Body CT Protocols — Interactive Reference

All Body CT Protocols — click a card to expand

Protocols

100mL

Std IV Contrast

3–5 mL/s

Injection Rate

50 HU

Liver SMART PREP

150 HU

Aorta SMART PREP

All

Abdomen

Liver

Renal

Vascular

Special

Routine Abdomen/Pelvis

Default abdomen exam · starting point for many studies

Portal Venous Water Oral SMART PREP 50 HU

Indications

Appendicitis (with water + IV), diverticulitis, cervical/endometrial cancer staging, general abdominal pathology. Base protocol for many tailored exams.

Contrast

Oral: 800 mL water (default)
IV: Omnipaque 350 · 100 mL · 3–5 mL/sec

Scan Method

Portal venous phase — SMART PREP, ROI over liver (50 HU above baseline), dome of liver → SP
Coronal + sagittal reformats, 3 mm reconstructions

Notes

Pediatric appendicitis: add oral contrast. Vaginal contrast (60–120 mL surgilube) for cervical/endometrial cancer.

Abdomen/Pelvis with Delay

Portal venous + 3-min delayed phase

Portal Venous 3-min Delay SMART PREP

Indications

Concern for pyelonephritis
Suspicion of non-GI bleeding following procedure

Contrast

Oral: 800 mL water
IV: Omnipaque 350 · 100 mL · 3–5 mL/sec

Scan Method

Portal venous phase — SMART PREP ROI liver (50 HU above baseline), dome → SP
Delay phase — 3 min post-contrast, dome → bottom of kidneys (extend through pelvis if bleeding concern)
Coronal + sagittal reformats of portal venous phase, 3 mm

Non-Contrast Abdomen/Pelvis

No IV contrast · hemorrhage / contraindication

No IV Contrast Retroperitoneal Hemorrhage

Indications

Suspicion for retroperitoneal hemorrhage (anticoagulation/spontaneous)
Pathology requiring IV contrast, but contrast contraindicated (use positive oral contrast)

Contrast

Oral: None / Omnipaque 350 50 mL in 1000 mL / Barium (if iodine allergy)
No IV contrast

Scan Method

Dome of liver → symphysis pubis
Coronal + sagittal reformats

⚠ Do NOT Use For

Retroperitoneal hemorrhage from intervention/trauma (use IV contrast)
Renal stones (use Renal Stone protocol — lower dose)

Trauma

Portal venous + 4-min renal delay

Trauma Portal Venous 4-min Delay

Contrast

Oral: Water 800 mL
IV: Omnipaque 350 · 100 mL · 3–5 mL/sec

Scan Method

Portal venous phase — SMART PREP ROI liver (50 HU), liver → inferior pubic rami
Delayed scans through kidneys at 4 min; extend to SP if pelvic injury suspected
Coronal + sagittal reformats of portal venous phase

Special Steps

Clamp Foley before scan
Renal injury: ensure collecting system opacified; repeat at 10 min if needed
Bladder injury suspected: perform CT Cystogram
Penetrating abdominal injury: add rectal contrast
Pelvic fractures: scan full abdomen + pelvis during delays

CT Cystography

Trauma & R/O bladder leak

Bladder Distension Foley Required Active Fill

Procedure

Foley catheter required (cleared from urethral injury in trauma)
Inject 200–300 mL dilute contrast via Foley by gravity (2–3% iodine: 75–100 mL Omnipaque 350 in 1 L saline)
Scan lower abdomen + pelvis
Passive filling via IV not sufficient to exclude rupture

What to Look For

Intraperitoneal extravasation: along gutters / between bowel loops
Extraperitoneal extravasation: anterior to bladder, abdominal wall, scrotum

Notes

For r/o leak: consider post-void imaging. Pre-filling images not needed if patient just had pelvic CT.

