section name header

Endpaper A

Principles of Treatment!!navigator!!

  1. Give high doses of oxygen
  2. Infuse physiologic fluids
  3. Establish adequate airway
  4. Monitor heart rate & blood pressure
  • No therapeutic role in acute adverse reaction: antihistamines, H2 antagonists, corticosteroids

Vasovagal Reaction!!navigator!!

  • hypotension (systolic blood pressure <80 mmHg) with sinus bradycardia (pulse <60 bpm)
  • dizziness, diaphoresis
  • loss of consciousness
  • Monitor vital signs
  • Leg elevation >60° + Trendelenburg position
  • Secure airway + O2 6–10 L/min
  • Secure IV access + rapid IV infusion of isotonic Ringer's lactate / normal saline

if symptoms persist, add:

  • atropineslowly IV 0.6–1.0 mg
  • Repeat atropine every 3–5 min slowly IV up to a total dose of 0.04 mg/kg (3 mg) in adults
    [pediatric: 0.02 mg/kg IV; starting dose: min. 0.1 mg, max. 0.6 mg; may repeat to total dose of 2 mg]

Dermal Contrast Reaction!!navigator!!

  • hives = urticaria
  • itching = pruritus
  • flushing
  • facial angioedema (= nonpruritic SQ edema of eyelid / peroral)

Mild Urticaria

  • Discontinue injection if not completed
  • No treatment needed in most cases
  • H1-antihistamine, ie
    diphenhydramine (Benadryl®) PO/IM/IV 25–50 mg
    or
    hydroxyzine (Vistaril®) PO/IM/IV 25–50 mg

Severe Urticaria

add H2-antihistamine:

  • cimetidine (Tagamet®) 300 mg PO / slowly IV (diluted in 20 mL D5W solution)
    [pediatric: 5–10 mg/kg diluted in 20 mL D5W solution]
    or
    ranitidine (Zantac®) 50 mg PO / slowly IV (diluted in 20 mL D5W solution)

if widely disseminated:

  • IV line started + kept open (with normal saline / Ringer's lactate)
  • epinephrine IV (1÷10,000) IV slowly over 2–5 min 1.0 mL (= 0.1 mg) if no cardiac contraindication

Nausea / Vomiting!!navigator!!

may be the 1st signs of a more severe reaction

  • watch patient closely

Respiratory Distress!!navigator!!

  • wheezing (inconsequential)
  • bronchoconstriction (life-threatening)
  • laryngeal edema (life-threatening)

Facial / Laryngeal Edema

  • epinephrine SQ (1÷1,000) 0.1–0.2 mL (= 0.1–0.2 mg)
    or – if patient hypotensive –
    epinephrine (1÷10,000) slowly IV 1.0 mL (= 0.1 mg)
    Repeat after 15 min up to a maximum of 1.0 mg
  • O2 6–10 L/min (via mask)
    monitor: ECG; O2 saturation (pulse oximeter); BP

If not responsive to therapy:

  • Seek assistance (CODE team)
  • Consider intubation

Bronchospasm (isolated)

  • O2 6–10 L/min (by mask, not nasal prongs)
    monitor: ECG; O2 saturation (pulse oximeter); BP
  • β2-agonist metered dose inhaler in 2–3 deep inhalations: metaproterenol (Alupent®) / terbutaline (Brethaire®) / albuterol (Proventil®)

NOT: diphenhydramine as it thickens secretions

If unrelieved

with normal blood pressure + stable bronchospasm

  • epinephrine SQ (1÷1,000) 0.1–0.2 mL (= 0.1–0.2 mg); may give 0.3 mg
    [pediatric: 0.01 mg/kg up to 0.3 mg max.]

with decreased blood pressure + progressive bronchospasm

  • epinephrine IV (1÷10,000) slowly over 2–5 min IV 1.0 mL (= 0.1 mg)
    [pediatric: 0.01 mg/kg IV]

Repeat after 15 min up to a maximum of 1.0 mg

Alternatively

  • aminophylline 6 mg/kg IV in D5W over 15–20 min (loading dose); then 0.4–1.0 mg/kg/hr
    Cx: hypotension, cardiac arrhythmia
    or
    terbutaline 0.25–0.50 mg IM/SQ
  • 200–400 mg hydrocortisone IV
    if unsuccessful, may require intubation
    if anxiety exacerbates bronchospasm, sedation with 5–10 mg Demerol IV
  • Call for assistance (CODE team) for severe bronchospasm / if O2 saturation persists <88%

Outline