Management Of Anaphylaxis Research Articles

Management of anaphylaxis in Spain: pediatric emergency care providers' knowledge.

Acute care providers must diagnose and treat patients with anaphylaxis. The objective was to analyze Spanish pediatric emergency departments' (ED) providers' knowledge of the international recommendations for the management of anaphylaxis. A web-based survey including providers (both attending and residents) from seven Spanish pediatric EDs was conducted. To analyze the knowledge of the identification of anaphylaxis, we used the diagnostic criteria given by the National Institute of Allergy and Infectious Disease and Food Allergy and the Food Allergy and Anaphylaxis Network (2005). To analyze the management, we used the practical recommendations on the management of anaphylaxis published by the Joint Task Force on Practice Parameters (2014). A total of 425 physicians received the link and 337 (79.2%) completed the survey (138 attending, 76.6%; 199 residents, 81.2%, P<0.05). More than 90% of the providers correctly identified the anaphylaxis, except for not diagnosing it when reduced blood pressure is detected after exposure to a known allergen (69.7%) and misdiagnosis of anaphylaxis in patients with progressive urticaria with significant angioedema (65.9%). Nearly 100% identified epinephrine as the first-line treatment. Main failures of treatment were related to the position of the patient, the effect of medications in preventing a biphasic reaction, the recommended time to observe patients, and those related to the follow-up. No significant differences were found between attendings and residents. Even though the Spanish pediatric ED providers' knowledge of the management of anaphylaxis is good, certain improvement areas are identified in both the identification and the management of these patients.

The Incidence, Characteristics, Management, and Outcomes of Anaphylaxis in Pregnancy: A Population-based Descriptive Study

(BJOG. 2018;125:965–971) Anaphylaxis in pregnancy is characterized by life-threatening breathing, circulatory or airway problems stemming from a systemic hypersensitivity reaction, often caused by exposure to allergens including antibiotics or latex. The incidence of anaphylaxis in pregnancy is unknown but thought to be rising. There is a lack of guidelines for the management of anaphylaxis in pregnancy. This study aimed to describe the incidence, characteristics, management and outcomes of anaphylaxis in pregnancy in the United Kingdom.

Are outcome measures in allergic diseases relevant for the WHO's International Classification of Diseases in allergology?

To review and understand the impact of the outcome measures of allergic and hypersensitivity conditions for the WHO's International Classification of Diseases (ICD) and its impact in the management of anaphylaxis and identify potential strategies to improve patients' care and prevention. The pioneer chapter addressed to allergic and hypersensitivity conditions in the 11th version of the WHO's ICD is the result of the evidence-based academic technical actions consistently following of collaborations of the allergy community and integrated international initiatives in order to reach quality outcomes measures of allergies worldwide. Allergic and hypersensitivity conditions are increasing worldwide, however, they have never been well represented in the international classification systems, such as the ICD. The ALLERGY in ICD-11 initiative has been launched in 2012 in order to gather a better representation of these conditions in the ICD-11. As a result of the evidence-based academic technical actions acknowledged by the Joint Allergy Academies and the WHO, the pioneer chapter Allergy and hypersensitivity conditions has been constructed. This framework can be considered a milestone in the history of the allergy specialty. More reliable, accurate and comparable epidemiological data will be able to provide a big picture of these conditions and will support improvements in many levels of the health system. As knowledge derived from populations is key information for more realistic decision-making, the construction of the new section addressed to allergic and hypersensitivity conditions in the ICD-11 will allow the collection of more accurate epidemiological data to support quality management of patients, and better facilitate healthcare planning to implement public health measures to prevent and reduce the morbidity and mortality attributable to these conditions.

Diagnosis and management of drug-induced anaphylaxis in children: An EAACI position paper.