Quad Phase Liver (±Pelvis)

Non-contrast · Arterial · Portal Venous · Equilibrium

4 Phases 125 mL Contrast SMART PREP Aorta 150 HU

Indications

After chemoembolization or ablation of primary/metastatic liver malignancy
Follow-up of metastatic disease with prior high attenuation (calcifications, hemorrhage)

Contrast

Oral: Water 800 mL
IV: Omnipaque 350 · 125 mL · 4–5 mL/sec

Scan Method

Pre-contrast — top → bottom of liver
Arterial phase — SMART PREP Aorta (150 HU), ≥25 sec delay, top → bottom liver. Goal: hepatic arterial opacification, minimal portal vein contrast
Portal venous phase — 80 sec delay, abdomen (±pelvis)
Equilibrium phase — 3 min delay, top of liver → bottom of kidneys
Coronal + sagittal reformats of arterial + portal venous phases

⚠ Do NOT Use For

HCC/Cholangio surveillance without prior treatment → use Triple Phase
Characterization of indeterminate liver lesion → use Triple Phase

Pelvis

Include if known pelvic pathology in primary liver malignancy OR for metastatic disease

Triple Phase Liver (±Pelvis)

Arterial · Portal Venous · Equilibrium

3 Phases 125 mL HCC Surveillance

Indications

Surveillance or follow-up for primary liver malignancy (HCC/Cholangio)
Characterization of previously indeterminate liver lesion

Contrast

Oral: Water 800 mL
IV: Omnipaque 350 · 125 mL · 4–5 mL/sec

Scan Method

Arterial phase — SMART PREP Aorta (150 HU), ≥25 sec, top → bottom liver
Portal venous — 80 sec delay, abdomen (±pelvis)
Equilibrium — 3 min delay, top of liver → bottom of kidneys
Coronal + sagittal reformats of arterial + portal venous phases

⚠ Do NOT Use For

After ablation/embolization → use Quad Phase (need non-contrast for high-attenuation material)

Dual Phase (±Pelvis)

Arterial · Portal Venous

2 Phases 125 mL Hypervascular Mets

Indications

Hypervascular metastases: renal, melanoma, neuroendocrine (carcinoid, islet cell, pheo), GIST, sarcoma, thyroid
Pre-treatment staging of adrenal malignancy
Post-treatment follow-up for renal/pancreatic malignancy
Follow-up of previously characterized renal mass (size only)
Complications of pancreatitis
Liver transplant follow-up (non-HCC indication)

Contrast

Oral: Water 800 mL
IV: Omnipaque 350 · 125 mL · 4–5 mL/sec

Scan Method

Arterial phase — SMART PREP Aorta (150 HU), ≥25 sec, top of liver → iliac crest
Portal venous — 80 sec delay, abdomen (±pelvis)
Coronal + sagittal reformats of portal venous phase

⚠ Do NOT Use For

Breast or testicular cancer → use Routine Abdomen/Pelvis
Indeterminate liver lesion / primary hepatic malignancy → use Triple Phase

Liver Donor

Angiographic · Portal Venous · pre-op evaluation

2 Phases 125 mL Coronal MIP

Indication

Preoperative evaluation of living related liver donor

Contrast

Oral: Water 800 mL
IV: Omnipaque 350 · 125 mL · 4–5 mL/sec

Scan Method

Angiographic phase — top of liver → iliac crest
Portal venous — 80 sec delay, top of liver → iliac crest
Coronal + sagittal reformats of both phases
Coronal MIP of angiographic phase

Adrenal Mass (±Pelvis)

Non-contrast · Portal Venous · 15-min Delay

3 Phases 15-min Delay Washout Analysis

Indications

Known adrenal lesion incompletely characterized
Follow-up of indeterminate or benign adrenal lesion
Biochemical evidence of adrenal pathology

Contrast

Oral: Water 800 mL
IV: Omnipaque 350 · 100 mL · 4–5 mL/sec

Scan Method

Non-contrast — single breath-hold, liver dome → iliac crest (check images before continuing)
Portal venous — 80 sec delay, abdomen (±pelvis)
Delay phase — 15 min post-injection, top of liver → iliac crest
Coronal + sagittal reformats of portal venous phase

Key Decision Point

If non-contrast shows homogeneous lesion <10 HU → likely adenoma → radiologist may stop exam (unless other abdomen/pelvis eval needed).

