1. Radiology Life Support: Dealing with Acute Contrast Reactions William H. Bush, Jr., MD, FACR University of Washington

2. Contrast Use Test Yourself

3. 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 ?

4. 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

5. Question # 3 Your patient complains of shortness of breath. The most likely reaction occurring is: 1. Vagal reaction with bradycardia 2. Urticaria 3. Bronchospasm

6. 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

7. 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.

8. 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

9. 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

10. 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

11. Question # 9 Initial treatment of laryngeal edema is: (a, b, c, or d) a.Atropine b.Benadryl® c.Beta-agonist inhaler d.Epinephrine

12. Question # 10 Your patient is hypotensive; the most effective route for epinephrine administration is: (a or b) a. Intravenously b. Subcutaneously

13. 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

14. Anticipate Potential Problems: Chemotoxic effects of contrast Anaphylaxis-like reactions

15. 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.

16. 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.

17. 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.

18. 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)

19. 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.

20. PREMEDICATION WHEN IS IT NECESSARY? History of a few scattered hives: No History of treatment for prior reaction: Yes

21. 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

22. 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

23. PREMEDICATION Corticosteroids: necessary to decrease risk of contrast reactions needing treatment Antihistamines: alone are not adequate

24. PREMEDICATION Corticosteroids are essential Need minimum of 6 hours before contrast (preferably longer) ** Reduces risk but does not eliminate it

25. Recognition & Treatment of Systemic Reactions

26. Patient Presentations Uncomfortable Calm, poorly responsive to commands Anxious, agitated

27. 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)

28. Responding to a Possible Reaction Take their pulse Talk with them

29. Responding to a Possible Reaction Taking their pulse: 1. Palpable: systolic is 80-90 mmHg 2. Rate: rapid or slow

30. Responding to a Possible Reaction Talking with the patient: 1. Assess for laryngeal edema 2. Assess degree of SOB 3. Assess responsiveness

31. Uncomfortable Skin reaction: Redness, itching, hives Nausea & vomiting

32. Uncomfortable Skin reaction: Redness, itching, hives Nausea & vomiting Plan: observation (may be first signs of a more serious reaction)

33. SERIOUS, LIFE-THREATENING REACTIONS

34. RESPONDING TO A SERIOUS REACTION Multiple tasks to accomplish 1. Airway / suction / oxygen 2. Obtain pulse; I.V. access 3. Leg elevation 4. Provide medications 5. Cardiac monitor / pulse oximeter 6. Obtain Blood pressure Take “ownership” of a task

35. Calm, Unresponsive Hypotension Hypoglycemia

36. HYPOTENSION With Tachycardia With Bradycardia

37. HYPOTENSION WITH TACHYCARDIA Leg elevation (approx. 60°) Oxygen by mask ( 6-10 L/min ) IV fluids (normal saline or Ringer’s lactate) Treatment includes :

38. 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:

39. VAGAL REACTION Key finding = decreased pulse rate

40. 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

41. Anxious, Agitated HYPOXIA (lack of oxygen)

42. ACUTE BRONCHOSPASM Recommended treatment: Beta-2 agonist inhaler (2 - 3 puffs) Supplementary treatment: Epinephrine

43. LARYNGEAL EDEMA Goals: Oxygenation Reduce edema of upper airway Treatment: Oxygen by mask Epinephrine, 1:10,000 IV

44. EPINEPHRINE: Route of Administration If hypotension is not significant – can use I.M. or subcutaneous route With significant Hypotension – Use IV

45. Epinephrine for I.V. use

46. 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)

47. EPINEPHRINE: Route of Administration If hypotension is not significant – can use I.M. or subcutaneous route

48. 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

49. 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

50. 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

51. LARYNGEAL EDEMA Beta-2 agonist inhaler: may make edema worse Benadryl®: thickens secretions; may cause hypotension

52. AD BENRYL

53. PEDIATRIC REACTIONS Children have good hearts If a problem develops, think AIRWAY

54. RESUSCITATION Airway: – clear, suction – jaw lift – oral airway Ventilation: – mouth-valve-mask – bag-valve-mask (Ambu ® )

55. OXYGEN IS GOOD ! ( for all reactions )

56. 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)

57. OXYGEN Via mask High flow rate ( 6 – 10 L / min. )

58. RESPONDING TO A SERIOUS REACTION Multiple tasks to accomplish 1. Airway / suction / oxygen 2. Obtain pulse; I.V. access 3. Leg elevation 4. Provide medications 5. Cardiac monitor / pulse oximeter 6. Obtain Blood pressure Take “ownership” of a task

59. QUIZ REVIEW

60. 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)

61. 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

62. 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

63. 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

64. 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.

65. Answer to 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

66. 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

67. 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

68. 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

69. Answer to Question # 10 Your patient is hypotensive; the most effective route for epinephrine administration is: (a or b) a. Intravenously b. Subcutaneously

70. 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

71. THANK YOU