Drug hypersensitivity reactions (DHR) constitute a major and common public health problem, particularly in children. One of the most severe manifestations of DHR is anaphylaxis, which might be associated with a life-threatening risk. During those past decades, anaphylaxis has received particularly a lot of attention and international consensus guidelines have been recently published. Whilst drug-induced anaphylaxis is more commonly reported in adulthood, less is known about the role of drugs in pediatric anaphylaxis. Betalactam antibiotics and non-steroidal anti-inflammatory drugs are the most commonly involved drugs, probably related to high prescription rates. Diagnosis relies on the recognition of symptoms pattern and is based on complete allergic workup, particularly including skin tests and/or specific IgE. However, the real diagnostic value of those tests to diagnose immediate reactions in children remains not well defined for a significant number of the drugs. Generally, a drug provocation test is discussed to confirm or exclude an immediate-onset drug-induced hypersensitivity. Although avoidance of the incriminated drug (and related drug) is the rule, rapid desensitization is useful in selected subgroups of patients. There is a need for large, multicentric studies, to evaluate the real diagnostic value of the currently available skin tests. Moreover there is also a need to develop new diagnostic tests in the future to improve the management of these children.

Evaluation of Prehospital Management in a Canadian Emergency Department Anaphylaxis Cohort

Studies assessing the use of antihistamines and corticosteroids for the treatment of anaphylaxis have not supported a conclusive effect. To assess prehospital management of anaphylaxis by measuring the effect of epinephrine use compared with antihistamines and corticosteroids on negative outcomes of anaphylaxis (intensive care unit/hospital ward admission, multiple doses of epinephrine in the emergency department [ED], and intravenous fluids given in the ED). The Cross-Canada Anaphylaxis Registry is a cohort study that enrolls anaphylaxis cases presenting to EDs in 5 Canadian provinces over a 6-year period. Participants were recruited prospectively and retrospectively and were excluded if the case did not meet the definition of anaphylaxis. A total of 3498 cases of anaphylaxis, of which 80.3% were children, presented to 9 EDs across Canada. Prehospital treatment with epinephrine was administered in 31% of cases, whereas antihistamines and corticosteroids were used in 46% and 2% of cases, respectively. Admission to the intensive care unit/hospital ward was associated with prehospital treatment with corticosteroids (adjusted odds ratio, 2.84; 95% confidence interval [CI], 1.55, 6.97) while adjusting for severity, treatment with epinephrine and antihistamines, asthma, sex, and age. Prehospital treatment with epinephrine (adjusted odds ratio, 0.23; 95% CI, 0.14, 0.38) and antihistamines (adjusted odds ratio, 0.61; 95% CI, 0.44, 0.85) decreased the likelihood of receiving multiple doses of epinephrine in the ED, while adjusting for severity, treatment with corticosteroids, asthma, sex, and age. Prompt epinephrine treatment is crucial. Use of antihistamines in conjunction with epinephrine may reduce the risk of uncontrolled reactions (administration of 2 or more doses of epinephrine in the ED), although our findings do not support the use of corticosteroids.

Changes in Emergency Department Concordance with Guidelines for the Management of Food-Induced Anaphylaxis: 1999-2001 versus 2013-2015

Awareness about food allergy and food-induced anaphylaxis (FIA) has increased dramatically over the past decade. It remains unclear, however, whether concordance with guidelines for FIA management has improved over time. Our objective was to describe changes in emergency department (ED) concordance with guidelines for FIA management. We analyzed data from 2 multicenter retrospective studies of patients with food-related acute allergic reactions seen in 1 of 17 EDs during 2 time periods: 1999 to 2001 and 2013 to 2015. Visits were identified similarly across years-for example, using International Classification of Diseases, Ninth Revision, Clinical Modification codes 693.1, 995.60, 995.61-995.69, 995.0, and 995.3. Anaphylaxis was defined as an acute allergic reaction with involvement of 2+ organ systems or hypotension. We compared concordance between time periods for 4 guideline recommendations: (1) treatment with epinephrine, (2) discharge prescription for an epinephrine autoinjector (EAI), (3) referral to an allergist/immunologist, and (4) instructions to avoid offending allergen. We compared 290 patients with FIA during 1999 to 2001 and 459 during 2013 to 2015. Any treatment with epinephrine (pre-ED or in the ED) for patients with FIA increased over time (38% vs 56%; P < .001). Prescriptions for EAI at discharge (24% vs 54%; P < .001) and documentation for referral to an allergist/immunologist (14% vs 24%; P= .001) approximately doubled, whereas instructions to avoid the offending allergen did not change significantly (37% vs 43%; P= .08). Receipt of 3+ guideline recommendations remained low but almost quadrupled over the study interval (6% vs 23%; P < .001). Over the nearly 15-year study interval, we observed clinically and statistically significant increases in ED concordance with epinephrine-related guidelines for FIA. Management gaps remain and interventions to standardize care still appear warranted.

