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De Souza RL, Short T, Warman GR, Maclennan N, Young Y. Anaphylaxis with Associated Fibrinolysis, Reversed with Tranexamic Acid and Demonstrated by Thrombelastography. Anaesth Intensive Care 2019; 32:580-7. [PMID: 15675222 DOI: 10.1177/0310057x0403200419] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the surgical setting, fibrinolysis can be a serious complication of anaphylaxis. We present four cases of anaphylaxis that were associated with fibrinolysis during anaesthesia, and the use of the thrombelastograph to demonstrate this haemostatic defect and its correction using tranexamic acid.
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Affiliation(s)
- R L De Souza
- Anaesthetic Department, Auckland Hospital, Auckland, New Zealand
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2
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Rodrigues SF, Granger DN. Blood cells and endothelial barrier function. Tissue Barriers 2015; 3:e978720. [PMID: 25838983 DOI: 10.4161/21688370.2014.978720] [Citation(s) in RCA: 190] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 10/15/2014] [Indexed: 12/18/2022] Open
Abstract
The barrier properties of endothelial cells are critical for the maintenance of water and protein balance between the intravascular and extravascular compartments. An impairment of endothelial barrier function has been implicated in the genesis and/or progression of a variety of pathological conditions, including pulmonary edema, ischemic stroke, neurodegenerative disorders, angioedema, sepsis and cancer. The altered barrier function in these conditions is often linked to the release of soluble mediators from resident cells (e.g., mast cells, macrophages) and/or recruited blood cells. The interaction of the mediators with receptors expressed on the surface of endothelial cells diminishes barrier function either by altering the expression of adhesive proteins in the inter-endothelial junctions, by altering the organization of the cytoskeleton, or both. Reactive oxygen species (ROS), proteolytic enzymes (e.g., matrix metalloproteinase, elastase), oncostatin M, and VEGF are part of a long list of mediators that have been implicated in endothelial barrier failure. In this review, we address the role of blood borne cells, including, neutrophils, lymphocytes, monocytes, and platelets, in the regulation of endothelial barrier function in health and disease. Attention is also devoted to new targets for therapeutic intervention in disease states with morbidity and mortality related to endothelial barrier dysfunction.
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Key Words
- AJ, Adherens junctions
- ANG-1, Angiopoietin 1
- AQP, Aquaporins
- BBB, blood brain barrier
- CNS, Central nervous system
- COPD, Chronic obstructive pulmonary disease
- EAE, Experimental autoimmune encephalomyelitis
- EPAC1, Exchange protein activated by cyclic AMP
- ERK1/2, Extracellular signal-regulated kinases 1 and 2
- Endothelial barrier
- FA, Focal adhesions
- FAK, focal adhesion tyrosine kinase
- FoxO1, Forkhead box O1
- GAG, Glycosaminoglycans
- GDNF, Glial cell-derived neurotrophic factor
- GJ, Gap junctions
- GPCR, G-protein coupled receptors
- GTPase, Guanosine 5'-triphosphatase
- HMGB-1, High mobility group box 1
- HRAS, Harvey rat sarcoma viral oncogene homolog
- ICAM-1, Intercellular adhesion molecule 1
- IL-1β, Interleukin 1 beta
- IP3, Inositol 1,4,5-triphosphate
- JAM, Junctional adhesion molecules
- MEK, Mitogen-activated protein kinase kinase
- MLC, Myosin light chain
- MLCK, Myosin light-chain kinase
- MMP, Matrix metalloproteinases
- NO, Nitric oxide
- OSM, Oncostatin M
- PAF, Platelet activating factor
- PDE, Phosphodiesterase
- PKA, Protein kinase A
- PNA, Platelet-neutrophil aggregates
- ROS, Reactive oxygen species
- Rac1, Ras-related C3 botulinum toxin substrate 1
- Rap1, Ras-related protein 1
- RhoA, Ras homolog gene family, member A
- S1P, Sphingosine-1-phosphate
- SCID, Severe combined immunodeficient
- SOCS-3, Suppressors of cytokine signaling 3
- Shp-2, Src homology 2 domain-containing phosphatase 2
- Src, Sarcoma family of protein kinases
- TEER, Transendothelial electrical resistance
- TGF-beta1, Transforming growth factor-beta1
- TJ, Tight junctions
- TNF-, Tumor necrosis factor alpha
- VCAM-1, Vascular cell adhesion molecule 1
- VE, Vascular endothelial
- VE-PTP, Vascular endothelial receptor protein tyrosine phosphatase
- VEGF, Vascular endothelial growth factor
- VVO, Vesiculo-vacuolar organelle
- ZO, Zonula occludens
- cAMP, 3'-5'-cyclic adenosine monophosphate
- erythrocytes
- leukocytes
- pSrc, Phosphorylated Src
- platelets
- vascular permeability
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Affiliation(s)
- Stephen F Rodrigues
