Customizing Anaphylaxis Guidelines for Emergency Medicine

[Prehospital care of anaphylactic reactions by the air rescue and ground-based emergency services Dresden : An analysis of treatment and outcome]

BACKGROUND

Anaphylaxis can lead to a life-threatening situation. Therefore, rapid diagnosis and emergency treatment is indicated. Immediate treatment with intramuscular adrenaline (or intravascularly with sufficient medical expertise) in anaphylaxis with cardiovascular and/or respiratory symptoms is recommended by various guidelines. Previous studies have shown that anaphylaxis is often not treated according to guidelines and that adrenaline in particular is rarely administered.

OBJECTIVE

The aim of the study was to investigate the data on emergency treatment and outcomes of patients with anaphylaxis by the air rescue and ground-based emergency services Dresden. Moreover, the results of the air- and ground-based services were compared. The focus was on administration of adrenaline and outcomes.

MATERIALS AND METHODS

Data from the ground-based emergency service Dresden (from 2012 to 2016) and the air rescue service Dresden (from 2008 to 2015) related to anaphylactic reactions were analyzed retrospectively. The severity of the anaphylaxis, the emergency medication administered, further monitoring, and outcomes were analyzed.

RESULTS

Data from 152 adults/29 children were analyzed for air rescue and 1131 adults/223 children for the ground-based emergency service. Adults with grade II-IV anaphylaxis received adrenaline in 19% (air rescue) and 7% (ground rescue) of cases. Children with grade II-IV anaphylaxis received adrenaline in 7% (air rescue) and 8% (ground rescue) of cases. Immediate drug therapy led to an improvement in general condition in 96-98% (air rescue) and 72-77% (ground-based emergency service) of cases. A significant correlation was found between the administration of adrenaline and the improvement in outcome in the ground-based emergency cohort.

CONCLUSION

Guideline-compliant first-line therapy with adrenaline was not performed in the majority of the cases analyzed in this study. The significant effect of adrenaline on outcome demonstrated in this study emphases the need to improve the emergency treatment of anaphylactic reactions.

Anaphylaxis: A 2023 practice parameter update

This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.

Anaphylaxis among elderly emergency department patients in a large health system in New York

BACKGROUND

Anaphylaxis in the elderly is poorly understood.

OBJECTIVE

To elucidate demographic, clinical, and management characteristics of older adults presenting to emergency departments (EDs) with National Institute of Allergy and Infectious Diseases (NIAID) criteria-confirmed anaphylaxis vs milder, non-anaphylactic acute allergic reactions (AARs).

METHODS

A retrospective analysis of ED patients more than or equal to 65 years was conducted, using anaphylaxis International Classification of Diseases, Ninth Revision (ICD-9) codes or ICD-9-based algorithms incorporating the NIAID diagnostic criteria. Descriptive statistics were generated, and the abovementioned characteristics were compared between cohorts.

RESULTS

Of 164 eligible visits, 71 (43.3%), 90 (54.9%), and 3 (1.8%) cases were identified by ICD-9 codes, the algorithms, or both, respectively. Only half fulfilled NIAID diagnostic criteria. Compared with the non-anaphylactic AAR group, criteria-confirmed anaphylaxis group had lower drug allergy rates (43.9% vs 61.0%, P = .03) but higher food allergy rates (26.8% vs 12.2%, P = .02). For the criteria-confirmed anaphylaxis group, presenting signs and symptoms in descending frequency were mucocutaneous, respiratory, cardiovascular, and gastrointestinal. Criteria-confirmed anaphylaxis group had higher rates of prior anaphylaxis (13.4% vs 2.4%, P = .009), pre-ED (12.2% vs 0.0%, P = .001) or ED (72.0% vs 4.9%, P < .001) epinephrine administration, and allergy referral (17.1% vs 2.4%, P = .002). Tryptase levels were rarely ordered, occurring once in the criteria-confirmed anaphylaxis group and never in the non-anaphylactic AAR group. Despite low mortality (n = 1), 64.6% of the criteria-confirmed anaphylaxis cohort required hospitalization, with 23.2% admitted to intensive care unit.

CONCLUSION

Diagnosis of elderly ED patients with anaphylaxis remains suboptimal. Identifying NIAID criteria-confirmed cases remain challenging, using the existing methods. Management of these patients poorly adheres to current guidelines.