My Throat is Itchy! An In-situ Simulation for Interprofessional Healthcare Education.

In-situ simulation occurs in the clinical environment. This allows healthcare providers greater access to the educational session while providing the opportunity to test systems or protocols in place. Anaphylaxis is a rare and life-threatening event. As such, many healthcare providers are uncomfortable managing it. The use of simulation as an educational methodology allows the learners to practice rare, high-risk scenarios in a low-risk environment. There is no negative impact to an actual patient when an in-situ simulation education session is provided. Usually there are positive results due to increased staff awareness and improved process.In the spring of 2015, stakeholders at the outpatient antibiotic therapy program (OPAT) at The Ottawa Hospital (TOH) approached the nurse educator team to develop an education session around anaphylaxis management. The nurse educators chose to design and implement an in-situ simulation scenario involving the inter-professional clinic team. Through the use of inter-professional in-situ simulation the team was able to clarify roles, identify equipment issues and rectify those issues as this technical report describes.

An update on allergic emergencies.

To provide an updated framework of management for allergic emergencies. The most frequent causes of anaphylaxis include medications, foods, and stinging insects. Early and appropriate administration of epinephrine is critical to managing anaphylaxis. Although epinephrine is well tolerated and there is no absolute contraindication to using epinephrine in first-aid management of anaphylaxis, many patients at risk for anaphylaxis still fail to carry and use the medication prior to seeking emergency care. Outcomes of allergic emergencies can be improved by educational efforts that focus on adherence to emergency plans, as well as asthma controller treatments in patients with persistent asthma. Though venom immunotherapy is known to decrease the risk for stinging insect anaphylaxis, the role of emerging strategies for food allergen immunotherapy in reducing cases of anaphylaxis requires further study. Fatalities resulting from anaphylaxis and asthma are rare. Patient education serves an important role in preparing for unexpected emergencies, instituting prompt and appropriate treatment, and incorporating effective strategies into the lives of children and families.

Cardiovascular complications and acute ischemic stroke after the treatment with epinephrine in an anaphylactic patient

Anaphylaxis is a serious clinical condition that can affect all ages and many systems (skin, gastrointestinal system, respiratory and cardiovascular systems). There are a few case reports of cardiac and cerebrovascular complications due to the anaphylaxis and/or the treatment with epinephrine. A 69-year-old female patient with known coronary artery disease (CAD), coronary artery bypass graft (CABG), and diabetes mellitus (DM) was admitted to the emergency department. She was brought to the emergency service with the complaints of shortness of breath, swelling of the tongue and lip, widespread itching and nausea after the use of amoxicillin-clavulonic acid due to soft tissue infection. The patient was considered as having anaphylaxis. 0.5 mg intramuscular (IM) epinephrine was administered. Following the emergency electrocardiography (ECG), the rate was 140/min and the rhythm was evaluated as atrial fibrillation. We present a case of cardiovascular complications and acute ischemia stroke following intramuscular epinephrine administration with anaphylactic diagnosis in this study. As a result, anaphylaxis management is extremely important in elderly patients with preexisting cardiovascular conditions.

Simulation training as a tool to improve confidence in managing medical emergencies and leading cardiac arrests for core medical trainees

A simulation-based training course was designed with the aim of improving confidence of core medical trainees (CMTs) in managing emergency presentations and cardiac arrest. Four 10-minute high-fidelity simulation scenarios were designed to cover management of anaphylaxis, shock, and unconscious

Prise en charge de l’anaphylaxie en médecine générale en région Occitanie, à partir d’un questionnaire