Notes

All phases must include aortic bifurcation (rule out paraganglioma)
Do NOT use to pre-op stage adrenal malignancy → use Dual Phase A/P

Renal Mass (±Pelvis)

Non-contrast · Corticomedullary · Nephrographic · Delayed

4 Phases 30s · 90s · 4-min Low-dose Non-con

Indications

Initial evaluation with symptoms worrisome for renal malignancy (no prior imaging)
Characterization of inadequately assessed or indeterminate renal lesion (Bosniak 2F)
First post-treatment scan for renal malignancy
Pre-treatment staging of known renal malignancy
High suspicion for complicated pyelonephritis (abscess/phlegmon)

Contrast

Oral: Water 800 mL
IV: Omnipaque 350 · 100 mL · 4–5 mL/sec

Scan Method

Non-contrast — top → bottom of kidneys (low-dose technique)
Corticomedullary phase — 30 sec delay, top of liver → bottom of kidneys
Nephrographic phase — 90 sec delay, abdomen (±pelvis)
Delayed phase — 4 min delay, top of liver → bottom of kidneys
Coronal + sagittal reformats of nephrographic phase
Coronal MIP of corticomedullary phase

Notes

Medullary low-attenuation masses may be missed on corticomedullary phase alone
Non-contrast critical for abscess (<10 HU enhancement) vs phlegmon differentiation
Pyelonephritis without complication → use Routine Abdomen/Pelvis

Renal Stone

Non-contrast low-dose · No IV / No oral

No Contrast Low Dose Non-contrast Only

Indications

History of renal/ureteral stones with symptoms consistent with renal colic
Follow-up stone burden in patient with known stones
High suspicion for renal/ureteral stones

Contrast

Oral: None
IV: None

Scan Method

Non-contrast — top of kidneys → SP using low-dose technique
Coronal + sagittal reformats

Notes

Most ureteral stones are at UVJ — look for hydronephrosis, periureteral stranding, enlarged kidney
AIDS patients on protease inhibitors (Indinavir) may have non-opaque stones
If concern for other acute pathology → use Routine Abdomen/Pelvis

Renal Artery Stenosis

Arterial · Nephrographic · 3D reconstructions

2 Phases Coronal MIP 3D VR

Contrast

Oral: Water 800 mL
IV: Omnipaque 350 · 100 mL · 4–5 mL/sec

Scan Method

Arterial — top of kidneys → SP
Nephrographic — 90 sec, top of kidneys → iliac crest
Coronal + sagittal reformats of arterial phase
Coronal MIP of arterial phase

3D Reconstructions

Shaded surface display of renal arteries + aorta
Curved MPR of each renal artery

Renal Donor / UPJ

Non-contrast · Arterial · Nephrographic · 7–10 min Delay

4 Phases Detailed Measurements 3D VR

Contrast

Oral: Water 800 mL
IV: Omnipaque 350 · 100 mL · 4–5 mL/sec

Scan Method

Non-contrast — top → bottom of kidneys (check: hydronephrosis in donor may require full A/P before contrast)
Arterial — top of kidneys → iliac bifurcation
Nephrographic — 90 sec, top of liver → SP
Delay — 7–10 min
Coronal + sagittal reformats of nephrographic phase
Coronal MIP of arterial phase

Required Measurements

Total renal lengths
Renal artery lengths: aorta → hilum (+ first branch if proximal)
Right renal vein: hilum → IVC
Left renal vein: hilum → IVC; left lateral aortic border → hilum

