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Anaphylaxis: Emergency treatment

Authors
Ronna L Campbell, MD, PhD
John M Kelso, MD
Section Editors
Ron M Walls, MD, FRCPC, FAAEM
Adrienne G Randolph, MD, MSc
Deputy Editor
Anna M Feldweg, MD

INTRODUCTION

Anaphylaxis is a potentially fatal disorder that is under-recognized and undertreated. This may partly be due to failure to appreciate that anaphylaxis is a much broader syndrome than "anaphylactic shock," and the goal of therapy should be early recognition and treatment with epinephrine to prevent progression to life-threatening respiratory and/or cardiovascular symptoms and signs, including shock.

This topic will discuss the treatment of anaphylaxis. The clinical manifestations and diagnosis of anaphylaxis, pathophysiology, and unique features of anaphylaxis in specific patient groups are reviewed separately:

(See "Anaphylaxis: Acute diagnosis".)

(See "Pathophysiology of anaphylaxis".)

(See "Fatal anaphylaxis".)

                                     

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Literature review current through: Nov 2016. | This topic last updated: Thu Jul 21 00:00:00 GMT+00:00 2016.
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References
Top
  1. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000; 30:1144.
  2. Sampson HA, Mendelson L, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med 1992; 327:380.
  3. Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol 2001; 107:191.
  4. Bock SA, Muñoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol 2007; 119:1016.
  5. Pumphrey R. Anaphylaxis: can we tell who is at risk of a fatal reaction? Curr Opin Allergy Clin Immunol 2004; 4:285.
  6. Pumphrey RS, Gowland MH. Further fatal allergic reactions to food in the United Kingdom, 1999-2006. J Allergy Clin Immunol 2007; 119:1018.
  7. Greenberger PA, Rotskoff BD, Lifschultz B. Fatal anaphylaxis: postmortem findings and associated comorbid diseases. Ann Allergy Asthma Immunol 2007; 98:252.
  8. Shen Y, Li L, Grant J, et al. Anaphylactic deaths in Maryland (United States) and Shanghai (China): a review of forensic autopsy cases from 2004 to 2006. Forensic Sci Int 2009; 186:1.
  9. Yilmaz R, Yuksekbas O, Erkol Z, et al. Postmortem findings after anaphylactic reactions to drugs in Turkey. Am J Forensic Med Pathol 2009; 30:346.
  10. Simons KJ, Simons FE. Epinephrine and its use in anaphylaxis: current issues. Curr Opin Allergy Clin Immunol 2010; 10:354.
  11. Sheikh A, Ten Broek V, Brown SG, Simons FE. H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2007; 62:830.
  12. Sheikh A, Shehata YA, Brown SG, Simons FE. Adrenaline for the treatment of anaphylaxis: cochrane systematic review. Allergy 2009; 64:204.
  13. Simons FE. Emergency treatment of anaphylaxis. BMJ 2008; 336:1141.
  14. McLean-Tooke AP, Bethune CA, Fay AC, Spickett GP. Adrenaline in the treatment of anaphylaxis: what is the evidence? BMJ 2003; 327:1332.
  15. Simons FE. Pharmacologic treatment of anaphylaxis: can the evidence base be strengthened? Curr Opin Allergy Clin Immunol 2010; 10:384.
  16. Brown SG. Cardiovascular aspects of anaphylaxis: implications for treatment and diagnosis. Curr Opin Allergy Clin Immunol 2005; 5:359.
  17. Brown SG, Blackman KE, Stenlake V, Heddle RJ. Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation. Emerg Med J 2004; 21:149.
  18. Simons FE. First-aid treatment of anaphylaxis to food: focus on epinephrine. J Allergy Clin Immunol 2004; 113:837.
  19. Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol 2001; 108:871.