Anaphylaxis: Epidemiology and Differential Diagnosis

Anaphylaxis-related emergency department (ED) visits and hospitalizations are increasing. Triggers for anaphylaxis include food, medications, and stinging insects. Idiopathic anaphylaxis accounts for 30% to 60% of cases of anaphylaxis in adults and up to 10% of cases in children with novel allergens such as galactose-α-1,3 galactose reclassifying these cases. Recent practice guidelines have recommended against the routine use of systemic corticosteroids and antihistamines for the prevention of biphasic reactions and recommend an extended observation, up to 6 hours, for those with risk factors for biphasic anaphylaxis and those with lack of access to epinephrine and to emergency medical services.

A Mixed-Methods Approach-Based Study of Anaphylaxis Awareness and Educational Needs among Nursing Students

In this mixed-methods study, we identified anaphylaxis awareness among nursing students through a survey, and the needs for anaphylaxis education through focus group interviews (FGIs). Anaphylaxis awareness was surveyed from 10 June–30 July 2018 using a structured questionnaire with 221 junior or senior nursing students. To assess the needs for anaphylaxis education, 14 senior nursing students were interviewed using FGIs from 10–22 June 2018. Quantitative data were analyzed descriptively using SPSS, and qualitative data were assessed using thematic analysis. Nursing students’ awareness of anaphylaxis was identified by correct answers to items concerning symptoms (33.0%), causes (64.6%), and treatments (55.8%), with an overall average of 51.5%. The thematic analysis identified four themes reflecting students’ educational needs: the need for anaphylaxis education, various education methods, field training-based study of educational content, and repeated education. Nursing students’ anaphylaxis awareness is low. Their specific needs derived in this study for anaphylaxis education should draw special attention when planning nursing curriculum. Incorporating these findings in future education programs may promote students’ confidence in treating anaphylaxis.

Emergency Treatment of Anaphylactic Reactions in Air Rescue Missions: An Eight-Year Analysis of a German Rescue Helicopter Base

INTRODUCTION

Anaphylactic reactions can lead to a life-threatening situation. In the event of anaphylaxis, rapid and targeted emergency treatment is indicated.

STUDY OBJECTIVE

The study sought to determine the emergency therapy administered for anaphylaxis in children and adults. Focus was placed on therapy with adrenaline. In addition, the study aimed to investigate demographic data, triggers, and hospitalization rates of the different severities of anaphylaxis.

METHODS

A retrospective analysis of anaphylactic reactions was conducted using data from prehospital emergency missions performed by the Air Rescue Dresden/Germany from 2008 through 2015 using the standardized application protocol EPRO-5.0 (MIND 3) anonymized. Data from 152 adults and 29 children were evaluated, focusing especially on the acute treatment as well as demographic information, triggers, and symptoms of anaphylactic reactions.

RESULTS

In total, 152 adults (73 female, 79 male) from 18 to 87 years (mean 50.5 years) and 29 children (9 female, 20 male) from 1 to 16 years (mean 7.5 years) with anaphylactic reactions were analyzed. The most common trigger for severe anaphylactic reactions (Grade II-IV; classification modified according to Ring and Messmer) was food in children (33%) and insect venom in adults (59%). The data show that 19% of adults with Grade II-IV anaphylactic reactions (classification modified according to Ring and Messmer) received adrenaline. Regarding children, the appliance of adrenaline was only administered in seven percent of the cases of Grade II-IV anaphylactic reactions. Adults with Grade II or higher anaphylactic reactions were hospitalized in 92%. Three percent refused hospitalization and five percent were not transferred to hospital. One-hundred percent of the children with Grade II-IV anaphylaxis were hospitalized.

CONCLUSIONS

Analysis of data from the Air Rescue Dresden/Germany shows that despite existing recommendations, only 19% of adults with severe anaphylaxis received adrenaline. Among children, only in seven percent was a treatment with adrenaline performed.On the other hand, all patients survived the acute emergency treatment without apparent adverse outcomes. Thus, further studies are needed to determine the proper use of adrenaline in anaphylactic reactions.

A severity grading system of food-induced acute allergic reactions to avoid the delay of epinephrine administration

BACKGROUND

Substantial discrepancies among anaphylaxis severity scores may delay epinephrine administration.

OBJECTIVE

The study aims to develop a transparent severity grading system of food-induced acute allergic reactions with a decision model for epinephrine use.

METHODS

The natural course of 315 acute food-induced allergic reactions in children hospitalized at the Allergology department between May 2016 and July 2019 owing to follow-up treatment and allergy diagnostics was evaluated. The severity of episodes was classified according to the 5 most accepted grading systems. The interrater reliability of classification between anaphylaxis severity scores was assessed. All symptoms were grouped into a heat map according to their real-life incidence and clinical relevance. Based on the heat map analysis, a severity grading system of food-induced acute allergic reactions in children with the epinephrine administration decision model was created.