3D Reconstructions

Shaded surface displays of arterial, venous, and delayed phases

Renal Recipient

Arterial · 2-min Venous

2 Phases Coronal MIP

Contrast

Oral: Water 800 mL
IV: Omnipaque 350 · 100 mL · 4–5 mL/sec

Scan Method

Arterial — top of kidneys → SP
Venous — 2 min delay, iliac crest → SP
Coronal + sagittal reformats + Coronal MIP of arterial phase
3D: Shaded surface display of arterial phase

Urogram (CT Urography)

Non-contrast · Nephrographic · Excretory (prone 10 min)

3 Phases Prone Excretory 250 mL Saline Flush

Indications

Hematuria workup
Known/suspected urothelial malignancy (not previously treated / incompletely evaluated)

Contrast

Patient drinks 32 oz water on arrival
IV: Omnipaque 350 · 100 mL + 250 mL normal saline flush

Scan Method

Non-contrast — top → bottom of kidneys (low dose)
Nephrographic — 90 sec, dome of liver → SP
Excretory — 10 min delay, prone position, top of kidneys → SP
Coronal + sagittal reformats + MIP of both phases
3D: Shaded surface display of collecting systems; Thick MIP

Notes

Post-treatment surveillance → use Urogram Post Treatment
If little excretion on delayed: consider rescan or follow-up KUB
Patient <50 yrs, ordered by non-urologist: discuss stopping after non-con if stones found

Pancreatic Mass (±Pelvis)

Arterial · Portal Venous · 32 oz water + large IV

2 Phases 125 mL IV Duodenum Distension

Indications

Initial evaluation: symptoms worrisome for pancreatic malignancy, no prior imaging
Initial staging / characterization of pancreatic lesion inadequately imaged

Contrast

Oral: Water (+ 32 oz on arrival) — OPACIFICATION AND DISTENTION OF DUODENUM IS VERY HELPFUL
IV: Omnipaque 350 · 125 mL · 4–5 mL/sec

Scan Method

Try to scan entire pancreas in single breath-hold for all phases
Arterial — top of liver → iliac crest
Portal venous — 80 sec delay, abdomen (±pelvis)
Coronal + sagittal reformats of arterial + portal venous phases

⚠ Do NOT Use For

Routine pancreatitis → Routine A/P
Pancreatitis complications → Dual Phase
Post-pancreatic surgery follow-up → Dual Phase
Follow-up size of pancreatic cystic lesions of low malignant potential → Routine A/P

Enterography — IBD

Volumen oral · Enteric 50 sec · IBD / adhesions

1 Phase Volumen 3×450 mL 50-sec Enteric

Indications

Inflammatory bowel disease or malabsorptive disorder
Intermittent bowel obstruction — evaluate for adhesions

Contrast

Oral: VoLumen 0.1% v/v — 3 bottles × 450 mL (60 min prior / 40 min prior / 20 min prior + 400 mL water at table)
IV: Omnipaque 350 · 100 mL · 4–5 mL/sec

Scan Method

Enteric phase — 50 sec delay, liver dome → SP
Coronal + sagittal reformats of enteric phase

⚠ Do NOT Use For

GI bleed or bowel tumor → Enterography GI Bleed/Tumor
Acute small bowel obstruction → Routine A/P
Consider MR enterography for young patients / multiple prior exams (discuss with ordering physician)

Enterography — GI Bleed/Tumor

Volumen · Enteric 50 sec · 2-min Delay

2 Phases Volumen Obscure GI Bleed

Indications

Obscure gastrointestinal bleeding (not seen on upper or lower endoscopy)
Suspicion for or history of small bowel tumor

Contrast

Oral: VoLumen 0.1% v/v — 3 × 450 mL
IV: Omnipaque 350 · 100 mL · 4–5 mL/sec

Scan Method

Enteric phase — 50 sec, liver dome → SP
Delay phase — 2 min, liver dome → SP
Coronal + sagittal reformats of enteric phase

⚠ Do NOT Use For

IBD → Enterography IBD
Acute GI bleeding (emergent/inpatient) → Mesenteric Ischemia protocol

