Management of reactions to contrast agents.
Reaction     Treatment   Adult dosing       Pediatric dosing (< 50 kg)    
Anaphylaxis   Call CPR team.              
Generalized Systemic Reaction Elevate legs if decreased BP      
Hypotension may be a significant  O2 by mask 6-10 L/min.      
component   IV normal saline      
    Epinephrine 1:10,000 0.1 mg IV over 2-5 min, repeat PRN to 1 mg total. 0.01 mg/kg (max 0.1 mg) repeat PRN to max of 0.05 mg
    Fomoterol (>5 yo) 1 puff (12 mcg)   Not Applicable  
    Albuterol (<5 yo) Not applicable   2.5 mg < 30 kg; 5 mg > 50 kg via nebulizer  
    Diphenhydramine 25-50 mg IV (may drop BP)   1-2 mg/kg (50 mg max) IV  
      Methylprednisolone 80 mg IV (2 x 40 mg vials)     1-2 mg/kg (80 mg max) IV    
Angina/Pulmonary Edema Elevate head, ECG monitoring              
  O2 by mask 6-10 L/min.      
BP > 90 systolic: IV normal saline SLOWLY      
  Nitroglycerin   0.4 mg SL, repeat prn max 3 doses   Not Applicable  
  Morphine   2 mg IV     Not Applicable  
      Furosemide   20 mg IV, may repeat once     1 mg/kg/dose IV (max 20 mg)  
Bronchospasm   O2 by mask 6-10 L/min.            
Normal BP; stable:   Fomoterol (>5 yo) 1 puff (12 mcg)   Not Applicable  
    Albuterol (<5 yo) Not applicable   2.5 mg < 30 kg; 5 mg > 50 kg via nebulizer  
Vasomotor collapse, unstable, Epinephrine 1:10,000 0.1 mg IV over 2-5 min, repeat PRN to 1 mg total. 0.01 mg/kg (max 0.1 mg) repeat PRN to max of 0.05 mg
BP drop:     Epinephrine 1:1,000 0.1-0.2 mg IM (max 0.3 mg)     0.01-0.02 mg/kg (max 0.2 mg) IM    
Hypertension   O2 by mask 6-10 L/min.              
    IV normal saline KVO      
      Nitroglycerin   0.4 mg SL, repeat prn max 3 doses     Not Applicable  
Hypotension   Elevate patient's legs                    
    O2 by mask 6-10 L/min.      
    IV normal saline push Primary treatment!   20 mL/kg (1000 mL max) IV  
Unresponsive:   Call CPR team.      
      Epinephrine 1:10,000 0.1 mg IV over 2-5 min, repeat PRN to 1 mg total. 0.01 mg/kg (max 0.1 mg) repeat PRN to max of 0.05 mg
Laryngeal Edema   O2 by mask 6-10 L/min.              
Stable   Epinephrine 1:1,000 0.1-0.2 mg IM (max 0.3 mg)   0.01-0.02 mg/kg (max 0.2 mg) IM  
Unstable   Call CPR team.      
    Epinephrine 1:10,000 0.1 mg IV over 2-5 min, repeat PRN to 1 mg total. 0.01 mg/kg (max 0.1 mg) repeat PRN to max of 0.05 mg
Mild urticaria/pruritus Diphenhydramine 25-50 mg PO/IM/IV       1-2 mg/kg (50 mg max) IV    
if severe:   Add: Normal Saline      
    Epinephrine 1:1,000 0.1-0.2 mg IM (max 0.3 mg)   0.01-0.02 mg/kg (max 0.2 mg) IM  
    Epinephrine 1:10,000 0.1 mg IV over 2-5 min, repeat PRN to 1 mg total. 0.01 mg/kg (max 0.1 mg) repeat PRN to max of 0.05 mg
      Methylprednisolone 80 mg IV (2 x 40 mg vials)     1-2 mg/kg (80 mg max) IV    
Vasovagal response   Elevate legs                
Hypotension and bradycardia: O2 by mask 6-10 L/min.      
    IV normal saline push   20 mL/kg (1000 mL max) IV  
      Atropine   0.6-1mg repeat prn (max 3 mg)              
Table of risk factors for contrast agents. Pre-treatment of contrast induced nephropathy
Risk Factor     Action         Acetylcysteine 800 mg PO BID day before and of test
Any previous reaction     Pretreatment required         Hydrate with NS or D5 1/2 NS if needed  
Asthma with daily medication or symptoms Pretreatment suggested   Obtain BUN/Cr in:  
Asthma history   Pretreatment optional   1. Diabetics  
Multiple or severe allergies   Pretreatment optional   2. Solitary kidney  
Sickle Cell or PNH   Consider non-contrast study   3. Transplant patients  
Pheochromocytoma (known or suspect) Alpha blockade required   4. Patients with known renal insufficiency  
Arrhythmia   Consider anti-arrhythmic availability  
Angina   Consider nitroglycerin SL availability   Allergy Preps
CHF   Use Iso-osmolar agent or noncontrast study   Full   13 hours 50 mg prednisone PO
Cardiac disease with BB or ACE   Pretreatment optional       7 hours 50 mg prednisone PO
Myasthenia gravis central type   Consider edrophonium       1 hour 50 mg prednisone PO
Hyperthyroid or active nodule   Watch for thyroid storm       1 hour or 50 mg diphenhydramine PO
IL-2 therapy, current or past   Avoid steroid usage       5 mins 50 mg diphenhydramine IV
Metformin   Take dose of day of test, hold after, resume once labs are normal Urgent   4-6 hours 40 mg methylprednisolone IV
Lactation       Pump; Stop active feeding for 24 hours after test   NOT PROVEN! 1 hour 40 mg methylprednisolone IV
    1 hour or 50 mg diphenhydramine PO
Exstravasation     5 mins 50 mg diphenhydramine IV
Condition Action     Emergent   30-60 mins 40 mg methylprednisolone IV
< 20 mL None unless symptoms       2 mins 40 mg methylprednisolone IV
20-100 mL Elevate, ice, vitals, watch 2-4 hours     5 mins 50 mg diphenhydramine IV
>100 mL Consider plastics consult  
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