- Department of Clinical and Toxicological Analyses; School of Pharmaceutical Sciences; University of Sao Paulo ; Sao Paulo, Brazil
| | - D Neil Granger
- Department of Molecular and Cellular Physiology; Louisiana State University Health Sciences Center ; Shreveport, LA USA
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Song TT, Worm M, Lieberman P. Anaphylaxis treatment: current barriers to adrenaline auto-injector use. Allergy 2014; 69:983-91. [PMID: 24835773 DOI: 10.1111/all.12387] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2014] [Indexed: 12/18/2022]
Abstract
Anaphylaxis is a life-threatening condition that is increasing in prevalence in the developed world. There is universal expert agreement that rapid intramuscular injection of adrenaline is life-saving and constitutes the first-line treatment of anaphylaxis. The unpredictable nature of anaphylaxis and its rapid progression makes necessary the availability of a portable emergency treatment suitable for self-administration. Thus, anaphylaxis treatment guidelines recommend that at-risk patients are provided with adrenaline auto-injectors (AAIs). Despite these clear recommendations, current emergency treatment of anaphylaxis continues to be inadequate in many cases. The aim of this review is to highlight the barriers that exist to the use and availability of AAIs and that prevent proper management of anaphylaxis. In addition, we review the characteristics of all AAIs that are presently available in Europe and the USA and discuss the need for regulatory requirements to establish the performance characteristics of these devices.
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Affiliation(s)
- T. T. Song
- Department of Medicine, Allergy and Immunology; University of Washington; Seattle WA USA
| | - M. Worm
- Department of Dermatology and Allergology; Charité - Universitätsmedizin; Berlin Germany
| | - P. Lieberman
- Department of Medicine & Pediatrics; University of Tennessee College of Medicine; Memphis TN USA
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Goldman RD. Acute treatment of anaphylaxis in children. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2013; 59:740-741. [PMID: 23851537 PMCID: PMC3710037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
QUESTION A 3-year-old was rushed to my office after eating a friend's chocolate bar that contained nuts. He immediately developed urticaria on his face and swelling of his lips, and he had a persistent cough. What is the best treatment for a child with anaphylaxis? Should this family receive a prescription for an epinephrine autoinjector device? ANSWER Intramuscular epinephrine injection is a safe and effective treatment of anaphylaxis in children. Children with systemic allergic reactions should carry epinephrine autoinjectors at all times, and should certainly have one with them at school. In order for epinephrine autoinjectors to be effective, children and their families need to be educated on how to properly use the devices, as well as keep in mind the product's expiration date.
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Affiliation(s)
- Ran D Goldman
- BC Children's Hospital, Department of Pediatrics, Room K4-226, Ambulatory Care Bldg, 4480 Oak St, Vancouver, BC V6H 3V4.
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Rama-Maceiras P, Unzueta MC, Soro M, González de Castro R, Belda J. [Airway pressure elevation during mechanical ventilation: beyond considerations of bronchospasm]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:70-73. [PMID: 21427821 DOI: 10.1016/s0034-9356(11)70002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Teo SL, Gerez IFA, Ang G, Shek LP. Food-dependent Exercise-induced Anaphylaxis – A Review of 5 Cases. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n10p905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Introduction: Food-dependent exercise-induced anaphylaxis (FDEIA) is an uncommon and under-recognised syndrome that clinicians may not consider in a patient presenting with ana- phylaxis.
Clinical Picture: We describe here 5 patients aged 9 to 20 years old who presented at a local tertiary hospital over a 2-year period from August 2006 to July 2008. All presented with urticaria, 4 were hypotensive, 2 had angioedema and another 2 had dyspnoea. The symptoms occurred between 15 and 150 minutes (mean, 81) after exercising and consuming various food. All had consumed shellfish. All patients were admitted with the diagnosis of anaphylaxis of undefined aetiology. Diagnosis of FDEIA was only reached upon referral to an allergist.
Treat- ment and Outcome: Patients were treated with standard medicines for anaphylaxis including adrenaline, antihistamines, steroids and fluid flushes. Symptoms resolved in 2 to 3 days with no further episodes. At discharge, patients were prescribed epinephrine auto-injectors and given written anaphylaxis management plans.