Mesenteric Ischemia

Arterial · Venous 90 sec · Coronal MIP

2 Phases Acute Ischemia Coronal MIP

Indications

Concern for acute mesenteric ischemia
Suspected acute gastrointestinal bleeding

Contrast

Oral: Water 800 mL
IV: Omnipaque 350 · 100 mL · 4–5 mL/sec

Scan Method

Arterial — liver dome → SP
Venous — 90 sec delay, liver dome → SP
Coronal + sagittal reformats of arterial + venous phases
Coronal MIP of enteric phase

Notes

This protocol does NOT actively distend small bowel — limited for soft-tissue mass evaluation. Do NOT use for IBD or small bowel tumor.

Aortic Dissection

Non-contrast · Arterial (apices→SP) · 4-min organ perfusion

3 Phases No Oral Contrast SMART PREP Arch 150 HU

Contrast

Oral: None (interferes with 3D reconstruction)
IV: Omnipaque 350 · 100 mL · 4–5 mL/sec

Scan Method

Non-contrast — top of arch → diaphragm (intramural hematoma may not be visible with contrast)
Arterial — SMART PREP aortic arch (150 HU), apices → SP
Delays — 4 min, dome of liver through kidneys (organ perfusion)
Coronal + sagittal reformats + Coronal MIP of arterial phase
3D: Shaded surface display of aorta + branch vessels

⚠ Critical Note

If aortic dissection found on abdominal scan → consult radiologist re: immediate chest CT.

Aortic Aneurysm — Pre-EVT

Arterial · 4-min Delay · Detailed measurements

2 Phases Stable Pts Only AAA Measurements

Contrast

Oral: None or Water 800 mL
IV: Omnipaque 350 · 100 mL · 4–5 mL/sec

Scan Method

Arterial — SMART PREP abdominal aorta (150 HU), liver dome → SP
Delays — 4 min, liver + kidneys
Coronal + sagittal reformats + Coronal MIP of arterial phase
3D: Shaded surface display of aorta + branch vessels

Required Measurements

Diameter adventitia-to-adventitia: max aorta at lower renal artery, 1 cm below, 2 cm below, widest point
Minimum diameters: each common iliac, each external iliac, common femorals at inguinal ligament
Lengths: lower renal artery → neck of aneurysm; aneurysmal segment; aortic bifurcation → each common iliac bifurcation

⚠ Note

Hemodynamically unstable patients → OR directly. Quick non-contrast may be diagnostic if patient becomes unstable in CT.

Aortic Aneurysm — Post-EVT

Non-contrast · Arterial · 4-min Delayed (endoleak)

3 Phases Endoleak Detection Same Parameters All Phases

Contrast

Oral: None or Water
IV: Omnipaque 350 · 100 mL · 4–5 mL/sec

Scan Method

Non-contrast — dome → SP (assess pre-existing high density: calcifications, prior embolization)
Arterial — SMART PREP abdominal aorta (150 HU), liver dome → SP
Delayed — 4 min, liver dome → SP (same parameters as non-contrast — for delayed endoleak)
Coronal + sagittal reformats + Coronal MIP of arterial phase

Lower Extremity Run-Off

Peripheral vascular disease · Diaphragm → toes

2 Phases HiRes HD Mode ASIR 30%

Contrast

Oral: Water
IV: 4–5 mL/sec (125 mL)

Scan Method

Non-contrast — diaphragmatic hiatus → toes
Arterial — HiRes HD mode with Volume ASIR 30%
SMART PREP over knees — trigger at first blush of contrast (do NOT use ROI)
Coverage: diaphragmatic hiatus → toes
Coronal + sagittal reformats + Coronal MIP of arterial phase

CT Colonography

CO₂ insufflation · Supine + Prone · Low mAs

No IV (default) CO₂ at 25 mmHg Stool Tagging

Prep

Dry prep preferred (fleet soda/clean prep)
Stool/fluid tagging: Tagitol with breakfast, lunch, dinner (day before); 60 cc gastrograffin night before
Bowel prep: night before + morning of procedure
1 mg glucagon SC 10 min prior to scanning

