Emergencies in radiology Daniel Jayaprakash

Emergencies in Radiology
Daniel Jayaprakash
Technologist
Khorfakkan hospital
R D MET

EMERGENCIES IN RADIOLOGY
stable
Critically ill
Cardio
respiratory
collapse
instability
Rescue
intervention M.E.T

EMERGENCIES IN RAIOLOGY
M.E.T activated for
1.Neurological(39%).
2.Cardiac (38%).
3.Respiratory (22%)
TREATED FOR
1.Neurological (20%).
2Cardiovascular
(16%).
3.Abdominal (16%).
4.Respiratory (14%).
Comorbid conditions.
1.COPD(23%).
2DM(20%).
3.CCF(19%).

M.E.T. CALLS
1.CT.
2.MR.
3.ROUTINE XRAY
UNITS.
1.OPD.
2.ICU.
3.A/E

Pre-Quiz
 1. A patient experiences an acute adverse
contrast reaction. Symptoms include facial
swelling and strider.What is the first medication
that should be administered?
 a. Benadryl
 b.Epinephrine
 c.Corticosteroid
 d.Atropine

Pre-Quiz
 2.The correct dose/route/concentration of
epinephrine that should be administered in the
setting of an acute allergic contrast reaction is:
 a. 1 mg, IV, 1:10,000
 b. 0.3 mg, IV, 1:1,000
 c. 0.3 mg, IM, 1:1,000
 d. 1 mg, IM, 1:10,000

Pre-Quiz
 3. A patient experiences an acute adverse
reaction during a CT scan. Symptoms include
diaphoresis, hypotension and bradycardia.
What medication should be administered?
 a. Benadryl
 b.Epinephrine
 c.Corticosteroid
 d.Atropine

Pre-Quiz
 4. A patient in the Radiology department suddenly
becomes pulse less and unresponsive.You initiate
CPR. What is the appropriate rate of compressions:
breaths?
 a.15:2
 b.15:1
 c.30:2
 d.100:2

Pre-Quiz
 5. According to the 2010 American Heart
Association Basic Life Support guidelines, what
is the first step when encountering an
unresponsive person?
 a. Open airway
 b.Provide rescue breaths
 c.Perform chest compressions
 Activate emergency response system .

Pre-Quiz
 6. According to the 2010 American Heart
Association Basic Life Support guidelines, what
is the second step when encountering an
unresponsive person?
 a. Open airway
 b.Provide rescue breaths
 c.Perform chest compressions
 Activate emergency response system

PRIMARY
APPROACH
SECONDARY
APPROACH
SKILLS AND
EQUIPMENT

 RE
EARLY
RECOGNITION
AGRESSIVE
INTERVENTION
RAPID
RESPONSE
INSTABILITY
1.BP.
2HEART RATE.
3 .RESPIRATORY RATE.
4.O2 SATURATION .

M.E.T. CRITEREA
FOR CALL
RESPIRATORY
1.RATE <8/mt or >36/mt.
2.Breathing difficulty.
3.O2 < 85 %
Cardiovascular.
1.Heart rate
<40/mt or >140-
160/mt.
2.BP<80mmHg
or >200mmHg
Systolic.or
>110mmHg
Diastolic

 Level of consciousness.
 Pupillary assessment.
 Motor function .
 Sensory function.
 Vital signs.
Neurologic
changes
WHO CAN CALL?
PUBLIC,RT, NURSE
/PHYSICIAN

CPR
1.ACTIVATE M.E.T.
2.START CPR (30:2).
3.O2 ADMINISTRATION

CPR-2010 guidelines
 Tap patient on shoulder and shout at them
 Activate MET
 Chest compressions should be initiated
immediately.(30:2)
 (CAB rather than ABC)
 •Provide 2 breaths AFTER first 30 chest compressions

GLOSSARY:
Anaphylactic-an extremely life threatening
allergic reaction to an antigen.(previous exp).
Diaphoresis-increase in sweating.
Inotropic-a drug that acts on myocardium
affecting its contraction.

 Ventricular fibrillation-twitching of the
ventricle,causing a non effective contraction.
 Ventricular tachycardia-rapid contraction of
ventricle causing insufficient flow out of heart.
 Pulseless electrical activity-electrical activity
insufficient to produce a contraction.(PEA)

Allergy like Physiologic
Urticaria Nausea/vomiting
Diffuse erethema Flushing/warmth/chills
Angio edema(facial edema) Anxiety
Laryngeal edema Hypertensive emergency
bronchospasm Seizures
Anaphylactic shock(hypotension
+,tachycardia)
Vasovagal reaction(hypotension +
bradycardia)

Allergic-Like Reactions
 Urticaria -raised red skin wheals and pruritis .
 Erythema -Diffuse skin redness .
 Bronchospasm -resembles asthma attack and
patients may have history of asthma attacks
Anxious patient ,wheezing, shortness of
breath

 Angioedema -swelling of face and lips
 Laryngeal edema -serious, life threatening
condition ,Anxious patient .
 Stridor, coughing, hoarseness, feeling of
lump in throat

 Anaphylactic reaction.
 Hives, skin redness, angioedema, airway
narrowing, and hypotension with tachycardia.
 Life-threatening

 Adrenaline :( IM 0.3ml of 1:1000) upto 2ml.
IV 1ml of 1:10000.
 It’s a cardiac stimulant,vasoconstriction of
peripheral vessels,bronchodilator.
 Used in anaphylactic shock,laryngeal edema and
severe bronchospasm.
 Chlorpheniramine:10-20 mg slow IV .
 Blocks the action of histamines.
 Used to treat urticaria,and anaphylactic reaction.

