= acute rapidly progressing generalized systemic reaction characterized by multisystem involvement
- tachycardia (pulse >100 bpm)
- hypotension (systolic blood pressure <80 mmHg)
- dizziness, diaphoresis
- loss of consciousness
Hypotension with Tachycardia
- leg elevation >60° + Trendelenburg position
- monitor: ECG; pulse oximeter; BP
- O2 6–10 L/min (via mask, not nasal prongs)
- rapid IV infusion of isotonic Ringer's lactate / normal saline
- suction as needed
if poorly responsive to fluid therapy add vasopressors
- call CODE
- epinephrine IV (1÷10,000) slowly over 2–5 min IV 1.0 mL (= 0.1 mg);
[pediatric: 0.02 mg/kg IV; starting dose of min. 0.1 mg to max. 0.6 mg; may repeat to 2 mg total dose]
repeat after 15 min up to a maximum of 1.0 mg (titrated to effect) - dopamine
if still poorly responsive:
- transfer to ICU
in adults without IV access:
- epinephrine SQ (1÷1,000) 0.3 mL (= 0.3 mg)
in infants / children:
- epinephrine SQ (1÷1,000) with body weight determining the correct dose
Seizure / Convulsion
- protect patient from injury
- monitor airway from obstruction by tongue
- suction as needed
- O2 6–10 L/minute (by mask)
if uncontrolled:
- diazepam (Valium®) 5.0 mg / midazolam (Versed®) 2.5 mg IV
- monitor: ECG, O2 saturation (pulse oximeter), BP
if longer effect needed:
- obtain consultation
- phenytoin (Dilantin®) infusion 15–18 mg/kg at 50 mg/minute
- consider CODE for intubation
Pulmonary Edema
- Elevate torso
- Apply rotating tourniquets for venous compression
- O2 6–10 L/minute (via mask)
- furosemide (Lasix®) 40 mg IV, slow push
- Consider morphine
- Transfer to ICU
- Corticosteroids optional
- monitor: ECG, pulse oximeter, BP
- IV fluids very slowly to maintain venous access
- nitroglycerin 0.4 mg tablet sublingual; may repeat x 3; topical 1–2” strip of 2% ointment
- sodium nitroprusside arterial line (infusion pump necessary to titrate)
- transfer to ICU
for pheochromocytoma:
- phentolamine (Regitin®)
Adult dose: 5.0 mg IV; Pediatric dose: 1.0 mg IV
- O2 6–10 L/min (via mask, not nasal prongs)
- IV fluids, very slowly
- nitroglycerin 0.4 mg, sublingually; may repeat q 15 minutes
- morphine 2 mg IV
- air hunger, dyspnea, expiratory wheezing, cough
- chest pain, pulmonary edema, tachycardia, hypotension
- stroke ← decreased cardiac output / paradoxical air embolism / pulmonary AVM / R-to-L intracardiac shunt
Rx:
- 100% O2 administration
- left lateral decubitus position
= escape of contrast material from vascular lumen + infiltration of interstitial tissue during injection
Incidence: 0.1–0.4%; no direct correlation with injection flow rate (although frequent with power injectors)
Risk: fragile veins, IV catheter indwelling for many days, multiple puncture attempts during IV placement
Effect:
- acute inflammatory response (peaking in 24–48 hrs) related to hyperosmolality of contrast material
- compartment syndrome
- ulceration + tissue necrosis (as early as 6 hours)
- fibrosis
- muscle atrophy
- may be asymptomatic; edema, erythema
- swelling, tightness, tenderness, stinging, burning pain
Evaluate for:
- Skin injury (blanching, discoloration)
- Nerve compromise
- Vascular compromise
Dx:
- Palpate catheter venipuncture site during initial seconds of injection
- Ask patient to report any sensation of pain / swelling at injection site
Severe Cx (uncommon): compartment syndrome, skin ulceration, tissue necrosis
Rx:
- Elevation of affected extremity above heart → decrease capillary hydrostatic pressure
- Cold compress → decreases cellular uptake
- Warm compress → vasodilatation promotes absorption
- Discharge with instructions to watch for symptoms that indicate a need for surgical evaluation
- Surgical consultation if
- extravasation >50 mL
- ↑in swelling / pain after 2–4 hours
- ↓in capillary refill time
- change in sensation (paresthesia) in affected limb
- skin ulceration / blistering
- Documentation in medical record
- Notification of referring physician
- 24-hour follow up (phone call, examination)