Contrast

No oral contrast
No IV contrast (unless radiologist indicates otherwise)

Procedure

Lateral decubitus: place rectal tube, inflate balloon cuff
Start insufflation prone → right decubitus → supine → left side
CO₂ autoinsufflator at 25 mmHg pressure limit (usual volume 4–6 L)
Scout to ensure adequate insufflation before scanning

Scan Method

Scan supine + prone
Low mAs: 100 mA if BMI <40; 150 mA if BMI >40
Send data to 3D workstation
At end: cut tubing before removing rectal catheter for immediate relief

Tissue / Finding	HU Range	Notes
Air	Very negative	Lungs, bowel gas
Fat	Negative HU	Subcutaneous, mesenteric
Fluid	0–20 HU	Ascites, simple cyst
Abscess	0–40 HU	Enhancement <10 HU
Parenchyma (non-con)	40–70 HU	Liver, spleen, kidney
Bone	>500 HU	Cortical bone
Calcified Lung Nodule	>200 HU	Benign calcification criterion
Adrenal adenoma (likely)	<10 HU non-con	Homogeneous → likely adenoma → stop exam
SMART PREP — Liver	50 HU above baseline	Portal venous phase trigger
SMART PREP — Aorta	150 HU	Arterial phase trigger (aneurysm, dissection)
SMART PREP — Aorta (cardiac low output)	150 HU	Use for poor cardiac output patients

Agent	Dose / Timing	Indications
None	—	Renal stone, CT colonography, acute SBO, aortic procedures
Water	400 mL at 20 min; 400 mL at table	Routine A/P, CTAs, HCC screen, CTU, adrenal/renal mass, pancreatic mass
VoLumen / Breeza	3 × 450–500 mL: 60/40/20 min + 400 mL water at table	IBD, small bowel mass, GI bleed, malabsorption, CTA mesenteric
Barium 2.1%	225 mL at 60 min; 225 mL at 30 min + 400 mL water	Iodine allergy requiring positive oral contrast
Iodinated (Omnipaque)	50 mL in 1000 mL: 500 mL at 60 min; 500 mL at 30 min	Suspected proximal bowel perforation/leak, non-acute SBO transit, no IV contrast possible

Protocol	Volume	Rate
Routine A/P · Trauma · Non-con A/P · Adrenal · Renal Mass · Renal Stone · Renal Art Stenosis · Renal Donor · Renal Recipient · Urogram · Mesenteric Ischemia · Rectal Contrast · CT Pelvis · Aortic Dissection · Pre/Post EVT	100 mL	3–5 mL/s
Quad Phase Liver · Triple Phase Liver · Dual Phase · Liver Donor · Pancreatic Mass	125 mL	4–5 mL/s
Urogram (saline flush)	+250 mL NS	immediately after contrast
Lower Extremity Run-Off	125 mL	4–5 mL/s
CT Cystography bladder fill	200–300 mL dilute (2–3%)	Gravity via Foley
Renal Stone / CT Colonography	No IV contrast

Phase	Delay	Protocols
Arterial (SMART PREP)	≥25 sec (≥35 sec 4-slice)	Liver phases, Renal Artery Stenosis, Aortic, Pancreatic Mass
Enteric	50 sec	Enterography IBD, GI Bleed/Tumor
Portal Venous	SMART PREP 50 HU liver	Routine A/P, Trauma, most protocols
Venous	80–90 sec	Most multi-phase protocols
Corticomedullary	30 sec	Renal Mass
Nephrographic	90 sec	Renal Mass, Renal Donor, Renal Artery Stenosis, Urogram
Delay (renal/liver)	3–4 min	A/P with Delay, Renal Mass, Aortic Dissection, Trauma
Delay (renal collecting)	7–10 min	Renal Donor/UPJ
Excretory	10 min (prone)	Urogram
Adrenal washout	15 min	Adrenal Mass
Equilibrium	3 min	Triple/Quad Phase Liver

