Contrast Extravasation Detected
Iodinated or gadolinium contrast has leaked outside the vein during injection (adult or child)
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RadiologyEmergency
Contrast Extravasation Management (ACR Manual 2026)
Contrast Extravasation Management (ACR Manual 2026): Contrast Extravasation Detected → Stop the Injection Now → Examine the Limb → Any Sign of Severe In...
Pathway Overview
12 steps
Algorithm Steps
12 total
01Start 02Warning Stop the Injection Now
Stop the injection and call a doctor (ideally the radiologist) to examine the patient. Central line, PICC or port: do not remove the line; get senior advice
- Stop the injection at once; do not flush the line. Adult peripheral cannula: remove it. Child: leave it in until reviewed
- Do not aspirate, puncture or squeeze the site
- Contrast was still given: watch for a contrast reaction as usual; if IV access is needed, use another limb
03Action Examine the Limb
Ask about pain, numbness and tingling. Examine every patient, whatever the volume
- Tenderness, swelling and redness; mark the edge of the swelling
- Numbness or tingling (paraesthesia)
- Active and passive movement of fingers, wrist and elbow (or toes, ankle)
- Perfusion: colour, capillary refill, distal pulses
- Skin: blisters or ulceration
- Volume is a guide only: severe injury can follow a small volume
04Decision Any Sign of Severe Injury?
Severe or increasing pain, progressive swelling, slow capillary refill, change in sensation, worse finger/wrist/elbow movement, or blisters or ulcers
- If Yes
05Warning Severe Signs: Urgent Surgical Review
Possible compartment syndrome or severe skin injury. Call plastic or hand surgery now; do not wait for a volume threshold
- Urgent plastic or hand surgery review now; the surgeon decides on compartment pressure measurement and fasciotomy without delay
- Suspected compartment syndrome: keep the limb at heart level, not above; remove tight dressings, splints and jewellery
- Analgesia and hourly limb checks until review; no hyaluronidase, steroid injection or aspiration
06Action If Blisters, Ulcer or Necrosis: Wound Care
Skin injury can appear hours to days later; manage with the surgical team
- Photograph and document the skin
- Wound care as advised by the surgical team
- Deep necrosis may need debridement or grafting
07Action Document and Report
Record the event for follow-up and quality review
- Cannula site and gauge; power or hand injection; injection rate
- Contrast agent, concentration and estimated volume extravasated
- Exam findings, treatment, advice given and follow-up plan
- Incident report as per local policy
08Outcome Expected Course
Most extravasations resolve within hours to days without lasting harm. Severe injury is very rare (well under 1%); compartment syndrome is the most common severe injury
- Local inflammation can peak at 24 to 48 hours
- Gadolinium extravasation injury is much less likely than with iodinated contrast
- Prevention: cannula (not butterfly), test saline flush, secure the cannula, prefer the antecubital fossa, watch the site during injection
If No09Warning No Severe Signs: Check for Higher Risk
These patients need closer and longer observation and a lower threshold for surgical review. Child: also follow the local paediatric extravasation guideline
- Cannot report pain or severely ill: infant, child, elderly, confused, sedated or unconscious patient
- Poor limb circulation: peripheral arterial disease, diabetic vascular disease, Raynaud's, venous thrombosis, lymphoedema, prior radiation or node dissection
- Site in hand, wrist, foot or ankle, or a large volume
10Action No Severe Signs: Elevate and Cold Pack
Conservative care. No medicine has proven benefit
- Elevate the limb above heart level
- Cold pack wrapped in cloth at first; cold or warm packs may then continue on and off until symptoms settle
- Poor arterial circulation or Raynaud's: avoid direct or prolonged ice
- Simple analgesia as needed
- Adult: no hyaluronidase, steroid injection or aspiration. Child: treatment as per the paediatric guideline
11Decision Worse on Reassessment?
Repeat the limb exam before discharge. New or worse pain, swelling, numbness, reduced movement, slow capillary refill or blisters? If yes: urgent surgical review (Severe Signs step)
- If Yes
- Path rejoins step 05Shared downstream outcome
If No12Action Stable or Improved: Discharge With Written Advice
Discharge only when the doctor is satisfied that signs have improved and no new symptoms have developed
- Continue elevation and cold or warm packs at home until symptoms settle
- Return at once for severe or increasing pain, numbness or tingling, reduced movement, skin blisters or ulcers, or colour change
- Severe injury can start hours later; initial signs may be mild
- Inpatients: continue care and repeat limb checks on the ward
- Path rejoins step 07Shared downstream outcome
Guideline Source
ACR Manual on Contrast Media (2026 version), Chapter 7 Extravasation of Contrast Media (2022 evidence-based update)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Severe injury (compartment syndrome) can follow a small volume, especially in the hand, wrist, foot or ankle: decide on signs, not volume
- Patients who cannot report pain (infants, children, confused or sedated patients) need closer observation
- No treatment has proven benefit; evidence for elevation and compresses is weak
- Exact extravasated volume is often unknown
- Covers peripheral IV extravasation. Central line, PICC or port extravasation (chest wall, neck, mediastinum) needs senior advice
- Children: Australian paediatric guidelines (e.g., RCH) grade by percentage of limb swelling and may use washout or hyaluronidase; follow the local paediatric guideline
Applicable Regions
USEUAU
AU: RANZCR Iodinated Contrast Media Guideline V2.3 (R34-R35) agrees: limb elevation, cold or warm compresses, monitoring for compartment syndrome, and surgical referral for ulceration, necrosis or compartment syndrome. Emergency: call 000.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Contrast Extravasation Management (ACR Manual 2026)?
The Contrast Extravasation Management (ACR Manual 2026) is a emergency clinical algorithm for Radiology. It provides a structured decision tree to guide clinical decision-making, based on ACR Manual on Contrast Media (2026 version), Chapter 7 Extravasation of Contrast Media (2022 evidence-based update).
What guideline is the Contrast Extravasation Management (ACR Manual 2026) based on?
This algorithm is based on ACR Manual on Contrast Media (2026 version), Chapter 7 Extravasation of Contrast Media (2022 evidence-based update).
What are the limitations of the Contrast Extravasation Management (ACR Manual 2026)?
Known limitations include: Severe injury (compartment syndrome) can follow a small volume, especially in the hand, wrist, foot or ankle: decide on signs, not volume; Patients who cannot report pain (infants, children, confused or sedated patients) need closer observation; No treatment has proven benefit; evidence for elevation and compresses is weak; Exact extravasated volume is often unknown; Covers peripheral IV extravasation. Central line, PICC or port extravasation (chest wall, neck, mediastinum) needs senior advice; Children: Australian paediatric guidelines (e.g., RCH) grade by percentage of limb swelling and may use washout or hyaluronidase; follow the local paediatric guideline. Individual patient factors may require deviation from these recommendations.
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