Conclusions: More public awareness and strategies to ensure accurate diagnosis and management of this condition are necessary.
Key words: Anaphylaxis, Epinephrine, Exercise, Food
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Affiliation(s)
| | | | - Gerez Ang
- National University of Singapore, Singapore
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Sheikh A, Shehata YA, Brown SGA, Simons FER. Adrenaline for the treatment of anaphylaxis: cochrane systematic review. Allergy 2009; 64:204-12. [PMID: 19178399 DOI: 10.1111/j.1398-9995.2008.01926.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. Adrenaline is recommended as the initial treatment of choice for anaphylaxis. OBJECTIVES To assess the benefits and harms of adrenaline in the treatment of anaphylaxis. METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to March 2007), EMBASE (1966 to March 2007), CINAHL (1982 to March 2007), BIOSIS (to March 2007), ISI Web of Knowledge (to March 2007) and LILACS (to March 2007). We also searched websites listing ongoing trials: http://www.clinicaltrials.gov/, http://www.controlledtrials.com and http://www.actr.org.au/ and contacted pharmaceutical companies and international experts in anaphylaxis in an attempt to locate unpublished material. Randomized and quasi-randomized controlled trials comparing adrenaline with no intervention, placebo or other adrenergic agonists were eligible for inclusion. Two authors independently assessed articles for inclusion. RESULTS We found no studies that satisfied the inclusion criteria. CONCLUSIONS On the basis of this review, we are unable to make any new recommendations on the use of adrenaline for the treatment of anaphylaxis. In the absence of appropriate trials, we recommend, albeit on the basis of less than optimal evidence, that adrenaline administration by intramuscular injection should still be regarded as first-line treatment for the management of anaphylaxis.
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Affiliation(s)
- A Sheikh
- Allergy & Respiratory Research Group, Division of Community Health Sciences: GP Section, The University of Edinburgh, Edinburgh, UK
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Sheikh A, Shehata YA, Brown SG, Simons FER. Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock. Cochrane Database Syst Rev 2008; 2008:CD006312. [PMID: 18843712 PMCID: PMC6517064 DOI: 10.1002/14651858.cd006312.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may cause death. Adrenaline is recommended as the initial treatment of choice for anaphylaxis. OBJECTIVES To assess the benefits and harms of adrenaline (epinephrine) in the treatment of anaphylaxis. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to March 2007), EMBASE (1966 to March 2007), CINAHL (1982 to March 2007), BIOSIS (to March 2007), ISI Web of Knowledge (to March 2007) and LILACS (to March 2007). We also searched websites listing ongoing trials: http://clinicaltrials.gov/, http://www.controlledtrials.com and http://www.actr.org.au/; and contacted pharmaceutical companies and international experts in anaphylaxis in an attempt to locate unpublished material. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing adrenaline with no intervention, placebo or other adrenergic agonists were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently assessed articles for inclusion. MAIN RESULTS We found no studies that satisfied the inclusion criteria. AUTHORS' CONCLUSIONS Based on this review, we are unable to make any new recommendations on the use of adrenaline for the treatment of anaphylaxis. Although there is a need for randomized, double-blind, placebo-controlled clinical trials of high methodological quality in order to define the true extent of benefits from the administration of adrenaline in anaphylaxis, such trials are unlikely to be performed in individuals with anaphylaxis. Indeed, they might be unethical because prompt treatment with adrenaline is deemed to be critically important for survival in anaphylaxis. Also, such studies would be difficult to conduct because anaphylactic episodes usually occur without warning, often in a non-medical setting, and differ in severity both among individuals and from one episode to another in the same individual. Consequently, obtaining baseline measurements and frequent timed measurements might be difficult, or impossible, to obtain. In the absence of appropriate trials, we recommend, albeit on the basis of less than optimal evidence, that adrenaline administration by intramuscular (i.m.) injection should still be regarded as first-line treatment for the management of anaphylaxis.
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Affiliation(s)
- Aziz Sheikh
- Division of Community Health Sciences: GP Section, University of Edinburgh, 20 West Richmond Street, Edinburgh, UK, EH8 9DX.
