Acute Contrast Reaction: Documentation Form
For recording an acute reaction to iodinated or gadolinium-based contrast media. Severity categories harmonised with ACR, RCR/UK and ESUR guidance.
On this page
1. Patient & study details2. Contrast agent administered3. Reaction type4. Severity (tick one): ACR / RCR / ESUR5. Observations at reaction6. Treatment given7. Outcome & disposition8. External adverse-reaction reporting9. Completed by1. Patient & study details
Patient name
ID / MRN
Date of birth
Weight (kg)
Date of reaction
Time of reaction
Examination / indication
Referring clinician
Location (scanner / room)
Relevant history (prior reaction, asthma, allergy, renal, cardiac, beta-blocker)
2. Contrast agent administered
Agent / trade name
Type
Dose (mL / mmol)
Concentration
Route
Injection rate
Batch / lot no.
Expiry
Time of injection
Onset after injection
Premedication given? (drug / dose / time)
3. Reaction type
Allergic-like
- Urticaria / itching
- Erythema / flushing
- Angio-oedema (facial / lip / periorbital)
- Throat tightness / hoarseness
- Bronchospasm / wheeze
- Stridor / laryngeal oedema
- Anaphylaxis
Physiologic
- Nausea / vomiting
- Flushing / warmth / chills
- Headache / dizziness / anxiety
- Vasovagal (bradycardia + hypotension)
- Hyper- / hypotension
- Chest pain / arrhythmia
- Seizure / convulsion
Extravasation? Volume / site / management
4. Severity (tick one): ACR / RCR / ESUR
Mild reaction
Limited urticaria / itching, limited cutaneous oedema, “scratchy” throat, nasal congestion, sneezing, mild nausea/vomiting, transient flushing/warmth, mild headache/dizziness, self-limited vasovagal. Usually observation ± reassurance.
Moderate reaction
Diffuse urticaria, facial oedema without dyspnoea, throat tightness without dyspnoea, mild bronchospasm/wheeze, protracted vomiting, hypertensive urgency, vasovagal needing treatment. Requires treatment and monitoring.
Severe reaction
Diffuse / facial oedema with dyspnoea, laryngeal oedema with stridor/hypoxia, bronchospasm with significant hypoxia, anaphylactic shock (hypotension + tachycardia), hypotension with allergic signs, vasovagal resistant to treatment, arrhythmia, seizures, cardiopulmonary arrest. Emergency: adrenaline, call resus team.
5. Observations at reaction
Time
GCS / consciousness
BP
Heart rate
Resp rate
SpO₂ (%)
Temperature
Peak flow (if done)
6. Treatment given
- Stopped injection / removed cause
- Called for help / resus team (2222 / code)
- Airway support / positioning
- High-flow oxygen, rate: __________
- IM adrenaline 0.5 mg (0.5 mL 1:1000), time: ______
- IV fluids (crystalloid), volume: __________
- Salbutamol / bronchodilator
- H1 antihistamine (e.g. chlorphenamine)
- Hydrocortisone
- Atropine (vasovagal / bradycardia)
- Anti-emetic
- Other: __________________________
Drugs / doses / times (free text)
7. Outcome & disposition
- Full recovery on site
- Observed, duration: __________
- Referred to ED / admitted
- Discharged with advice
- Patient informed of reaction
- GP / referrer notified
Follow-up / discharge advice given
Recommendation for future contrast (avoid / alternative agent / premedication)
Incident / clinical governance report filed?
Yellow Card / MHRA reported? (if applicable)
8. External adverse-reaction reporting
Report suspected reactions to your national pharmacovigilance body. Tick the one used and record the reference number returned.
- New Zealand (CARM / Medsafe): report to the Centre for Adverse Reactions Monitoring (report-a-problem via medsafe.govt.nz, or nzphvc.otago.ac.nz; email nzphvc@otago.ac.nz)
- UK (MHRA Yellow Card): yellowcard.mhra.gov.uk
- Australia (TGA): tga.gov.au (Adverse Medicines Event Line 1300 134 237)
- USA (FDA MedWatch): fda.gov/medwatch
- Other / EU national authority: ______________________________
Reported by
Date reported
Reference / report number
Manufacturer notified? (batch recall)
9. Completed by
Name
Role / grade
Signature
Date & time
Supervising radiologist / clinician informed (name & time)
Severity framework harmonised from the ACR Manual on Contrast Media, the RCR (UK) standards for intravascular contrast, and the ESUR Contrast Media Safety Committee Guidelines 2025. Treatment doses shown are typical adult examples. Always follow your local resuscitation and anaphylaxis protocol and current drug formulary.