CONTRAST REACTION MANAGMENT

  1. Stop the contrast
  2. Start with cardiac leads, pulse ox, BP cuff
  3. Get oxygen face mask ready
  4. Get the Anaphylaxis kit
  5. Know your BLS/ACLS




ANAPHYLAXIS KIT CONTENTS

  1. Albuterol nebulizer 0.083% (2.5 mg/3 mL)
  2. Diphenhydramine 50 mg vial
  3. Epinephrine 1:1,000 vial (1 mL)
  4. Glucagon 1 mg/1 mL vial
  5. Methylprednisolone 125 mg/2 mL vial
  6. 18G 1-1/2" safety needle
  7. 1 mL syringe
  8. Alcohol prep pads
  9. Anaphylaxis box diagram
  10. Pediatric dosing chart (glucagon/methylprednisolone)
  11. Anaphylaxis adult algorithm


Rapid Response Team/CODE call 23-4444

SafetyNet Incident Reporting Form (for reporting contrast reactions) 


REFERENCES



LIMITED CUTANEOUS REACTION: rash or mild hives
  1. Stop injection, no treatment needed in most cases, observe
  2. Diphenhydramine (Benadryl®) PO 25-50 mg


SEVERE DISSEMINATED URTICARIA
  1. Diphenhydramine (Benadryl®) IM or IV 25-50 mg
  2. Epinephrine IM (1:1,000) 0.3 mL (0.3 mg)


BRONCHOSPASM AND/OR FACIAL OR LARYNGEAL EDEMA
  1. O2 6-10 liters/min (via mask)
  2. Attach monitors
  3. Beta-agonist inhalers 2-3 puffs, repeat prn (albuterol, metaproterenol (Alupent®), terbutaline (Brethaire®) 
  4. If unresponsive to inhalers, give Epinephrine IM (1:1,000) 0.3 mL (0.3 mg)
  5. OR if hypotension evident, Epinephrine (1:10,000) slowly IV 1 mL (0.1 mg), repeat PRN to max 1 mg


ANAPHYLACTOID REACTION: hypotension and tachycardia
  1. Legs elevated > 60° or Trendelenburg position
  2. Give O2 6-10 liters/min (via mask)
  3. Attach monitors
  4. NS or LR 1000 mL bolus 
  5. Unresponsive to IVF: Epinephrine (1:10,000) slowly IV 1 ml (=0.1 mg), repeat prn to max 1 mg


VAGAL REACTION: hypotension and bradycardia
  1. Legs elevated > 60° or Trendelenburg position
  2. Give O2 6-10 liters/min (via mask)
  3. Attach monitors
  4. NS or LR 1000 mL bolus
  5. Unresponsive to IVF: Atropine 0.6-1 mg IV slowly, repeat atropine up to total of 0.04 mg/kg (2-3 mg) in adult 


HYPERTENSIVE CRISIS
  1. Give O2 6-10 liters/min (via mask)
  2. Attach monitors
  3. Give nitroglycerin 0.4 mg SL (may repeat x 3) OR topical 2% ointment, apply 1 inch strip
  4. Transfer to intensive care unit or emergency department
  5. For pheochromocytoma—phentolamine 5 mg IV


SEIZURES
  1. Give O2 6-10 liters/min (via mask)
  2. Attach monitors
  3. Anticonvulsants 
    • Lorazepam (Ativan®) 4 mg IV
    • Diazepam (Valium®) 5-10 mg IV
    • Midazolam (Versed®) 0.5-1 mg IV
  4. Call Rapid Response Team 23-4444 


PULMONARY EDEMA
  1. Elevate torso; rotating tourniquets (venous compression)
  2. Give O2 6-10 liters/min (via mask)
  3. Give diuretics – furosemide (Lasix®) 20-40 mg IV, slow push
  4. Consider giving morphine (1-3 mg IV)
  5. Transfer to intensive care unit or emergency department
  6. Corticosteroids optional





CONTRAST EXTRAVASATION

What do I need to do at home?

 

Continue to apply cold packs for 10-15 minutes each hour for at least 3 hours. Be careful NOT to use ice directly on the skin (you may wrap an icepack in a dish towel or pillowcase, so it does NOT directly sit on the skin.)

 

Elevate the extremity to encourage the fluid to drain. This may be easier to do if you are laying down on your back, by placing the injection site on a pillow so it is above the level of your torso.

 

Avoid tourniquet or tightfitting clothes over the affected area for 24-48 hours.

 

Do I need to follow up?

 

We will want to speak with you within 24 hours of the extravasation, or another doctor who you are seeing can assess the site as well. Please contact the appropriate radiology department at which your extravasation occurred, if the affected site or symptoms worsens and/or have questions.

 

Mount Sinai West: 212-523-7191

Mount Sinai St. Luke’s: 212-523-4272

Mount Sinai Beth Israel: 212-420-2540

Mount Sinai Union Square: Monday – Friday: 212-844-8865; Saturday/Sunday: 212-420-2540

Mount Sinai Hospital: 212-241-7401

 

When do I seek emergent help?

 

If you develop limb tightness, weakness, numbness, skin ulcer or worsening pain, please go to your nearest emergency department or call 911.

 

Will my risk for contrast extravasation in the future increase?

 

No. A contrast extravasation event does not increase or decrease your risk for having one in the future.





HOSPITAL EMERGENCY CODES

CODEMEANINGIMMEDIATE RESPONSE 
Medical CodeCardiopulmonary response
  • Initiate BCLS
  • Code team responds to provide ACLS
Rapid Response TeamRRT
  • RRT responds to location to initiate resuscitation of patient, visitor or employee
Code RedSmoke/Fire condition 
  • Rescue
  • Alarm
  • Contain
  • Evacuate/Extinguish
  • Fire Safety Team responds to location
Code BlueSecurity response
  • Security responds to location to provide assistance
Code PinkInfant/Pediatric abduction
  • Security responds to location
  • Initiate access control plan 
Code H.I.C.S.Hospital Incident Command System
  • Hospital Emergency System activated
  • Remain on duty until relieved
Code SilverArmed intruder/Active shooter
  • Avoid intruder
  • "Run, Hide, Fight"
  • Follow instructions from Security & Police 
Code ClearSituation resolved
  • Initiate recovery
  • Resume normal operations