** Note: second generation antihistamines cause less drowsiness; may be beneficial in patients that need to drive themselves home.

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1 Table 5 : Management of Acute Reactions to Contrast Media in Adults HIVES Mild (scattered and/ transient) No treatment often needed; however, if symptomatic, can consider: Diphenhydramine (Benadryl )* Fexofenadine (Allegra )** mg PO 180 mg PO Moderate (me numerous/bothersome) Monit vitals Consider diphenhydramine (Benadryl )* Fexofenadine (Allegra )** Consider diphenhydramine (Benadryl )* mg PO 180 mg PO mg IM IV (administer IV dose slowly over 1 2 min) Severe (widespread and/ progressive) Monit vitals Consider Diphenhydramine (Benadryl )* mg IM IV (administer IV dose slowly over 1 2 min) Can also consider Epinephrine (IM) IM 0.3 mg (0.3 ml of 1:1,000 dilution) Epinephrine (IV) * Note: all fms can cause drowsiness; IM/IV fm may cause wsen hypotension. IM EpiPen equivalent (0.3 ml of 1:1,000 dilution, fixed) IV 1 3 ml of 1:10,000 dilution; running IV infusion of saline ** Note: second generation antihistamines cause less drowsiness; may be beneficial in patients that need to drive themselves home. ACR Manual on Contrast Media Version 9, 2013 Table 5 / 111

2 DIFFUSE ERYTHEMA All fms Monit vitals Nmotensive No other treatment usually needed Hypotensive IV fluids 0.9% nmal saline 1,000 ml rapidly If profound unresponsive to fluids alone can also consider Lactated Ringers Epinephrine (IV)* (if no IV access available) 1,000 ml rapidly IV 1 3 ml of 1:10,000 dilution; can repeat every 5 10 minutes up to 10 ml total Epinephrine (IM)* IM 0.3 mg (0.3 ml of 1:1,000 Consider calling emergency response team 911 IM EpiPen equivalent (0.3 ml of 1:1,000 dilution, fixed); can repeat up to three times * Note: in hypotensive patients, the preferred route of epinephrine delivery is IV, as the extremities may not be perfused sufficiently to allow f adequate absption of IM administered drug. 112 / Table 5 ACR Manual on Contrast Media Version 9, 2013

3 BRONCHOSPASM All fms Monit vitals Mild Beta agonist inhaler (Albuterol ) 2 puffs (90 mcg/puff) f a total of 180 mcg; can repeat Consider sending patient to the Emergency Department calling emergency response team 911, based upon the completeness of the response Moderate Consider adding epinephrine (IM)* IM 0.3 mg (0.3 ml of 1:1,000 Epinephrine (IV)* IM EpiPen equivalent (0.3 ml of 1:1,000 dilution, fixed; can repeat up to three times) IV 1 3 ml of 1:10,000 dilution; can repeat up to Consider calling emergency response team 911 based upon the completeness of the response Severe Epinephrine (IV)* IV 1 3 ml of 1:10,000 dilution; can repeat up to ACR Manual on Contrast Media Version 9, 2013 Table 5 / 113 Epinephrine (IM)* IM 0.3 mg (0.3 ml of 1:1,000 Call emergency response team 911 IM EpiPen equivalent (0.3 ml of 1:1,000 dilution, fixed); can repeat up to three times * Note: in hypotensive patients, the preferred route of epinephrine delivery is IV, as the extremities may not be perfused sufficiently to allow f adequate absption of IM administered drug.

4 LARYNGEAL EDEMA All fms Monit vitals Epinephrine (IV)* 6 10 L /min IV 1 3 ml of 1:10,000 dilution; can repeat up to Epinephrine (IM)* IM 0.3 mg (0.3 ml of 1:1,000 Consider calling emergency response team 911 based upon the severity of the reaction and the completeness of the response IM EpiPen equivalent (0.3 ml of 1:1,000 dilution, fixed); can repeat up to three times * Note: in hypotensive patients, the preferred route of epinephrine delivery is IV, as the extremities may not be perfused sufficiently to allow f adequate absption of IM administered drug. HYPOTENSION (systolic blood pressure < 90 mm Hg) All fms Monit vitals Elevate legs at least 60 degrees Consider IV fluids: 0.9% nmal saline Lactated Ringers 1,000 ml rapidly 1,000 ml rapidly Hypotension with bradycardia (pulse < 60 bpm) (Vasovagal reaction) If mild If severe (patient remains symptomatic despite above measures) No other treatment usually necessary In addition to above measures: Atropine (IV) Consider calling the emergency response team mg; administer slowly, followed by saline flush; can repeat up to 3 mg total 114 / Table 5 ACR Manual on Contrast Media Version 9, 2013