  20. Simons FE, Roberts JR, Gu X, Simons KJ. Epinephrine absorption in children with a history of anaphylaxis. J Allergy Clin Immunol 1998; 101:33.
  21. Pumphrey RS. Fatal posture in anaphylactic shock. J Allergy Clin Immunol 2003; 112:451.
  22. Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis--a practice parameter update 2015. Ann Allergy Asthma Immunol 2015; 115:341.
  23. Simons FE, Ardusso LR, Bilò MB, et al. World Allergy Organization anaphylaxis guidelines: summary. J Allergy Clin Immunol 2011; 127:587.
  24. Soar J, Pumphrey R, Cant A, et al. Emergency treatment of anaphylactic reactions--guidelines for healthcare providers. Resuscitation 2008; 77:157.
  25. Brown SG, Mullins RJ, Gold MS. Anaphylaxis: diagnosis and management. Med J Aust 2006; 185:283.
  26. Muraro A, Roberts G, Clark A, et al. The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology. Allergy 2007; 62:857.
  27. Campbell RL, Li JT, Nicklas RA, et al. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol 2014; 113:599.
  28. Brown SG. The pathophysiology of shock in anaphylaxis. Immunol Allergy Clin North Am 2007; 27:165.
  29. Brown SG. Anaphylaxis: clinical concepts and research priorities. Emerg Med Australas 2006; 18:155.
  30. Geerts BF, van den Bergh L, Stijnen T, et al. Comprehensive review: is it better to use the Trendelenburg position or passive leg raising for the initial treatment of hypovolemia? J Clin Anesth 2012; 24:668.
  31. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S876.
  32. Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2013; :CD000567.
  33. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006; 117:391.
  34. Simons FE. Anaphylaxis, killer allergy: long-term management in the community. J Allergy Clin Immunol 2006; 117:367.
  35. Kanwar M, Irvin CB, Frank JJ, et al. Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution. Ann Emerg Med 2010; 55:341.
  36. Kmietowicz Z. UK trainee doctors are still unsure about how to treat anaphylaxis. BMJ 2015; 350:h171.
  37. Halbrich M, Mack DP, Carr S, et al. CSACI position statement: epinephrine auto-injectors and children < 15 kg. Allergy Asthma Clin Immunol 2015; 11:20.
  38. Sicherer SH, Simons FE, Section on Allergy and Immunology, American Academy of Pediatrics. Self-injectable epinephrine for first-aid management of anaphylaxis. Pediatrics 2007; 119:638.
  39. Song TT, Nelson MR, Chang JH, et al. Adequacy of the epinephrine autoinjector needle length in delivering epinephrine to the intramuscular tissues. Ann Allergy Asthma Immunol 2005; 94:539.
  40. Stecher D, Bulloch B, Sales J, et al. Epinephrine auto-injectors: is needle length adequate for delivery of epinephrine intramuscularly? Pediatrics 2009; 124:65.
  41. Kemp SF, Lockey RF, Simons FE, World Allergy Organization ad hoc Committee on Epinephrine in Anaphylaxis. Epinephrine: the drug of choice for anaphylaxis. A statement of the World Allergy Organization. Allergy 2008; 63:1061.
  42. Hegenbarth MA, American Academy of Pediatrics Committee on Drugs. Preparing for pediatric emergencies: drugs to consider. Pediatrics 2008; 121:433.
  43. Brown SG, Stone SF, Fatovich DM, et al. Anaphylaxis: clinical patterns, mediator release, and severity. J Allergy Clin Immunol 2013; 132:1141.
  44. Ben-Shoshan M, La Vieille S, Eisman H, et al. Anaphylaxis treated in a Canadian pediatric hospital: Incidence, clinical characteristics, triggers, and management. J Allergy Clin Immunol 2013; 132:739.
  45. Korenblat P, Lundie MJ, Dankner RE, Day JH. A retrospective study of epinephrine administration for anaphylaxis: how many doses are needed? Allergy Asthma Proc 1999; 20:383.