Hydrocortisone :200mg slow IV.
 Inhibits inflammatory mediators
 Used in treatment and prevention of severe
reaction .action is too slow and not useful in acute
reaction.
 Prednisolone:50mg orally
 13,7, and 1hr before contrast study.
 Buscopan:40mg
 It is antispasmodic,and reduces peristalsis.
 Metaclopramide:5-10mg IV
 Its an anti emetic, increases gastric motility and
gastric emptying

Atropine:0.5-1mg IV
 restores normal conduction and electrical
activity of heart.
 Used in Asystole,Bradycardia,PEA.
 Furosemide:20-40mg IV.(lasix)
 It’s a diuretic that inhibits reabsorption of
sodium and chloride.
 Used to relieve pulmonary congestion

 Local anaesthetics:
 Lignocaine hydrochloride 10mg/ml (20ml).
 stabilises nerve membrane preventing
generation and transmission of impulse.
 Used in ventricular fibrillation,ventricular
tachycardia,ventricular arrhythmia.

 Analgesics:
 Morphine and pethidine (1-3mg slow IV 5mt).
 It increases the venous capacitance and reduces
systemic vascular resistance relieving
pulmonary congestion.
 Is effective in chest pain and acute pulmonary
edema

 Sedatives:
 Diazepam-(2-10mg slow IV ).
 It’s a muscle relaxant and anticonvulsant also relieves
anxiety and tension
 Antihypertensive drugs:
 Nifedepine -10mg (30mg)
 Vasodilators-prevent and relieve vascular spasm.

Case 1
 A 56 year old female is scanned to rule out
acute diverticulitis. After contrast injection
patient is experiencing dyspnea, urticaria,
and facial swelling. What is to be done?

Allergic
Algorythm
Assessment Activate MET
IV ACCSESS
100% O2 ADM
BRONCHIAL
SPASM
INHALER 2 PUFFS ADRENALINE
IM:0.3mg(0.3ml of 1:1000)
upto 1ml
IV:0.1mg(iml of 1:10000)
URTICARIA/ERYTHEMALARYNGEAL OEDEMA
BENADRYL25-50MG

Anaphylaxis
algorythm
Assesment Activate MET
IV ACCSESS
100% O2 ADM
SYSTEMIC
SYMPTOMS
HYPOTEN+TACHY
EPINEPHRINE
IM:0.3mg(0.3ml of 1:1000)
upto 1ml
IV:0.1mg(iml of 1:10000)
IV fluids: 1 L rapid bolus
normal saline

Case 2
 A 23 yrs male is scheduled to have a MR
arthrogram of the right shoulder. Upon
seeing the needle, he immediately becomes
diaphoretic and light-headed.
 How do you respond?

VASOVAGAL
ALGORITHM
Assessment:ABC’s
and vital signs
Activate emergency
response team
IV access 100% O2 by
mask Monitor, pulse
oximeter
1.Trendelenburg position –
elevate legs by 60 degrees
2.IV fluids – 1 L rapid bolus
normal saline
MILD
SEVERE,
BRADYCARDIC
No other treatment
necessary
Atropine 0.6-1.0 mg IV administered
slowly, followed by saline flush Repeat
q3-5 min, up to 3 mg total

Case 3
 18 yrs male sent for CT head for seizures.
While on the CT table, the patient starts
seizing again. What do you do?

SEIZURES
ALGORITHM
Assessment:ABC’s
and vital signs
Activate emergency
response team
•Protect patient, clear area
•Turn patient on side to avoid
aspiration
•Suction airway as needed
IV access 100 % O2 by
mask if not vomiting
UNREMITTING
SEIZURE
Lorazepam IV 2-4 mg,
administered slowly, max
dose of 4 mg

Case 4
 NPO prior to exam
 Diabetics
 Patients feel weak, dizzy or lightheaded
 Patient looks pale or diaphoretic .
 What will you do when the patient gets
hypoglycemic ?

HYPOGLYCEMIA
ALGORITHM
Assessment:ABC’s
and vital signs
Activate emergency
response team
IV access
100% O2 by mask
Monitor, pulse oximeter
HYPOGLYCEMIA
Oral glucose
Juice
Glucose tablet/gel 15 g
D50W 1 ampule (25 g)
IV Administer slowly
over 2 min
Glucagon 1 mg IM
Patient can’t swallow
No IV access

Case 5
 35 yrs female is having a CT scan to rule out
acute appendicitis. During the injection, the
patient complains of severe burning pain in
the forearm at the injection site.The
technologists stop the injection and notice
marked edema and erythema at the injection
site. What do you do?

