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Emergencies in Radiology Daniel Jayaprakash Technologist Khorfakkan hospital R D MET
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EMERGENCIES IN RADIOLOGY stable Critically ill Cardio respiratory collapse instability Rescue intervention M.E.T
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EMERGENCIES IN RAIOLOGY M.E.T activated for 1.Neurological(39%). 2.Cardiac (38%). 3.Respiratory (22%) TREATED FOR 1.Neurological (20%). 2Cardiovascular (16%). Abdominal (16%). Respiratory (14%). Comorbid conditions. 1.COPD(23%). 2DM(20%). 3.CCF(19%).
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EMERGENCIES IN RADIOLOGY M.E.T. CALLS 1.CT. 2.MR. 3.ROUTINE XRAY UNITS. OPD. ICU. A/E
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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 .
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY PRIMARY APPROACH SECONDARY APPROACH SKILLS AND EQUIPMENT
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EMERGENCIES IN RADIOLOGY  EARLY RECOGNITION AGRESSIVE INTERVENTION RAPID RESPONSE INSTABILITY 1.BP. 2HEART RATE. 3 .RESPIRATORY RATE. 4.O2 SATURATION .
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EMERGENCIES IN RADIOLOGY M.E.T. CRITEREA FOR CALL RESPIRATORY 1.RATE <8/mt or >36/mt. 2.Breathing difficulty. 3.O2 < 85 % Cardiovascular. Heart rate <40/mt or >140- 160/mt. BP<80mmHg or >200mmHg Systolic.or >110mmHg Diastolic
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EMERGENCIES IN RADIOLOGY Level of consciousness. Pupillary assessment. Motor function . Sensory function. Vital signs. Neurologic changes WHO CAN CALL? PUBLIC,RT, NURSE /PHYSICIAN
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EMERGENCIES IN RADIOLOGY CPR ACTIVATE M.E.T. START CPR (30:2). O2 ADMINISTRATION
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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.
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EMERGENCIES IN RADIOLOGY 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)
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EMERGENCIES IN RADIOLOGY
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY Allergic-Like Reactions Angioedema -swelling of face and lips Laryngeal edema -serious, life threatening condition ,Anxious patient . Stridor, coughing, hoarseness, feeling of lump in throat
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EMERGENCIES IN RADIOLOGY Allergic-Like Reactions Anaphylactic reaction. Hives, skin redness, angioedema, airway narrowing, and hypotension with tachycardia. Life-threatening
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EMERGENCIES IN RADIOLOGY 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.
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY Local anaesthetics: Lignocaine hydrochloride 10mg/ml (20ml). stabilises nerve membrane preventing generation and transmission of impulse. Used in ventricular fibrillation,ventricular tachycardia,ventricular arrhythmia.
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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.
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EMERGENCIES IN RADIOLOGY 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?
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EMERGENCIES IN RADIOLOGY 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/ERYTHEMA LARYNGEAL OEDEMA BENADRYL25-50MG
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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?
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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?
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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 ?
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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?
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EMERGENCIES IN RADIOLOGY Assessment and vital signs EXTRAVASATION ALGORITHM 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
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EMERGENCIES IN RADIOLOGY 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?
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EMERGENCIES IN RADIOLOGY AIR EMBOLISM ALGORITHM Assessment: ABC’s and vital signs Activate emergency response team Place patient in left lateral decubitus position 100% O2 by mask
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EMERGENCIES IN RADIOLOGY Case 7 A 75 yo female is brought to the CT scanner. She suddenly becomes unresponsive. You are alone . What do you do?
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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
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EMERGENCIES IN RADIOLOGY 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.
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EMERGENCIES IN RADIOLOGY Summary: Early recognition,rapid response, efficient support toMET. Basic things –activate MET, administer O2,
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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 on August 26, 2013. •Berg RA, Hemphill R, Abella BS, Aufderheide TP, Cave DM, Hazinski MF, Lerner EB, Rea TD, Sayre MR, Swor RA. Part 5: Adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S685–S705. •Bush WH and Segal AJ. Recognition and treatment of acute contrast reactions. Applied Radiology 2009;38:16-21. Choo KJL, Simons E, Sheikh A. Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2010;65:1205–1211 •Lightfoot CB et al. Survey of radiologists’ knowledge regarding the management of severe contrast material–induced allergic reactions. Radiology 2009;251:691-696 •Sheikh A, ShehataYA, Brown SGA, Simons FER. Adrenaline for the treatment of anaphylaxis: cochrane systematic review. Allergy 2009;64:204–212. •Sheikh A et al. H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2007;62:830–837.
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