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Jevon P. Severe allergic reaction: management of anaphylaxis in hospital. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2008; 17:104-108. [PMID: 18414282 DOI: 10.12968/bjon.2008.17.2.28137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Anaphylaxis is an acute, severe, hypersensitivity reaction that can lead to asphyxia, cardiovascular collapse and cardiac arrest. This reaction is sudden, severe, and involves the whole body. Common causes include foods such as nuts, shellfish, dairy products and eggs. Non-food causes include bee/wasp stings, latex and drugs, e.g. penicillin. Common clinical features include urticaria, angioedema, respiratory distress and shock. Summoning expert help, reclining the patient flat, administering high concentration oxygen, and administering intramuscular adrenaline are key aspects of the nursing management of anaphylaxis in hospital. The aim of this article is to understand the management of anaphylaxis in hospital, with particular reference to national consensus guidelines.
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Affiliation(s)
- Phil Jevon
- Learning Department, Manor Hospital,Walsall
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10
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Richardson J, Holdcroft A. Results of forty years Yellow Card reporting for commonly used perioperative analgesic drugs. Pharmacoepidemiol Drug Saf 2007; 16:687-94. [PMID: 17436358 DOI: 10.1002/pds.1403] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND A variety of analgesics are used perioperatively and associated adverse drug reactions (ADRs) may complicate anaesthesia and recovery. METHODS We aimed to measure the demographics of reported suspected ADRs to alfentanil, fentanyl, ketorolac, morphine, nalbuphine, papaveretum, pethidine and remifentanil. We report a retrospective analysis of Yellow Card reports of suspected ADRs from 1965-2004 as classified in the Adverse Drug Reaction On-line Tracking database (ADROIT) of the Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS In total, 1312 reactions were retrieved. A single drug was reported in 908, 39 were fatal and 219 categorised as 'allergic'. Allergic phenomenon varied from 2/33 (6%) for remifentanil to 11/53 (21%) for alfentanil. 'Cardiovascular' reactions were reported frequently with remifentanil (18/33, 55%) and alfentanil (19/53, 36%) and these generated a signal for possible hazards from proportional reporting ratios (PRRs). The opioid fentanyl was associated with similar hazard signals for muscular and psychiatric ADRs. CONCLUSIONS Perioperative vigilance may reduce morbidity and mortality from preventable ADRs to analgesic drugs. Denominator and diagnostic data are essential for prospective studies.
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Currie M, Kerridge RK, Bacon AK, Williamson JA. Crisis management during anaesthesia: anaphylaxis and allergy. Qual Saf Health Care 2007; 14:e19. [PMID: 15933292 PMCID: PMC1744023 DOI: 10.1136/qshc.2002.004465] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Anaphylactic and anaphylactoid reactions during anaesthesia are a major cause for concern for anaesthetists. However, as individual practitioners encounter such events so rarely, the rapidity with which the diagnosis is made and appropriate management instituted varies considerably. OBJECTIVES To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for anaphylaxis, in the management of severe allergic reactions occurring in association with anaesthesia. METHODS The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual performance as reported by the anaesthetists involved. RESULTS There were 148 allergic reactions among the first 4000 incidents reported to AIMS. It was considered that, properly applied, the structured approach would have led to a quicker and/or better resolution of the problem in 30% of cases, and would not have caused harm had it been applied in all of them. CONCLUSION An increased awareness of the diverse clinical manifestations of allergy seen in anaesthetic practice, together with the adoption of a structured approach to management should improve and standardise the treatment and improve follow up of patients suspected of having suffered a significant allergic reaction under anaesthesia.
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Affiliation(s)
- M Currie
- Goulburn Base Hospital, Goulburn, New South Wales, Australia
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Rahman SL, Harbinson MT, Mohiaddin R, Pennell DJ. Acute Allergic Reaction upon First Exposure to Gadolinium-DTPA: A Case Report. J Cardiovasc Magn Reson 2005; 7:849-51. [PMID: 16353448 DOI: 10.1080/10976640500288206] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
This is a case report of allergic reaction to Gadolinium-DTPA on first exposure, with a brief review of safety of MR contrast agents.
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Affiliation(s)
- Shelley L Rahman
- Department of Nuclear Medicine, Royal Brompton Hospital, London, UK.
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Evans C, Tippins E. Emergency treatment of anaphylaxis. ACTA ACUST UNITED AC 2005; 13:232-7. [PMID: 16182529 DOI: 10.1016/j.aaen.2005.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2005] [Accepted: 07/09/2005] [Indexed: 11/18/2022]
Affiliation(s)
- Cliff Evans
- Thames Valley University, London, United Kingdom.