EXTRAVASATION
ALGORITHM
Assessment
and vital signs
Examine affected limb, check
distal pulses, capillary refill,
motor function and sensation
- Elevate affected extremity
- Cold or warm compresses
(no evidence)
- Analgesia
HIGH CLINICAL
CONCERN*
LOW CLINICAL
CONCERN
Surgical
consultation
Clinical follow-
up required
*Progressive swelling or pain, altered tissue perfusion (decreased capillary refill),
change in sensation, skin ulceration or blistering

Case 6
 A 65 yrs male is having a CTA of the abdomen
to R/O abdominal aortic aneurysm.The
injection malfunctions and a large quantity of
air is injected.The man develops dyspnea and
chest pain. What do you do?

AIR EMBOLISM
ALGORITHM
Assessment:ABC’s
and vital signs
Activate emergency
response team
Place patient in left lateral
decubitus position
100% O2 by mask

Case 7
 A 75 yo female is brought to the CT scanner.
She suddenly becomes unresponsive.You are
alone . What do you do?

CARDIOVASCULAR
ALGORITHM
Assessment:ABC’s
and vital signs
Activate emergency
response team
IV access
100% O2 by mask
Monitor, pulse oximeter
HYPERTENSION
SBP > 200 mm Hg
DBP > 120 mm Hg
PULMONARY EDEMA ANGINA
Labetalol 20 mg IV
Administer slowly over
2 min
Elevate head of bed Nitroglycerin 0.4 mg
SL Morphine 2 mg IV
Nitroglycerin 0.4 mg SL
Furosemide 20-40 mg IV
(administer slowly over 2 min)
Furosemide 20-40 mg IV
(administer slowly over
2 min) Morphine 2 mg IV

Contrast in pregnancy
 Effects of iodinated contrast and gadolinium are
incompletely understood
 Both agents will cross the blood-placental barrier
and enter the fetus
 There is not enough evidence to suggest that
iodinated contrast is safe for the fetus

 Patient should be informed about the potential
risks and benefits, alternative diagnostic options,
and consent should be documented

Gadolinium
 No known teratogenic or mutagenic effects
 Theoretical potential risk for development of
NSF, although no cases have been reported
 Generally recommended that gadolinium
should not be used in pregnant patients
 Risks are unknown and gadolinium should
only be used with great caution

Iodinated contrast in women who are breast-
feeding
 Nearly 100% of iodinated contrast is cleared from
the bloodstream by 24 hours in patients with
normal renal function
 Therefore, less than 0.01% of injected IV contrast
is absorbed by infant from breast milk
 It is safe for mother and infant to continue breast
feeding
 If mother remains concerned, she may express
and discard breast milk for up to 24 hours
 No value to stop breast feeding beyond 24 hours

Universal precaution
 Steps to be taken on exposure to HIV,Hepatitis
B, other body fluids,& contaminated sharps.
 Needle sticks to be washed with soap and
water.
 Splashes to nose,mouth or skin to be flushed
with water.
 Eyes to be irrigated with water ,saline.
 Pricked fingers should not be put into mouth.
 Report the incident and treat as an emergency.

Summary:
Early recognition,rapid response,
efficient support toMET.
Basic things –activate MET,
administer O2,

References
•ACR Committee on Drugs and Contrast Media.ACR Manual on Contrast Media
Version 9. 2013. Accessed at http://www.acr.org/Quality-
Safety/Resources/Contrast-Manual onAugust 26, 2013.
•Berg RA, Hemphill R, Abella BS,AufderheideTP, Cave DM, Hazinski MF, Lerner
EB, ReaTD, Sayre MR, Swor RA. Part 5: Adult basic life support: 2010 American
Heart AssociationGuidelines for Cardiopulmonary Resuscitation and Emergency
CardiovascularCare. Circulation. 2010;122(suppl 3):S685–S705.
•BushWH and Segal AJ. Recognition and treatment of acute contrast reactions.
Applied Radiology 2009;38:16-21.
•Choo KJL, Simons E, SheikhA. Glucocorticoids for the treatment of anaphylaxis:
Cochrane systematic review. Allergy 2010;65:1205–1211
•LightfootCB et al. Survey of radiologists’ knowledge regarding the
management of severe contrast material–induced allergic reactions. Radiology
2009;251:691-696
•SheikhA, ShehataYA, Brown SGA, Simons FER. Adrenaline for the treatment of
anaphylaxis: cochrane systematic review. Allergy 2009;64:204–212.
•SheikhA et al. H1-antihistamines for the treatment of anaphylaxis:Cochrane
systematic review. Allergy 2007;62:830–837.

Emergencies in radiology Daniel Jayaprakash

Emergencies in radiology Daniel Jayaprakash

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