IntroductionThe incidence of anaphylaxis is increasing. Delayed epinephrine injection is a risk factor for death, as is asthma. General practitioners play a crucial role in the management of this uncommon event, mainly through preventive measures but sometimes through actual treatment of anaphylaxis. ObjectiveThe aim of the study was to evaluate the management of anaphylaxis by GPs, whether through preventive action (emergency kit prescription, with or without epinephrine) or through management of the anaphylactic reaction (epinephrine injection, referral to an allergist). Two thirds of the GPs interviewed expressed interest in training. Patients and methodsA questionnaire-based declarative electronic survey was addressed to 1301 GPs in the Occitanie region of France between February and April 2017. ResultsA total of 141 doctors (11%) completed the questionnaire. In all, 75% of GPs had prescribed between 1 and 5 emergency kits including epinephrine in the previous year. Among the 48 practitioners with a patient presenting anaphylaxis (i.e., 34% of the 141 doctors), 72.9% stated that epinephrine had been injected, two thirds stated that it was followed by a hospital surveillance period, and 79.1% referred their patient to an allergist. ConclusionIn most cases, GPs prescribe and use epinephrine if needed. However, we noticed a lack of knowledge and practice concerning patient education and allergy referral following an anaphylactic episode. Training courses involving simulation exercises, lectures and slots in congresses would help GPs improve their knowledge and management of anaphylaxis.

Detection and management of Anaphylaxis in children.

Anaphylaxis is an emergency condition. According to the latest international guide lines, early recognition and treatment with intramuscular epinephrine are associated with increased survival. To determine the level of knowledge of pediatricians in a tertiary Pediatric Hos pital about the diagnostic criteria and treatment of anaphylaxis. A cross-sec tional descriptive study was conducted, designing, applying, and validating an anonymous survey to physicians with complete residency in pediatrics who are on call at a third level hospital. The statisti cal analysis was made using the SPSS v.21 software, presenting measures of central tendency (median, range, and frequency table) and Chi-square test for comparison. A value of p < 0.05 was considered significant. 71 physicians completed the survey with a median of three years after the end of residency.35% of them identified all clinical criteria, 99% (70) indicated epinephrine, 73% chose the intramuscular route, and 55% indicated the correct dose. Only 48% of responders chose the dose and administration route correctly. In general, 21% recognized anaphylaxis and used epinephrine correctly. Physicians with less than five years of experience performed better in the intramuscular administration of epinephrine (83% vs 52% p = 0.005) and in the detection of gastrointestinal symp toms (60% vs 35% p = 0.043). There are difficulties in the identification and proper management of anaphylaxis by pediatricians of a tertiary Pediatric Hospital in a theoretical clinical setting. Although most of pediatricians chose epinephrine as a first-line drug, half of them did not indicate it correctly, and only one-third recognized anaphylaxis in all scenarios.

Cross- Canada Anaphylaxis Registry: comparing triggers and management of anaphylaxis in emergency medical service in Quebec over a 4-year period

Cross- Canada Anaphylaxis Registry: comparing triggers and management of anaphylaxis in emergency medical service in Quebec over a 4-year period

Emergency Management of Adult and Pediatric Idiopathic Anaphylaxis: A 7-year follow-up study in Canada

Emergency Management of Adult and Pediatric Idiopathic Anaphylaxis: A 7-year follow-up study in Canada

Future doctors and anaphylaxis: What do they know? what should we do?

Aim: Anaphylaxis is a severe, potentially life-threatening systemic hypersensitivity reaction. Previous studies reveal that there are many potential deficiencies in the knowledge of doctors regarding the diagnosis and management of anaphylaxis in different health-care settings.The main purpose of this study was to assess the knowledge of 4th-6th-year medical students regarding the diagnosis and management of anaphylaxis. Material and Methods: The study was designed as a cross-sectional survey. The total number of 4th-, 5th-, and 6th-grade medical students at Trakya University Medical School was 651, and 172 (26%) agreed to participate in the study. The participants were asked to answer the questionnaire forms were including the questions assessing students’ knowledge about the diagnosis and management of anaphylaxis, before and after a training session about anaphylaxis. Results:Awareness of students about symptoms indicating anaphylaxis other than cutaneous and respiratory symptoms was between 40% and 77% in the initial test. Although the majority of participants (94%) chose epinephrine as the first-line drug for the treatment of anaphylaxis, correct answers about dosage, concentration, and the route for administration of epinephrine were low when compared with the final test (p < 0.001 for each item). While 14% stated they felt they could diagnose and treat anaphylaxis in the initial test, this increased 83% after the training (p < 0.001). Conclusion: The study revealed that, knowledge of medical students relating diagnosis and treatment of anaphylaxis is unsatisfactory. Much more attention is needed in medical-school education concerning anaphylaxis management to prevent anaphylaxis-related mortalities in the future.

Saudi teachers' confidence and attitude about their role in anaphylaxis management.