5 Hypotension with tachycardia (pulse > 100 bpm) (Anaphylactoid reaction) If hypotension persists Epinephrine (IV)* IV 1 3 ml of 1:10,000 dilution; can repeat up to Epinephrine (IM)* IM 0.3 mg (0.3 ml of 1:1,000 Consider calling emergency response team 911 based upon the severity of the reaction and the completeness of the response IM EpiPen equivalent (0.3 ml of 1:1,000 dilution, fixed); can repeat up to three times * Note: in hypotensive patients, the preferred route of epinephrine delivery is IV, as the extremities may not be perfused sufficiently to allow f adequate absption of IM administered drug. HYPERTENSIVE CRISIS (diastolic BP > 120 mm Hg; systolic BP > 200 mm Hg; symptoms of end gan compromise) All fms Monit vitals Labetalol (IV) (if labetalol not available) Nitroglycerin tablet (SL) and Furosemide (Lasix ) (IV) Call emergency response team mg IV; administer slowly, over 2 min; can double the dose every 10 min (e.g., 40 mg 10 min later, then 80 mg 10 min after that) 0.4 mg tablet; can repeat every 5 10 min mg IV; administer slowly over 2 min ACR Manual on Contrast Media Version 9, 2013 Table 5 / 115

6 UNRESPONSIVE AND PULSELESS Check f responsiveness Activate emergency response team (call 911) CPR (30 compressions at a rate of 100 per min, then 2 respirations) Get defibrillat automated electronic defibrillat (AED); apply as soon as available; shock as indicated Epinephrine (between 2 min cycles) IV 10 ml of 1:10,000 dilution (administer entire ampule quickly) Note: Please also see BLS and ACLS booklets published by the American Heart Association. PULMONARY EDEMA Monit vitals Elevate head of bed, if possible Furosemide (Lasix ) Mphine (IV) Call emergency response team mg IV; administer slowly over 2 min IV 1 3 mg; repeat every 5 10 min, as needed SEIZURES/CONVULSIONS Observe and protect the patient Turn patient on side to avoid aspiration Suction airway, as needed Monit vitals If unremitting Call emergency response team 911 Lazepam (IV) IV 2 4 mg IV; administer slowly, to maximum dose of 4 mg 116 / Table 5 ACR Manual on Contrast Media Version 9, 2013

7 HYPOGLYCEMIA If patient is able to swallow safely Oral glucose Two sugar packets 15 g of glucose tablet/gel ½ cup (4 oz) of fruit juice If patient is unable to swallow safely and IV access available Dextrose 50% (IV) D5W D5NS (IV) as adjunct therapy If no IV access is available Glucagon (IM) IM 1 mg D50W 1 ampule (25 grams) IV administer over 2 min Administer at a rate of 100 ml/hour ANXIETY (PANIC ATTACK) Diagnosis of exclusion Assess patient f developing signs and symptoms that might indicate another type of reaction Monit vitals If no identifiable manifestations and nmal oxygenation, consider this diagnosis Reassure patient REACTION REBOUND PREVENTION Note: While IV cticosteroids may help prevent a sht-term recurrence of an allergic-like reaction, they are not useful in the acute treatment of any reaction. However, these may be considered f patients having severe allergic-like manifestations pri to transptation to an Emergency Department inpatient unit. Hydroctisone (Solu-Ctef ) (IV) Methylprednisolone (Solu-Medrol ) (IV) 200 mg IV; administer over 2 min 40 mg IV; administer over 2 min ACR Manual on Contrast Media Version 9, 2013 Table 5 / 117

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9 Table 6: Equipment f Contrast Reaction Kits in Radiology Depending on the size and function of the imaging site, it may be sufficient to have one reaction treatment cart designed to both treat contrast reactions and manage the initial steps in the treatment of cardiac/respiraty arrests. Other facilities may find it me cost-effective to have me widespread distribution of contrast reaction kits to treat non-arrest reactions with fewer full code carts. Some imaging sites will find that their institutions will have standard full code carts throughout the facility, but that smaller and me widely distributed contrast reaction kits may enable rapid implementation of treatment at considerably lower expense than opening an institutional full code cart to treat a non-arrest contrast reaction. In general, these larger institutional carts have me equipment than strictly necessary f radiologists to use, and smaller facilities may find the suggestions below helpful in designing a dedicated reaction treatment cart that can be used to manage arrests until the arrival of other emergency responders. The contact phone number of the cardiopulmonary arrest emergency response team should be clearly posted within near any room in which contrast media is to be injected. The following equipment must be readily available and within nearby any room in which contrast media is to be injected: masks* (adult and pediatric sizes). Epinephrine 1:10,000, 10-ml preloaded syringe (f IV injection) and/ Epinephrine 1:1,000, 1 ml (f SC/IM injection) and/ Epinephrine IM auto-inject. EpiPen Jr. ** ( equivalent) injects 0.15 mg 0.3 ml of 1:2000 EpiPen ** ( equivalent) injects 0.3 mg 0.3 ml of 1:1000 Atropine 1 mg in 10-ml preloaded syringe. Beta-agonist inhaler with without spacer. Diphenhydramine f PO/IM/IV injection. Nitroglycerin (NTG) 0.4 mg tabs, sublingual Aspirin 325 mg. Dextrose 50% 25mg/50mL syringe. The following items should be on the emergency/code cart*** within near any room in which contrast media is to be injected: Blood pressure/pulse monit.. * Although oxygen can be administered in a variety of ways, use of non-rebreather masks is preferred because of their ability to deliver me oxygen to the patient. ** Dey, L.P., Napa, CA *** If in a hospital clinic, the emergency/code cart should confm to hospital departmental policies and procedures, but often includes these listed items. ACR Manual on Contrast Media Version 9, 2013 Table 6 / 119

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