RESULTS

Data from 259 food-induced anaphylaxis episodes in 157 children were included in the analysis. Comparing the grading systems, we observed a 24.7% to 70.2% disagreement between severity scores. The heat map illustrated a strong association between 29 symptoms and their categorization. A new severity grading system was developed and a 2-stage decision model was proposed: "epinephrine yes" (any rapidly progressing symptoms, even mild ones or from 1 organ system; any symptoms from more than 1 organ system; or every grade of anaphylaxis), and "epinephrine available and prepared to use" (nonprogressing mild systemic allergic reaction from 1 system area only; no anaphylaxis).

CONCLUSION

A new severity grading system of food-induced acute allergic reactions in children could serve as a clinical tool for health care professionals to avoid epinephrine administration delay.

Pediatrician perspectives on symptom presentation and treatment of acute allergic reactions

BACKGROUND

Anaphylaxis remains difficult to diagnose and epinephrine underused.

OBJECTIVE

To better understand the thoughts of pediatricians regarding when acute allergic reactions constitute anaphylaxis and when epinephrine should be given by conducting an anonymous online survey.

METHODS

The survey consisted of 8 case-based scenarios of allergic reactions with the following 2 questions on each case: (1) does this case represent anaphylaxis? and (2) if this patient immediately presented to you, would you treat the patient with epinephrine during the reaction?

RESULTS

A total of 1001 responses were analyzed. When assessing all cases combined, there was discordance in whether a case represented anaphylaxis and administration of epinephrine was warranted in 8% of the cases. An average of 5% of all the respondents suggested that the case represented anaphylaxis but would not warrant epinephrine, whereas an average of 3% suggested that the case did not represent anaphylaxis but that epinephrine was warranted.

CONCLUSION

The results of this survey reveal that there is discordance among pediatricians on when an allergic reaction is considered anaphylaxis and when epinephrine is warranted. These data highlight the need for continued improvement of the definition of anaphylaxis and continued need for education regarding the diagnosis and management of anaphylaxis.

New York State cases of anaphylaxis in elderly patients from 2000 to 2010

BACKGROUND

Limited information is available on the effect of anaphylaxis, a severe, potentially life-threatening allergic reaction, in the elderly population.

OBJECTIVE

To elucidate the frequency of anaphylaxis and the demographic characteristics of elderly patients admitted to New York hospitals from 2000 to 2010.

METHODS

A retrospective analysis of hospitalized patients aged 65 years and older in New York from 2000 to 2010 was conducted using the Statewide Planning and Research Cooperative System, a statewide administrative database. Cases were identified using anaphylaxis International Classification of Diseases, Ninth Revision (ICD-9) codes or an ICD-9-based diagnostic algorithm incorporating the National Institutes of Allergy and Infectious Disease diagnostic criteria. The χ² test was used to measure the association between demographic characteristics and group membership. Regression was used to model group and age as a function of hospital rates.

RESULTS

A total of 3673 hospitalizations were analyzed. Anaphylaxis ICD-9 codes identified 1790 cases (48.7%), the algorithms identified 1701 cases (46.3.%), and 182 cases (5.0%) were identified by both. Hospitalization rates increased significantly during this period (P < .001). Women comprised 61.5% and people of white race comprised 69.8% of the sample. Distribution by age differed by ascertainment method (ICD-9 vs algorithm) among the early-old group (65-74 years of age; 53.8% vs 41.8%) and among the late-old group (≥85 years of age; 11.2% vs 19.3%).

CONCLUSION

Hospitalization rates and anaphylaxis cases increased during the study period among the hospitalized elderly population of New York. Relying on anaphylaxis ICD-9 codes alone missed approximately half of possible cases. The identification and possibly the effect of anaphylaxis among the elderly population may differ, depending on age, race, payer, New York County, and disposition.

Anaphylaxis-related Malpractice Lawsuits

INTRODUCTION

Anaphylaxis continues to cause significant morbidity and mortality. Healthcare providers struggle to promptly recognize and appropriately treat anaphylaxis patients. The goal of this study was to characterize anaphylaxis-related malpractice lawsuits.

METHODS

We collected jury verdicts, settlements, and court opinions regarding alleged medical malpractice involving anaphylaxis from May 2011 through May 2016 from an online legal database (Thomson Reuters Westlaw). Data were abstracted onto a standardized data form.

