Acute complications of nuclear medicine: an emergency medicine perspective

Abstract

BACKGROUND: Nuclear medicine procedures are increasingly integrated into routine clinical practice worldwide, including in low- and middle-income settings. Although radiopharmaceuticals have a well-established safety profile, the growing volume of diagnostic and therapeutic procedures means that acute adverse events, while uncommon, are encountered with sufficient frequency to present to emergency departments. Emergency physicians are often the first clinicians to assess patients with post-procedural symptoms, yet guidance tailored to emergency care remains limited. This review aims to provide an emergency medicine-focused synthesis of the incidence, clinical presentation, and acute management of adverse events associated with nuclear medicine procedures.We conducted a narrative review using a systematic search strategy across PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library, covering publications from January 2020 to December 2024. Studies reporting acute events related to radiopharmaceutical administration, including extravasation, allergic reactions, maladministration, and radiation contamination, were included. Evidence from cohort studies, surveillance registries, systematic reviews, and relevant case reports was synthesized narratively due to methodological heterogeneity. MAIN BODY: Sixty-eight studies encompassing over two million radiopharmaceutical administrations were included. Diagnostic radiopharmaceutical extravasation was common when systematically assessed but rarely resulted in clinically significant harm. Severe allergic reactions and anaphylaxis were exceedingly rare. Maladministration events occurred infrequently and were predominantly associated with diagnostic procedures, with minimal patient harm in most cases. In contrast, extravasation and toxicity related to therapeutic radiopharmaceuticals, particularly high-energy beta emitters, carried greater clinical significance. Newer agents such as lutetium-177-labelled therapies demonstrated predictable toxicity profiles, with hematologic adverse events representing the primary emergency care concern.Emerging alpha-emitting theranostic agents such as actinium-225-PSMA-617 demonstrate promising efficacy but may be associated with clinically relevant xerostomia and hematologic toxicity. CONCLUSION: Acute events related to nuclear medicine procedures are uncommon but clinically relevant in emergency practice. Diagnostic radiopharmaceuticals are generally safe and require supportive management, whereas therapeutic radiopharmaceutical complications warrant heightened vigilance and specialist consultation. Familiarity with these presentations can support timely, appropriate emergency care, particularly in settings with limited on-site nuclear medicine expertise.