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Abstract
The highest rates of anaphylaxis in humans occur in early childhood associated with food allergy. Latex allergy, pharmaceutical drugs, and stinging insect reactions are important later in childhood, with drug allergy peaking in adult populations. Knowledge about diagnosis and therapy of anaphylaxis is critical, because a large percentage of subjects are not previously known to be at risk at the time of initial reactions. This article summarizes the basic clinical knowledge of anaphylaxis in childhood.
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Affiliation(s)
- Asriani M Chiu
- Division of Allergy and Immunology, Medical College of Wisconsin, 9000 West Wisconsin, Suite 411, Milwaukee, WI 53226, USA.
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Management of Severe Anaphylactic Reactions Should Include Administration of Alpha Adrenergic Agonists: In Response. Anesth Analg 2004. [DOI: 10.1097/00000539-200405000-00059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mertes PM, Dewachter P, Laxenaire MC. Complications anaphylactiques et anaphylactoïdes de l'anesthésie générale. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/s0246-0289(03)00098-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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McLean-Tooke APC, Bethune CA, Fay AC, Spickett GP. Adrenaline in the treatment of anaphylaxis: what is the evidence? BMJ 2003; 327:1332-5. [PMID: 14656845 PMCID: PMC286326 DOI: 10.1136/bmj.327.7427.1332] [Citation(s) in RCA: 140] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2003] [Indexed: 11/03/2022]
Abstract
Adrenaline (epinephrine) is the recommended first line treatment for patients with anaphylaxis. This review discusses the safety and efficacy of adrenaline in the treatment of anaphylaxis in the light of currently available evidence. A pragmatic approach to use of adrenaline auto-injectors is suggested.
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Affiliation(s)
- Andrew P C McLean-Tooke
- Regional Department of Immunology and Allergy, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP.
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Stefanutto TB, Halbach V. Bronchospasm precipitated by ethanol injection in arteriovenous malformation. AJNR Am J Neuroradiol 2003; 24:2050-1. [PMID: 14625231 PMCID: PMC8148910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
We present an interesting case of profound bronchospasm that we postulate was caused by injection of ethanol during embolization of a left transverse sinus dural fistula. There is excellent documentation in the literature of the development of transient pulmonary hypertension and decreased right-side cardiac output following embolization with this agent; however, there have been only anecdotal reports of a temporal relationship between ethanol embolization and bronchospasm. We present this case that occurred on the third ethanol embolization treatment series.
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Affiliation(s)
- Tiscia B Stefanutto
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA
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Abstract
Epinephrine is the cornerstone of anaphylaxis management. Its administration should be immediate upon evidence of the occurrence of anaphylaxis. Delays in administration may be fatal. The most appropriate administration is 0.3 to 0.5 mL of 1:1000 dilution intramuscularly for adults and 0.01 mg/kg for children, given in the lateral thigh. Patients with known anaphylactic reactivity should be prescribed an epinephrine auto-injector to be carried at all times for treatment of potential recurrences. Education of the patient or parent regarding the proper use of this tool is paramount.
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Affiliation(s)
- Anne K Ellis
- Division of Allergy, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2V7, Canada.
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Longrois D. [Management of anaphylactoid reactions associated with anesthesia, and treatment of anaphylactic shock]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21 Suppl 1:168s-180s. [PMID: 12091981 DOI: 10.1016/s0750-7658(01)00554-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- D Longrois
- Département d'anesthésie-réanimation chirurgicale, CHU Nancy-Brabois, 4, rue du Morvan, 54511 Vandoeuvre-les-Nancy, France.
