: e.g., Ventolin 2-3 puffs
    • If not response, epinephrine SC or IM
  • If O2 sat < 88% or Severe, ask for help

Possible admission
Hypotension + HR > 100
  • Monitor: ECG, pulse oximeter, BP
  • O2 mask 6 - 10 LPM
  • Lift leg 60 deg / Trendelenburg
  • IV fluid (NSS or RLS) large volume
    • If not response, Epinephrine slow IV

Possible admission
Hypotension + HR < 60 (vagal reaction)
  • Monitor: ECG, pulse oximeter, BP
  • O2 mask 6 - 10 LPM
  • Lift leg 60 deg / Trendelenburg
  • IV fluid (NSS or RLS) large volume
    • If not response, Atropine 0.6-1 mg slow IV (maximum 2-3 mg)

Possible admission
Severe Hypertension
  • Monitor: ECG, pulse oximeter, BP
  • O2 mask 6 - 10 LPM
  • Nitroglycerine 0.4 mg tab SL (maximum 3 doses)
    • If not response, Labetalol 20 mg IV then 20-80 mg IV q 10 min (max 300 mg)

Admission
Seizures
  • Monitor: V/S (due to resp. depression effect of drug)
  • O2 mask 6 - 10 LPM
  • Diazepam 5 mg IV or Midazolam 0.5-1 mg IV

Possible admission
Pulmonary edema
  • O2 mask 6 - 10 LPM
  • Lift head up
  • Furosemide 20-40 mg IV slow push
  • Morphine 1-3 mg IV

Possible admission
Adapted from Table 3 of ACR Manual On Contrast Media (2022)