Telemedicine-guided management of iodinated contrast media-associated anaphylaxis: A case report

Abstract

Immediate hypersensitivity reactions to iodinated contrast media (ICM) are uncommon, and ICM-associated anaphylaxis with airway compromise is rare, but time critical. In recent years, radiology has increasingly incorporated telemedicine-enabled workflows, including forms of virtual direct supervision, supported in part by evolving U.S. reimbursement and supervision policies. As of January 1, 2026, the Centers for Medicare and Medicaid Services (CMS) has finalized policies indefinitely permitting direct supervision via real-time 2-way audiovisual communications in specified contexts, such as diagnostic imaging. A 63-year-old woman undergoing outpatient CT pelvis with contrast developed acute urticaria, hypotension, hypoxemia, and upper-airway angioedema within minutes of injection, meeting clinical criteria for anaphylaxis. An on-site technologist initiated emergency protocol and activated a telemedicine emergency alert, prompting real-time audiovisual communication with an already connected remote supervising physician. Under remote physician guidance, the on-site team administered two 0.3 mg intramuscular doses of epinephrine, supplemental oxygen, and airway positioning maneuvers, with subsequent improvement in oxygenation and systolic blood pressure before EMS arrival. The patient was later intubated in the emergency department for airway protection, extubated the following day, and discharged home without neurologic sequelae. This case suggests that telemedicine-enabled supervision platforms may support timely recognition and management of ICM-associated anaphylaxis when coupled with on-site preparedness, trained personnel, and readily available emergency medications and airway adjuncts. However, remotely witnessed emergencies introduce distinct operational risks (eg, connection latency, communication handoffs), and warrant rigorous protocols, simulation-based training, and systems-level redundancy. Similar events may become increasingly relevant as distributed imaging care models expand.