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Brown AF, McKinnon D, Chu K. Emergency department anaphylaxis: A review of 142 patients in a single year. J Allergy Clin Immunol 2001; 108:861-6. [PMID: 11692116 DOI: 10.1067/mai.2001.119028] [Citation(s) in RCA: 215] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND There are few data on the incidence, clinical features, and management of patients with acute anaphylaxis presenting to the emergency department. We investigated all presentations to one department during the course of a year to improve current awareness of this medical emergency. OBJECTIVE The purpose of the study was to describe the clinical features, management, and outcome of anaphylaxis presentations to a single Australian adult emergency department in a single year, 1998-1999. METHODS This was a retrospective, case-based study of adult patients (>or=13 years of age) attending a single emergency department in Brisbane, Australia, during the year 1998-1999. The medical records of 304 patients satisfying the relevant discharge diagnostic codes were studied. We determined incidence, sex ratio, age, clinical features, management, disposal, asthma prevalence, and causes in patients presenting with acute allergic reactions and anaphylaxis. RESULTS In all, 162 emergency department patients with acute allergic reactions and 142 emergency department patients with anaphylaxis, including 60 whose anaphylaxis was severe, were seen during the year, for an anaphylaxis presentation incidence of 1 in 439. One patient died; this gave a case fatality rate of 0.70%. Cutaneous features were present in 94% of the patients with anaphylaxis. Of those with severe anaphylaxis, 35% had dizziness/syncope before hospital presentation, 25% laryngeal edema, and 21.7% systolic hypotension on hospital presentation. A cause was recognized in 73% of the anaphylaxis cases; most commonly, the causative agent was a drug, insect venom, or food. Adrenaline was used in 57% of the severe cases before hospital presentation or in the hospital. The emergency department alone definitively cared for 94% of all patients, though only 43% severe anaphylaxis cases were referred for follow-up. CONCLUSION The emergency department anaphylaxis presentation incidence of 1 in 439 cases is greater than previously recognized, though death remains rare. In three fourths of cases, a precipitant was identified, a fact that emphasizes the need for a detailed initial history. Definitive management in the emergency department alone is possible in most cases, provided that the appropriate use of adrenaline and the need for allergy clinic follow-up are appreciated.
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Affiliation(s)
- A F Brown
- Department of Emergency Medicine, Royal Brisbane Hospital, QLD, Australia
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Affiliation(s)
- W M Miesen
- Academic Hospital Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands.
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Cianferoni A, Novembre E, Mugnaini L, Lombardi E, Bernardini R, Pucci N, Vierucci A. Clinical features of acute anaphylaxis in patients admitted to a university hospital: an 11-year retrospective review (1985-1996). Ann Allergy Asthma Immunol 2001; 87:27-32. [PMID: 11476457 DOI: 10.1016/s1081-1206(10)62318-6] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Although anaphylaxis is considered a life-threatening event, there is a lack of information on the clinical characteristics at presentation, both in adults and in children. OBJECTIVE To describe in a nonselected population the clinical characteristics and the treatments of acute anaphylaxis triggered by different agents. METHODS This is a retrospective review of the clinical features of 113 episodes of acute anaphylaxis resulting in admission to a university hospital. Initially, the 107 patients visited the emergency room and were then admitted to the hospital. RESULTS Most anaphylactic events (63%) occurred at home. The most frequent symptoms involved the respiratory system (78%) and the skin (90%). Drugs, especially nonsteroidal anti-inflammatory drugs and antibiotics, were the most frequent cause of anaphylaxis in adults (49%). Patients with drug-induced anaphylaxis were older and more often had cardiovascular symptoms (hypotension and tachycardia) (P = 0.0064). Hymenoptera venom was the second most frequent cause of anaphylaxis (29%). Most of the patients with hymenoptera venom anaphylaxis were male (80%) and more frequently they had no history of atopy (P = 0.012). In food-induced anaphylaxis, the cardiovascular system was less likely to be involved (P < 0.05) (39%). Seafood seems to be frequently involved in food-induced anaphylaxis in our area. Specific immunotherapy-induced anaphylaxis occurred more often in younger patients (P = 0.032). Epinephrine seems to be underused in Italy (only 15% of patients received it), especially for respiratory symptoms. CONCLUSIONS Anaphylaxis triggered by different agents may have different clinical presentations and may occur in different types of patients. In Italy, the inadequate use of epinephrine for anaphylaxis treatment needs to be publicized to both physicians and the general population.
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Affiliation(s)
- A Cianferoni
- Anna Meyer Children's Hospital, Department of Pediatrics, University of Florence, Italy.
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Razzaque M, Crowhurst JA, Plaat F. Angio-oedema following rectal diclofenac after caesarean section. Int J Obstet Anesth 2001; 10:135-8. [PMID: 15321629 DOI: 10.1054/ijoa.2000.0810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report a case of an acute allergic reaction to rectal diclofenac following elective caesarean section in a patient taking ibuprofen. The reaction presented as severe angio-oedema affecting the face and tongue. Serial blood samples failed to show the rise in tryptase levels characteristic of an anaphylactic or anaphylactoid reaction. Diclofenac is widely used for postoperative pain relief in women undergoing caesarean section. To our knowledge this is the first time that an adverse reaction to diclofenac given via this route has been reported in an obstetric patient.