Background and Aims:Anaphylaxis is a common emergency and life-threatening hypersensitivity reaction defined as a rapid generalized allergic reaction. Prior international studies have shown that school personnel is often not familiar with the signs of hypersensitivity or with appropriate management strategies that should be initiated at school for children with an anaphylactic reaction. Moreover, no studies have evaluated the awareness of anaphylaxis by school teachers in Saudi Arabia. The aim of this study was to determine teachers’ knowledge, attitudes, and practices toward anaphylaxis in Al-Qassim, Saudi Arabia.Methods:This was a cross-sectional study conducted at a public school in Al-Qassim, Saudi Arabia via a validated fourteen items questionnaire aimed to survey teacher knowledge, attitudes, and practices toward anaphylaxis. The questionnaires were disseminated using a multistage random sampling technique to Saudi national's teachers from different regions in Al-Qassim.Results:Most teachers had a low level of knowledge (85.3%) of anaphylaxis and positive attitudes (72.9%), and the level of practice was reported as low (48.9%) to moderate (47.5%). The most common sources of information regarding anaphylaxis were the internet and social media. When considering significant factors associated with knowledge, attitudes, and practices (KAP), we found that sex, years of experience in teaching and witnessing students suffering from anaphylaxis were all positively associated with KAP.Conclusion:The overall knowledge and practices of teachers regarding anaphylactic reactions were poor, although teachers’ attitudes toward learning this information were positive. Thus, teachers need further education regarding the management of allergic reaction.

The assessment of teachers' knowledge and schools'readiness about food allergy and anaphylaxis in a northwest city of Turkey

Aim: To investigate teachers’ knowledge and preparedness of schools about food allergy and anaphylaxis in elementary schools in Edirne city.Material and Methods: The study was performed as a cross sectional survey study. Questionnaires were answered by 560 teachers, all of them were working in 35 public elementary schools in Edirne. In addition to questions concerning food allergies, teachers were asked about their attitudes in the case of a life-threatening food-induced allergic reaction. The presence of a nurse or other trained personnel, an action plan for management of anaphylaxis, and/or epinephrine availability and use in these schools in the case of such a reaction were also evaluated.Results: The vast majority of teachers (97.3%) reported they had not been informed about food allergies, and only 19.1% stated that “shock” may be related to a food allergy situation. Only 4 schools (11.4%) employed a nurse. Examination of school drugs cabinets revealed no epinephrine in any school, and none of the students were found to carry epinephrine autoinjectors. Furthermore, none of the schools had an emergency action plan related to food-induced allergic reactions. Conclusion: The current study revealed an urgent need to inform elementary school teachers of Edirne about food allergies and their treatment and to improve access to emergency treatments and action plans.

Intervention in anaphylaxis: the experience of one paediatric centre based on NORA reports.

Intramuscular adrenaline administration is the primary intervention in anaphylaxis. To analyse the data on intervention in children admitted due to anaphylaxis to the tertiary paediatric centre and compare them to the data from the Network for Online-Registration of Anaphylaxis. A validated structured on-line questionnaire was used to collect data concerning the first and second-line intervention in anaphylaxis. The study was conducted in cooperation with the European Anaphylaxis Registry. The study group comprised 114 children (76 boys, 66.87%) aged 5 months-17 years with the predominance of moderate-to-severe anaphylaxis (grade III in Ring and Messmer's, and grade IV in Mueller's scale). In 103 (90.4%) children the first line of medical intervention was provided by medical staff. In the first-line intervention 39 (34.8%) children were given adrenaline. Five (4.4%) children were given the second dose of adrenaline and were admitted to the intensive care unit. In the second-line intervention adrenaline was given to 12 (15.6%) children. In one third it was at least the second reaction to the same trigger. Children treated with adrenaline were older (9.3 ±4.8 years), in comparison to those not treated (7.3 ±4.6 years, p = 0.034). Directly after the episode of anaphylaxis the children got the prescription for the adrenaline autoinjector in 35.1%, emergency training in 7.9%, and counselling on the avoidance of the anaphylaxis trigger in 30.7%. Grade III R&M reaction increased 3-fold the odds of AAI prescription (95% CI: 1.08-8.15). There is a strong need to continue education on proper management of anaphylaxis in children.