#	Problem	Action
1	Bowel loops not opacified	Distinguish from pathology using repeat imaging after positional changes or delayed imaging
2	Suspected bowel wall thickening	Obtain delayed scans + positional changes; ensure viscus is well distended
3	Stomach wall thickening suspected	Give fizzies + water for gastric distension before rescanning
4	Stoma / ileal loop adjacent bowel not opacified	Inject contrast directly through colostomy / stoma with a small catheter
5	Motility issues (slow transit)	Metoclopramide (Reglan) 10 mg PO promotes gastric emptying (rarely used)
6	Bowel perforation suspected	Use dilute iodinated contrast (NOT barium)
7	Iodine allergy requiring positive oral contrast	Use dilute barium instead
8	Bowel obstruction — no oral transit	No oral contrast needed — air/fluid provide natural negative contrast

Contrast Reaction Management — Emergency Reference

MILD Reaction

SELF-LIMITED · Usually no treatment needed

Signs & Symptoms

Urticaria / skin flushing
Itching (pruritus)
Mild nausea
Scattered hives (<10 wheals)
Nasal stuffiness
Sneezing / conjunctivitis

Management Steps

Stop injection. Observe patient.

Reassure patient — most mild reactions self-resolve.

For urticaria / itching: Diphenhydramine (Benadryl) 25–50 mg IV or IM.

Monitor vital signs q 5–10 min. Document.

Observe minimum 30 minutes before discharge.

MODERATE Reaction

REQUIRES ACTIVE TREATMENT · Call physician immediately

Signs & Symptoms

Diffuse urticaria / angioedema
Bronchospasm (wheezing)
Mild hypotension (responsive to treatment)
Severe nausea / vomiting
Tachycardia or bradycardia
Hypertension

Management Steps

Stop injection. Call physician. IV access confirmed.

Supplemental O₂ via mask at 6–10 L/min.

Bronchospasm: Albuterol inhaler 2–3 puffs or epinephrine 1:1000 — 0.3 mL IM.

Hypotension: Normal saline IV 1–2 L bolus rapidly.

Diphenhydramine 50 mg IV for urticaria/angioedema.

Monitor continuously. Prepare to escalate to SEVERE management.

SEVERE / ANAPHYLAXIS

LIFE-THREATENING · Activate emergency code NOW

Signs & Symptoms

Severe hypotension (unresponsive to fluids)
Severe bronchospasm / laryngeal edema
Loss of consciousness
Cardiopulmonary arrest
Angioedema with airway compromise

Management Steps

ACTIVATE CODE / CALL 911. Do not leave patient.

Epinephrine 1:1000 — 0.5 mL (0.5 mg) IM into outer thigh. Repeat q 5–15 min if needed.

Lay patient flat, legs elevated (unless breathing difficulty).

O₂ high-flow 10–15 L/min. Prepare for intubation.

IV fluids wide open — Normal saline 1–2 L bolus.

Cardiac arrest: Epinephrine 1 mg IV + CPR per ACLS.

Transfer to ED / ICU. Document everything with timestamps.

Emergency Drug Reference

Epinephrine 1:1000

0.3–0.5 mg IM (outer thigh)

First-line anaphylaxis; bronchospasm unresponsive to inhaler

Diphenhydramine (Benadryl)

25–50 mg IV / IM

Urticaria, pruritus, mild-moderate allergic reactions

Albuterol (Ventolin)

2–3 puffs inhaler

Bronchospasm / wheezing — mild to moderate

Normal Saline (0.9% NaCl)

1–2 L IV rapid bolus

Hypotension, volume replacement

Methylprednisolone

125 mg IV

Delayed anaphylaxis prevention; severe reactions (slow onset)

Atropine

0.6–1 mg IV

Vagal bradycardia associated with contrast reaction