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Affiliation(s)
- M Razzaque
- Department of Anaesthesia, Royal London Hospital, London, UK
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28
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Staikowsky F, Zanker C, Casenove L. Allergic emergencies in the emergency room. Clin Rev Allergy Immunol 2000; 17:429-47. [PMID: 10829813 DOI: 10.1007/bf02737648] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- F Staikowsky
- Service des Urgences Médico-Chirurgicales, Hôpital Rothschild, Paris
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Smith JE, Hodgetts TJ. Self Assessment Exercises. J ROY ARMY MED CORPS 2000. [DOI: 10.1136/jramc-146-02-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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30
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Adrenaline in reactions to intravenous contrast medium. Clin Radiol 2000; 55:1-3. [PMID: 10816394 DOI: 10.1053/crad.2000.0271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Envenomations are an important cause of injury in the Americas. While supportive care alone may result in an acceptable outcome, antivenom offers a specific therapy that can significantly reduce the injury and symptoms of the envenomation. Antivenoms are hyperimmune sera collected from animals immunised with venom. The antibodies contained in the serum bind and inactive venom components. This leads to cessation or reversal of the toxic effects of the venom. The serum is often processed to increase the level of antibodies directed against venom components and decrease the amount of inactive proteins that may cause allergic reactions. The processing may include precipitation of inactive proteins, chromatographic methods and cleavage of the immunoglobulins to form antibody fragments known as Fab or F(ab)2. In the Americas, antivenoms are produced to treat crotalid and Micrurus snake envenomations. Latrodectus and Loxosceles spider envenomations and Centruroides and Tityus scorpion envenomations. The indications, method of administration and incidence of adverse reactions differ greatly for each antivenom. The adverse effects encountered when using antivenoms are primarily allergic in nature. Anaphylaxis, which may be life threatening, is a major concern. Preparations to treat anaphylaxis must be made before initiating antivenom therapy. Serum sickness is also common with many of the antivenom preparations.
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Affiliation(s)
- K Heard
- Rocky Mountain Poison and Drug Center, Denver, Colorado, USA
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Hertzberg SR, Arunanthy S. A life‐threatening anaphylactoid reaction to polyvalent antivenom despite pretreatment. Med J Aust 1999. [DOI: 10.5694/j.1326-5377.1999.tb126895.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Two cases of fatal anaphylaxis caused by seafood allergy are reported. The first serves as a reminder of the importance of obtaining a full medical history and details of the circumstances of death, and of the need to be aware of forensic post-mortem artefacts. Observations on the immunological mechanisms of type 1 or immediate hypersensitivity seen in the second case, and a discussion of preventive measures, offer subjects for medicolegal deliberation.
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Affiliation(s)
- F Patel
- UMDS (University of London) Guy's Hospital, London Bridge
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36
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Brazil E, MacNamara AF. "Not so immediate" hypersensitivity--the danger of biphasic anaphylactic reactions. J Accid Emerg Med 1998; 15:252-3. [PMID: 9681309 PMCID: PMC1343138 DOI: 10.1136/emj.15.4.252] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess how commonly clinically significant biphasic anaphylactic reactions occur after apparently successful treatment of an anaphylactic reaction. Cases were analysed to determine whether there were any markers that would allow early identification of patients who would subsequently develop a biphasic response. METHOD Retrospective review of case notes of 34 patients admitted for observation after an anaphylactic reaction that had required treatment with adrenaline. RESULTS Six patients (18%) had biphasic reactions. No clinical features on initial presentation identified those likely to have a biphasic response. These patients however required significantly more adrenaline to ameliorate their initial symptoms (p = 0.03) compared with those having a simple uniphasic reaction. CONCLUSIONS Biphasic anaphylactic reactions occur frequently. There are no clinical features that allow identification of patients likely to have a biphasic response. These patients require higher doses of adrenaline to control their initial symptoms and this should be considered a marker for patients who may develop a biphasic response. These results confirm that all patients being discharged after treatment for an acute anaphylactic reaction must be made aware of the risk of a second phase response after apparent clinical resolution.
