UW MSK Residents' Manual

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====== Treating Contrast Reactions ======

===== 1. URTICARIA: =====

==== A. Mild urticaria and prutitis ====
 – Observation and H-1 antihistamine (diphenhydramine- 25-50mg PO/IM/IV)
==== B. Severe urticaria ====
  - ADD – IV fluids (normal saline, Lactated ringers)
  - Epinephrine (1:10,000)- 0.1mg – IV slowly
  - Epinephrine (1:1000) – 0.1-0.3mg – subcutaneously
  - H-2 antihistamine
  * cimetidine injectable-300mg-diluted to 20 ml-IV slowly [Pediatric-5-10mg/kg-diluted to 20ml- IV slowly]
  * ranitidine injectable-50mg-diluted to 20ml-IV slowly
===== 2. BRONCHOSPASM (ISOLATED): =====

==== A. Oxygen by mask ====
 – 10 L/min
==== B. Beta-2-agonist metered dose inhaler ====
 – 2-3 deep inhalations (metaproterenol, terbutaline or abuterol)
Use nebulizer if available- albuterol 0.5% solution- 0.5ml in 3ml normal saline- breathe through nebulizer tube for 8-10 minutes
==== C. Epinephrine ====
 
=== Normal blood pressure- stable bronchospasm  ===

(1:1000)-0.1-0.2mg- may give 0.3mg – subcutaneously [Pediatric- 0.01mg/kg up to 0.3mg maximum- subcutaneously]

=== Progressive bronchospasm or decreased blood pressure ===
(1:10,000) – 0.1mg – IV slowly [Pediatric- 0.01mg/kg – IV slowly]

===== 3. HYPOTENSION (ISOLATED): =====

==== A. Elevate patient legs ====

==== B. Oxygen by mask – 10 L/min ====

==== C. IV fluids (primary therapy) ====

  - normal saline or lactated ringers solution-Rapidly
  - If hypotension unresponsive- vasopressor (epinephrine or dopamine)
  - get appropriate assistance – Call CODE
  - Epinephrine – (1:10,000)- 0.1mg- IV slowly
  - IV solution – 1mg in 250ml D5W- start at 4mcgm/min (1ml/min)

===== 4. VAGAL REACTION (HYPOTENSION AND BRADYCARDIA): =====

==== A. Elevate patient legs ====
==== B. Oxygen by mask (10 L/min) ====

==== C. IV fluids ====
- normal saline or lactated ringers solution- Rapidly
==== D. Atropine ====
0.6-1.0mg IV- repeat q 3-5 min (as needed)- 3mg total [Pediatric- 0.02mg/kg IV-starting dose- 0.1-0.6mg dose- 2mg total]

===== 5. ANAPHYLACATOID REACTION (GENERALIZED SYSTEMIC REACTION): =====

==== A. Suction ====
 – as needed
==== B. Elevate patient legs ====
 – if hypotensive
==== C. Oxygen by mask ====
 (10 L/min)
==== D. IV fluids ====
 – normal saline or lactated ringers solution- Rapidly
==== E. Epinephrine ====
 – (1:10,000)- 0.1mg- IV slowly – incrementally over 2-5 minutes [Pediatric- 0.01mg/kg – IV slowly – 0.1mg total (Limit amount of Epinephrine in patients taking non-cardioselective beta-adrenergic blocking drugs]

=== Alternate drug therapy for severe reaction in patients taking beta-adrenergic blocking medications ===


  * Isoproterenol- (1:5000)- 0.2mg/ml- IV slowly- 0.5-1.0ml diluted to 10ml with normal saline- 1ml (20 microgram) increments
  * Glucagon- 1-5 mg IV bolus- followed by IV infusion of 5-15 microgram/min (may cause hypotension)
==== F. Antihistamines ====
  - H-1 blocker : diphenydramine 25-50mg- IV slowly- (may exacerbate or cause hypotension-may thicken bronchial secretions)
  - H-2 blocker
  * cimetidine injectable 300mg- diluted to 20 ml- IV slowly [Pediatric- 5-10mg/kg- diluted- IV slowly]
  * ranitidine injectable 50mg- diluted to 20 ml- IV slowly

==== G. Beta-2-agonist metered dose inhaler ====
- 2-3 deep inhalations (metaproterenol, terbutaline or abuterol)- Use nebulizer if availablealbuterol
0.5% solution- 0.5ml in 3ml normal saline- breathe through nebulizer tube for 8-10 minutes

==== H. Corticosteroids ====
- Hydrocortisone 200mg IV slowly
- Methylprednisolone 80mg IV slowly

===== 6. ANGINA: =====

==== A. Oxygen by mask ====
 – 10 L/min
==== B. IV fluids ====
 – very slowly
==== C. Nitroglycerin ====
 – 0.4mg-sublingually- may repeat q 15 minutes
==== D. Morphine ====
 – 2 mg IV slowly

===== 7. HYPERTENSION: =====

==== A. Oxygen by mask ====
 – 10 L/min
==== B. IV fluids ====
 – very slowly- primarily to maintain IV access
==== C. Nitroglycerin ====
 – 0.4mg-sublingually or 2% ointment topically-1-2 inch strip
==== D. If secondary to autonomic dysreflexia ====

~nifedipine 10mg capsule- punctured or chewed and swallowed
(nifedipine sublingually- is no longer recommended as the first line
drug for treatment of all hypertensive crises- due to very poor
sublingual absorption and reported serious adverse effects)

==== E. If secondary to pheochromocytoma ====
- phentolamine- 5mg- IV slowly

===== 8. SEIZURES: =====
==== A. Protect patient ====

==== B. Airway ====
- suction as needed- monitor airway for tongue obstruction
==== C. Oxygen by mask ====
 – 10 L/min
==== D. If caused by hypotension +/- bradycardia ====
- treat per protocols
==== E. Uncontrolled ====
- consider diazepam- 5mg IV slowly


===== 9. HYPOGLYCEMIA: =====

==== A. Oxygen by mask ====
 – 10 L/min
==== B. IV fluids ====
 – D5W
==== C. IV glucose ====
 – Dextrose 50% solution- IV push
==== D. Oral glucose ====
 – glass of orange juice plus sugar or glass of milk
UW MSK Residents' Manual

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