  46. Uguz A, Lack G, Pumphrey R, et al. Allergic reactions in the community: a questionnaire survey of members of the anaphylaxis campaign. Clin Exp Allergy 2005; 35:746.
  47. Järvinen KM, Sicherer SH, Sampson HA, Nowak-Wegrzyn A. Use of multiple doses of epinephrine in food-induced anaphylaxis in children. J Allergy Clin Immunol 2008; 122:133.
  48. Oren E, Banerji A, Clark S, Camargo CA Jr. Food-induced anaphylaxis and repeated epinephrine treatments. Ann Allergy Asthma Immunol 2007; 99:429.
  49. Kelso JM. A second dose of epinephrine for anaphylaxis: how often needed and how to carry. J Allergy Clin Immunol 2006; 117:464.
  50. Manivannan V, Campbell RL, Bellolio MF, et al. Factors associated with repeated use of epinephrine for the treatment of anaphylaxis. Ann Allergy Asthma Immunol 2009; 103:395.
  51. Rudders SA, Banerji A, Corel B, et al. Multicenter study of repeat epinephrine treatments for food-related anaphylaxis. Pediatrics 2010; 125:e711.
  52. Campbell RL, Bashore CJ, Lee S, et al. Predictors of Repeat Epinephrine Administration for Emergency Department Patients with Anaphylaxis. J Allergy Clin Immunol Pract 2015; 3:576.
  53. Campbell RL, Bellolio MF, Knutson BD, et al. Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine. J Allergy Clin Immunol Pract 2015; 3:76.
  54. Wheeler DW, Carter JJ, Murray LJ, et al. The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. Ann Intern Med 2008; 148:11.
  55. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S829.
  56. Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S501.
  57. Le A, Patel S. Extravasation of Noncytotoxic Drugs: A Review of the Literature. Ann Pharmacother 2014; 48:870.
  58. Reynolds PM, MacLaren R, Mueller SW, et al. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy 2014; 34:617.
  59. Vadas P, Perelman B. Effect of epinephrine on platelet-activating factor-stimulated human vascular smooth muscle cells. J Allergy Clin Immunol 2012; 129:1329.
  60. Kounis NG. Coronary hypersensitivity disorder: the Kounis syndrome. Clin Ther 2013; 35:563.
  61. Triggiani M, Patella V, Staiano RI, et al. Allergy and the cardiovascular system. Clin Exp Immunol 2008; 153 Suppl 1:7.
  62. Ridella M, Bagdure S, Nugent K, Cevik C. Kounis syndrome following beta-lactam antibiotic use: review of literature. Inflamm Allergy Drug Targets 2009; 8:11.
  63. Biteker M, Duran NE, Biteker FS, et al. Allergic myocardial infarction in childhood: Kounis syndrome. Eur J Pediatr 2010; 169:27.
  64. Anchor J, Settipane RA. Appropriate use of epinephrine in anaphylaxis. Am J Emerg Med 2004; 22:488.
  65. Fleming JT, Clark S, Camargo CA Jr, Rudders SA. Early treatment of food-induced anaphylaxis with epinephrine is associated with a lower risk of hospitalization. J Allergy Clin Immunol Pract 2015; 3:57.
  66. Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol 2011; 127:S1.
  67. Scranton SE, Gonzalez EG, Waibel KH. Incidence and characteristics of biphasic reactions after allergen immunotherapy. J Allergy Clin Immunol 2009; 123:493.
  68. Thomas M, Crawford I. Best evidence topic report. Glucagon infusion in refractory anaphylactic shock in patients on beta-blockers. Emerg Med J 2005; 22:272.
  69. Lieberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010; 126:477.
  70. Clark S, Bock SA, Gaeta TJ, et al. Multicenter study of emergency department visits for food allergies. J Allergy Clin Immunol 2004; 113:347.
  71. Clark S, Long AA, Gaeta TJ, Camargo CA Jr. Multicenter study of emergency department visits for insect sting allergies. J Allergy Clin Immunol 2005; 116:643.
  72. Gaeta TJ, Clark S, Pelletier AJ, Camargo CA. National study of US emergency department visits for acute allergic reactions, 1993 to 2004. Ann Allergy Asthma Immunol 2007; 98:360.