The knowledge of and attitudes toward anaphylaxis emergency management among Polish dentists

INTRODUCTION: Anaphylaxis is a life-threatening medical emergency condition requiring immediate diag- nosis and implementation of proper treatment. For the medical personnel facing a patient suspected of anaphylaxis, the necessary rapid initial management includes removing the allergen, calling for help, clear- ing the airway, laying the patient, and administering adrenaline in an intramuscular injection and oxygen. Airway management, intravenous access, and intravenous fluid challenge, as well as chlorphenamine and hydrocortisone injection, are also suggested if the medical personnel has appropriate skills and equipment available. Many studies emphasize that dentists feel inadequately trained to recognize and treat medical emergencies in dental offices, which especially refers to anaphylaxis. The aim of the study was to assess the dentists’ preparedness, knowledge, and attitudes with regard to anaphylaxis in dental offices in Poland. METHODS: The study was conducted between November 2016 and November 2017 during scientific meet- ings and congresses in Poland. The participants (Polish dentists) received information on the study objectives and voluntarily took part in the questionnaire survey. The questionnaire included 20 items concerning age, gender, work experience, specialization, latest training in cardiopulmonary resuscitation, onset time of aller- gic reaction, stridor, first line pharmacological treatment, route of administration and doses of adrenaline in different age groups, other medications recommended in anaphylaxis. RESULTS: Overall, 500 active dentists working in Poland were offered to participate in the questionnaire study; 268 questionnaires were returned (53.6%), including 18 partially filled. Finally, 250 questionnaires were further analyzed. The mean age of the participants was 42.33 ± 10.53 years, 226 (90.4%) were fe- male, and the mean work experience equaled 14.35 ± 9.27 years. The total of 28.8% of subjects attended cardiopulmonary resuscitation training within 12 months prior to the study, 38.40% within the previous 2–5 years, 17.20% within the previous 6–10 years, 8.00% 10 or more years earlier, and 7.60% had never participated in such training since graduation. 24.4% of the participants stated that ingestion of food to which a patient was allergic resulted in severe anaphylactic reaction typically within 30 minutes, and 21.60% stated that in the case of contact with bee or wasp venom, severe anaphylaxis typically occurred within 10–15 minutes. Out of the study participants, 66.40% maintained that adrenaline was the first line drug in anaphylaxis; 27.2% indicated intramuscular route as the standard route for adrenaline injection in anaphylaxis; 46.4% pointed at the correct dose of adrenaline in anaphylaxis. The proper adrenaline dose in anaphylaxis for a 4-year-old child was indicated by 42.00% and for a 10-year-old child by 36.4%. The correct dose of hydrocortisone in a 10-year-old child was provided by 18.40%. CONCLUSIONS: Among Polish dentists, the knowledge concerning the diagnosis and emergency treatment in anaphylaxis is low. Better postgraduate training including anaphylaxis management in dental offices should be recommended.

Impact of Specific Training in Anaphylaxis for Triage Nursing Staff in the Pediatric Emergency Department of a Tertiary Hospital.

After a diagnosis of anaphylaxis, patients receive action management plans to prevent and treat new episodes, including attending the emergency department for follow-up or further treatment. In a previous study, we observed that more than half of the children with anaphylaxis were incorrectly prioritized in our Pediatric Emergency Unit (PEU), thus delaying their treatment. In conjunction with our PEU staff, we designed a basic educational intervention (BEI) to try to solve this problem. We analyzed the effect of the intervention on triage of children subsequently diagnosed with anaphylaxis. Our BEI consisted of a training lecture given to the PEU triage nurses and the design of a reference card highlighting symptoms and risk factors of anaphylaxis. We included 138 children with a medical diagnosis of anaphylaxis and assessed modifications in their triage priority level and waiting times (WT) before seeing a physician after our intervention. According to the BEI implementation date, 69 children were diagnosed before the intervention (G1) and 69 after (G2). Clinical data were compared to assess the severity of the episodes. There were no differences between the groups. WT decreased (from 8 to 1 minute; P=.03), and the number of correctly identified patients increased after the BEI (36.2% [G1] and 72.2% [G2]; P=.0001). Our BEI was effective, improving the identification and prioritization of children with anaphylaxis and reducing their WT. We need to pay attention to the functioning of our patients' reference emergency department and establish interdisciplinary measures that enable optimal management of anaphylaxis.