RESULTS

We identified 30 anaphylaxis-related malpractice lawsuits. In 80% of cases, the trigger was iatrogenic (40% intravenous [IV] contrast, 33% medications, 7% latex). Sixteen (53%) cases resulted in death, 7 (23%) in permanent cardiac and/or neurologic damage, and 7 (23%) in less severe outcomes. Fourteen (47%) of the lawsuits were related to exposure to a known trigger. Delayed recognition or treatment was cited in 12 (40%) cases and inappropriate IV epinephrine dosing was reported in 5 (17%) cases. Defendants were most commonly physicians (n=15, 50%) and nurses (n=5, 17%). The most common physician specialties named were radiology and primary care (n=3, 10% each), followed by emergency medicine, anesthesiology, and cardiology (n=2, 7% each). Among the 30 cases, 14 (47%) favored the defendant, 8 (37%) resulted in findings of negligence, 3 (10%) cases settled, and 5 (17%) had an unknown legal outcome.

CONCLUSION

Additional anaphylaxis education, provision of epinephrine autoinjectors or other alternatives to reduce dosing errors, and stronger safeguards to prevent administration of known allergens would all likely reduce anaphylaxis-related patient morbidity and mortality and providers' legal vulnerability to anaphylaxis-related lawsuits.

An analysis of anaphylaxis cases at a single pediatric emergency department during a 1-year period

BACKGROUND

Case series of anaphylaxis can vary regarding causes, treatments, and follow-up of patients. Unfortunately, case series that are specific to the pediatric population are few.

OBJECTIVE

To describe confirmed cases of pediatric anaphylaxis in patients presenting to a pediatric hospital emergency department (ED).

METHODS

We identified all ED visits with the International Classification of Diseases, Ninth Revision (ICD-9) codes 995.XX (allergic reactions) and 989.5 (sting or venom reaction) for 1 calendar year (January 1, 2014, through December 31, 2014). Cases were reviewed by an allergist and an emergency medicine physician to identify true anaphylaxis cases using National Institute of Health/National Institute of Allergy and Infectious Diseases criteria. Any questionable or debatable cases were evaluated and adjudicated by a second allergist.

RESULTS

We identified 927 unique ED visits. Of these visits, 40 were determined to definitively meet anaphylaxis criteria. Median age of the patients was 6.5 years. A total of 70% of patients were male, and 80% were African American. Causes included foods (65%), venom or insect sting (12.5%), and medications (5%), and 17.5% were idiopathic. All patients had multiorgan involvement, with 98% having skin involvement, 78% having lower respiratory tract symptoms, and 40% having gastrointestinal symptoms. There were no deaths. Only 33% of patients received epinephrine at some point in their care. Only 12 patients were referred to an allergist, and only 4 of these were actually seen by an allergist.

CONCLUSION

At our center, foods are the most common trigger for pediatric anaphylaxis. Patients continue to be undertreated, and referral to an allergist from the ED is rare.

Dermatologic surgery emergencies: Complications caused by systemic reactions, high-energy systems, and trauma

While the overall incidence of emergencies in dermatologic surgery is low, emergent situations can occasionally pose a risk to patients undergoing such procedures. The clinical importance of several types of emergences related to systemic reactions, high energy systems, and trauma are reviewed, and relevant epidemiology, clinical manifestations, diagnosis, work-up, management, and prevention are discussed. Early detection of surgical emergencies can mitigate any associated adverse outcomes, thereby allowing the outstanding record of safety of dermatologic surgery to continue.

Addressing barriers to emergency anaphylaxis care: from emergency medical services to emergency department to outpatient follow-up

BACKGROUND

Anaphylaxis is a systemic life-threatening allergic reaction that presents unique challenges for emergency care practitioners. Allergists and emergency physicians have a history of collaborating to promote an evidence-based, multidisciplinary approach to improve the emergency management and follow-up of patients with or at risk of anaphylaxis.

OBJECTIVES

To review recent scientific literature about anaphylaxis, discuss barriers to care, and recommend strategies to support improvement in emergency anaphylaxis care.

METHODS

An expert panel of allergists and emergency physicians was convened by the American College of Allergy, Asthma and Immunology in November 2014 to discuss current knowledge about anaphylaxis, identify opportunities for emergency practitioners and allergists to partner to address barriers to care, and recommend strategies to improve medical management of anaphylaxis along the continuum of care: from emergency medical systems and emergency department practitioners for acute management through appropriate outpatient follow-up with allergists to confirm diagnosis, identify triggers, and plan long-term care.