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Affiliation(s)
- E Brazil
- Accident and Emergency Department, County Hospital, Lincoln
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37
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Müller UR, Bonifazi F, Przybilla B, Youlten L, Mosbech H, Fernandez Sanchez J, Vervloet D. Withdrawal of the Medihaler-epi/Adrenaline Medihaler: comments of the Subcommittee on Insect Venom Allergy of the EAACI. Allergy 1998; 53:619-20. [PMID: 9689345 DOI: 10.1111/j.1398-9995.1998.tb03939.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Green LC. Anaphylactic shock and its implication for nurses. ACCIDENT AND EMERGENCY NURSING 1998; 6:103-5. [PMID: 9677879 DOI: 10.1016/s0965-2302(98)90008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Anaphylactic shock can strike a patient at any time or place. It is sudden allergic response to an environmental situation, insect venom or medically-prescribed drug. Although some members of the public may present in the Accident and Emergency department with life-threatening symptoms, the situation is often most serious when a drug has been given. The mechanism of anaphylactic shock is discussed in this article as is the first line treatment. The immune system and the character of immunoglobulins are highlighted, and the role of the nurse in an emergency situation is given consideration. Legal implications of any action taken are looked at from the standpoint of litigation.
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Affiliation(s)
- L C Green
- Intensive Care Unit, Newcastle General Hospital, Newcastle-upon Tyne, UK
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Affiliation(s)
- A F Brown
- Department of Emergency Medicine, Royal Brisbane Hospital, Queensland, Australia
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40
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Abstract
The otolaryngic allergist should take every measure possible to prevent reactions during testing and treatment of the allergic patient. Because the risk of this rare complication cannot be completely eliminated, however, it is essential to be prepared for prompt recognition and proper treatment of an anaphylactic emergency. An emergency set, including airway management tools, oxygen, intravenous materials, and proper medication, is essential. The entire office staff should be educated to cope with the emergency. Finally, a medication history must be repeated at intervals to detect patients who are receiving beta blockers to either remove them from the patients' treatment regimen or to prepare for the special treatment of the patients on beta blockers.
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Affiliation(s)
- D H Hunsaker
- Department of Otolaryngology, Naval Medical Center, San Diego, USA
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41
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HARPER M, EDGE G. A lesson in the management of anaphylactic reactions. Anaesthesia 1996. [DOI: 10.1111/j.1365-2044.1996.tb04662.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Harper M, Edge G. A lesson in the management of anaphylactic reactions. Anaesthesia 1996; 51:705-6. [PMID: 8758172 DOI: 10.1111/j.1365-2044.1996.tb07862.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Fisher M. Treatment of acute anaphylaxis. Letters contained errors of logic. BMJ (CLINICAL RESEARCH ED.) 1996; 312:637-8. [PMID: 8595354 PMCID: PMC2350410 DOI: 10.1136/bmj.312.7031.637c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Luke LC. Treatment of acute anaphylaxis. Surviving the journey is a good prognostic indicator. BMJ (CLINICAL RESEARCH ED.) 1995; 311:1434. [PMID: 8520294 PMCID: PMC2544385 DOI: 10.1136/bmj.311.7017.1434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Finlay F, Simpson N. Treatment of acute anaphylaxis. Teachers need to know the basics too. BMJ (CLINICAL RESEARCH ED.) 1995; 311:1436. [PMID: 8520301 PMCID: PMC2544420 DOI: 10.1136/bmj.311.7017.1436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Alexander R, Pappachan R, Smith GB, Taylor BL. Treatment of acute anaphylaxis. Avoid subcutaneous or intramuscular adrenaline. BMJ (CLINICAL RESEARCH ED.) 1995; 311:1434-5. [PMID: 8520295 PMCID: PMC2544389 DOI: 10.1136/bmj.311.7017.1434c] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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47
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Scadding GK. Treatment of acute anaphylaxis. Remove the patient from contact with the allergen. BMJ (CLINICAL RESEARCH ED.) 1995; 311:1434. [PMID: 8520293 PMCID: PMC2544412 DOI: 10.1136/bmj.311.7017.1434a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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48
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Clear J, Yeoh M, Cockroft S. Treatment of acute anaphylaxis. Treatment takes precedence over monitoring. BMJ (CLINICAL RESEARCH ED.) 1995; 311:1435. [PMID: 8520298 PMCID: PMC2544404 DOI: 10.1136/bmj.311.7017.1435a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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49
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Hourihane JO, Warner JO. Treatment of acute anaphylaxis. Benign allergic reactions should not be treated with adrenaline. BMJ (CLINICAL RESEARCH ED.) 1995; 311:1434. [PMID: 8520292 PMCID: PMC2544393 DOI: 10.1136/bmj.311.7017.1434b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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50
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Robinson SM. Treatment of acute anaphylaxis. Investigations help to confirm diagnosis. BMJ (CLINICAL RESEARCH ED.) 1995; 311:1435. [PMID: 8520297 PMCID: PMC2544425 DOI: 10.1136/bmj.311.7017.1435b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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