Ten minutes after intravenous iodinated contrast injection, a 55-year-old man becomes pale and diaphoretic with blood pressure 80/50 mmHg and pulse rate 42/min. There is no urticaria, wheeze or stridor. What is the MOST appropriate immediate management?

• A Intramuscular adrenaline 0.5 mg
• B Leg elevation, rapid intravenous crystalloid, and atropine for persistent bradycardia ✓
• C Intravenous hydrocortisone 200 mg and chlorpheniramine
• D Nebulised salbutamol and intravenous furosemide

Explanation

Hypotension with bradycardia and vagal symptoms without urticaria or bronchospasm indicates a vasovagal reaction, not anaphylaxis. Treatment is supine positioning, leg elevation and aggressive crystalloid infusion, with atropine if bradycardia persists. Adrenaline is the key for anaphylaxis, which typically shows tachycardia with urticaria or airway involvement, so the heart rate and absence of allergic features kill that distractor.

Reference: ACR Manual on Contrast Media, current edition ed.

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Written and medically reviewed by the StethoPrep medical team.