RESULTS

The panel identified key barriers to anaphylaxis care, including difficulties in making an accurate diagnosis, low rates of epinephrine administration during acute management, and inadequate follow-up. Strategies to overcome these barriers were discussed and recommendations made for future allergist/emergency physician collaborations, and key messages to be communicated to emergency practitioners were proposed.

CONCLUSION

The panel recommended that allergists and emergency physicians continue to work in partnership, that allergists be proactive in outreach to emergency care practitioners, and that easy-to-access educational programs and materials be developed for use by emergency medical systems and emergency department practitioners in the training environment and in practice.

[Anaphylaxis: recognize and treat early]

Allergic emergencies in children are now more frequent and unpredictable and can cause death by anaphylactic shock, bronchospasm, and airway angioedema. Despite the publication of recent guidelines, many studies show that caregivers are still not at ease with the management of anaphylaxis and intramuscular administration of adrenaline. The prognosis depends on the early diagnosis of anaphylaxis and adrenaline administration before cardiorespiratory failure. The biphasic course of anaphylaxis requires systematic hospitalization of at least 6–24 hours depending on severity. To prevent recurrence, each child with anaphylaxis should permanently be in possession of two unexpired self-injectable adrenaline devices with a demonstration and written instructions on its use. Close collaboration between emergency departments, allergist, and family is essential to adapt therapeutic education and allergen avoidance to the allergen identified. This article focuses on opportunities to improve the skills of caregivers and standardize the management of anaphylaxis by proposing a practical definition and a therapeutic strategy based on Ring grading of severity.

Risk factors for severe anaphylaxis in patients receiving anaphylaxis treatment in US emergency departments and hospitals

BACKGROUND

Although reported risk factors for severe anaphylaxis include older age, presence of comorbid medical conditions, and concomitant medications, previous studies have used varying definitions for anaphylaxis and heterogeneous methodology.

OBJECTIVE

To describe risk factors for severe anaphylaxis among US patients treated in emergency departments (EDs) or hospitals for anaphylaxis.

METHODS

Individuals with an ED visit/hospitalization for anaphylaxis were identified from 2 MarketScan Research Databases using an expanded International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. Eligibility for the current study required continuous medical and prescription coverage for at least 1 year before and after the index date. Severe anaphylaxis was defined as a reaction requiring hospital admission.

RESULTS

Among 11,972 individuals, 2,622 (22%) had severe anaphylaxis. Unadjusted analysis showed that severe anaphylaxis was associated with older age and higher comorbidity burden. These patients were also less likely to have filled an epinephrine autoinjector (EAI) prescription or visited an allergist/immunologist, but more likely to have had an ED visit/hospitalization (any cause). On multivariable analysis, filling an EAI prescription (odds ratio [OR], 0.64; 95% CI, 0.53-0.78) or visiting an allergist/immunologist (OR, 0.78; 95% CI, 0.63-0.95) before the index event was associated with a lower risk of severe anaphylaxis, while any previous ED visit (OR, 1.18; 95% CI, 1.07-1.30) or hospitalization (OR, 1.55; 95% CI, 1.36-1.75) was associated with a higher risk of severe anaphylaxis.

CONCLUSIONS

In this large cohort with an ED visit or hospitalization for anaphylaxis, 22% had severe anaphylaxis. Pre-index preventive anaphylaxis care (ie, EAI prescription fill and allergist/immunologist visit) was associated with a significantly lower risk, supporting the benefits of preventive anaphylaxis care in real-world practice.

Evaluating the management of anaphylaxis in US emergency departments: Guidelines vs. practice

BACKGROUND

Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting. Current guidelines recommend: 1) quick diagnosis using standard criteria; 2) first-line treatment with epinephrine; and 3) discharge with a prescription for an epinephrine auto-injector, written instructions regarding long-term management, and a referral (preferably, allergy) for follow-up. However, studies suggest low concordance with guideline recommendations by emergency medicine (EM) providers. The study aimed to evaluate how emergency departments (EDs) in the United States (US) manage anaphylaxis in relation to guideline recommendations.

METHODS

This was an online anonymous survey of a random sample of EM health providers in US EDs.

RESULTS

Data analysis included 207 EM providers. For respondent EDs, approximately 9% reported using agreed-upon clinical criteria to diagnose anaphylaxis; 42% reported administering epinephrine in the ED for most anaphylaxis episodes; and <50% provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge. Most provided some written materials, and follow-up with a primary care clinician was recommended.

CONCLUSIONS

This is the first cross-sectional survey to provide "real-world" data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis, treatment, and follow-up of patients with anaphylaxis. The primary gaps are low (or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine. Prospective research is recommended.