  73. Banerji A, Long AA, Camargo CA Jr. Diphenhydramine versus nonsedating antihistamines for acute allergic reactions: a literature review. Allergy Asthma Proc 2007; 28:418.
  74. Park HJ, Kim JH, Kim JE, et al. Diagnostic value of the serum-specific IgE ratio of ω-5 gliadin to wheat in adult patients with wheat-induced anaphylaxis. Int Arch Allergy Immunol 2012; 157:147.
  75. Ellis BC, Brown SG. Parenteral antihistamines cause hypotension in anaphylaxis. Emerg Med Australas 2013; 25:92.
  76. Simons FE, Simons KJ. Histamine and H1-antihistamines: celebrating a century of progress. J Allergy Clin Immunol 2011; 128:1139.
  77. Lin RY, Curry A, Pesola GR, et al. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Ann Emerg Med 2000; 36:462.
  78. Nurmatov UB, Rhatigan E, Simons FE, Sheikh A. H2-antihistamines for the treatment of anaphylaxis with and without shock: a systematic review. Ann Allergy Asthma Immunol 2014; 112:126.
  79. Fedorowicz Z, van Zuuren EJ, Hu N. Histamine H2-receptor antagonists for urticaria. Cochrane Database Syst Rev 2012; :CD008596.
  80. Choo KJ, Simons FE, Sheikh A. Glucocorticoids for the treatment of anaphylaxis. Cochrane Database Syst Rev 2012; :CD007596.
  81. Grunau BE, Wiens MO, Rowe BH, et al. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses. Ann Emerg Med 2015; 66:381.
  82. Dewachter P, Mouton-Faivre C, Emala CW. Anaphylaxis and anesthesia: controversies and new insights. Anesthesiology 2009; 111:1141.
  83. Puttgen HA, Mirski MA. The level of evidence 5 blues: investigating medicine when experience trumps equipoise. Crit Care Med 2013; 41:359.
  84. Hosseinian L, Weiner M, Levin MA, Fischer GW. Methylene Blue: Magic Bullet for Vasoplegia? Anesth Analg 2016; 122:194.
  85. Bauer CS, Vadas P, Kelly KJ. Methylene blue for the treatment of refractory anaphylaxis without hypotension. Am J Emerg Med 2013; 31:264.e3.
  86. Lafforgue E, Sleth JC, Pluskwa F, Saizy C. [Successful extracorporeal resuscitation of a probable perioperative anaphylactic shock due to atracurium]. Ann Fr Anesth Reanim 2005; 24:551.
  87. Allen SJ, Gallagher A, Paxton LD. Anaphylaxis to rocuronium. Anaesthesia 2000; 55:1223.
  88. Campbell RL, Park MA, Kueber MA Jr, et al. Outcomes of allergy/immunology follow-up after an emergency department evaluation for anaphylaxis. J Allergy Clin Immunol Pract 2015; 3:88.
  89. Lee S, Bellolio MF, Hess EP, et al. Time of Onset and Predictors of Biphasic Anaphylactic Reactions: A Systematic Review and Meta-analysis. J Allergy Clin Immunol Pract 2015; 3:408.
  90. Rohacek M, Edenhofer H, Bircher A, Bingisser R. Biphasic anaphylactic reactions: occurrence and mortality. Allergy 2014; 69:791.
  91. Simons FE, Clark S, Camargo CA Jr. Anaphylaxis in the community: learning from the survivors. J Allergy Clin Immunol 2009; 124:301.
  92. The Be S.A.F.E. campaign is discussed on the website of the American College of Allergy, Asthma and Immunology. http://www.acaai.org/allergist/allergies/Anaphylaxis/Pages/safe-awareness-anaphylaxis.aspx (Accessed on May 09, 2014).
  93. Lieberman P, Decker W, Camargo CA Jr, et al. SAFE: a multidisciplinary approach to anaphylaxis education in the emergency department. Ann Allergy Asthma Immunol 2007; 98:519.
  94. Simons FE, Edwards ES, Read EJ Jr, et al. Voluntarily reported unintentional injections from epinephrine auto-injectors. J Allergy Clin Immunol 2010; 125:419.
  95. The American College of Allergy, Asthma and Immunology. www.acaai.org (Accessed on August 13, 2009).
  96. The American Academy of Allergy, Asthma and Immunology. www.aaaai.org (Accessed on August 13, 2009).