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Medline ® Abstracts for References 1-9

of 'Anaphylaxis: Emergency treatment'

1
TI
Lessons for management of anaphylaxis from a study of fatal reactions.
AU
Pumphrey RS
SO
Clin Exp Allergy. 2000;30(8):1144.
 
BACKGROUND: The unpredictability of anaphylactic reactions and the need for immediate, often improvised treatment will make controlled trials impracticable; other means must therefore be used to determine optimal management.
OBJECTIVES: This study aimed to investigate the circumstances leading to fatal anaphylaxis.
METHODS: A register was established including all fatal anaphylactic reactions in the UK since 1992 that could be traced from the certified cause of death. Data obtained from other sources suggested that deaths certified as due to anaphylaxis underestimate the true incidence. Details of the previous medical history, the reaction and necropsy were sought for all cases.
RESULTS: Approximately half the 20 fatal reactions recorded each year in the UK were iatrogenic, and a quarter each due to food or insect venom. All fatal reactions thought to have been due to food caused difficulty breathing that in 86% led to respiratory arrest; shock was more common in iatrogenic and venom reactions. The median time to respiratory or cardiac arrest was 30 min for foods, 15 min for venom and 5 min for iatrogenic reactions. Twenty-eight per cent of fatal cases were resuscitated but died 3 h-30 days later, mostly from hypoxic brain damage. Adrenaline (epinephrine) was used in treatment of 62% of fatal reactions but before arrest in only 14%.
CONCLUSIONS: Immediate recognition of anaphylaxis, early use of adrenaline, inhaled beta agonists and other measures are crucial for successful treatment. Nevertheless, a few reactions will be fatal whatever treatment is given; optimal management of anaphylaxis is therefore avoidance of the cause whenever this is possible. Predictable cross-reactivity between the cause of the fatal reaction and that of previous reactions had been overlooked. Adrenaline overdose caused at least three deaths and must be avoided. Kit for self-treatment had proved unhelpful for a variety of reasons; its success depends on selection of appropriate medication, ease of use and good training.
AD
Immunology Unit, Central Manchester Healthcare NHS Trust Hospitals, St Mary's Hospital, Hathersage Road, Manchester M13 0JH, UK.
PMID
2
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Fatal and near-fatal anaphylactic reactions to food in children and adolescents.
AU
Sampson HA, Mendelson L, Rosen JP
SO
N Engl J Med. 1992;327(6):380.
 
BACKGROUND AND METHODS: Reports of fatal or near-fatal anaphylactic reactions to foods in children and adolescents are rare. We identified six children and adolescents who died of anaphylactic reactions to foods and seven others who nearly died and required intubation. All the cases but one occurred in one of three metropolitan areas over a period of 14 months. Our investigations included a review of emergency medical care reports, medical records, and depositions by witnesses to the events, as well as interviews with parents (and some patients).
RESULTS: Of the 13 children and adolescents (age range, 2 to 17 years), 12 had asthma that was well controlled. All had known food allergies, but had unknowingly ingested the foods responsible for the reactions. The reactions were to peanuts (four patients), nuts (six patients), eggs (one patient), and milk (two patients), all of which were contained in foods such as candy, cookies, and pastry. The six patients who died had symptoms within 3 to 30 minutes of the ingestion of the allergen, but only two received epinephrine in the first hour. All the patients who survived had symptoms within 5 minutes of allergen ingestion, and all but one received epinephrine within 30 minutes. The course of anaphylaxis was rapidly progressive and uniphasic in sevenpatients; biphasic, with a relatively symptom-free interval in three; and protracted in three, requiring intubation for 3 to 21 days.
CONCLUSIONS: Dangerous anaphylactic reactions to food occur in children and adolescents. The failure to recognize the severity of these reactions and to administer epinephrine promptly increases the risk of a fatal outcome.
AD
Division of Pediatric Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, MD.
PMID
3
TI
Fatalities due to anaphylactic reactions to foods.
AU
Bock SA, Muñoz-Furlong A, Sampson HA
SO
J Allergy Clin Immunol. 2001;107(1):191.
 
Fatal anaphylactic reactions to foods are continuing to occur, and better characterization might lead to better prevention. The objective of this report is to document the ongoing deaths and characterize these fatalities. We analyzed 32 fatal cases reported to a national registry, which was established by the American Academy of Allergy, Asthma, and Immunology, with the assistance of the Food Allergy and Anaphylaxis Network, and for which adequate data could be collected. Data were collected from multiple sources including a structured questionnaire, which was used to determine the cause of death and associated factors. The 32 individuals could be divided into 2 groups. Group 1 had sufficient data to identify peanut as the responsible food in 14 (67%) and tree nuts in 7 (33%) of cases. In group 2 subjects, 6 (55%) of the fatalities were probably due to peanut, 3 (27%) to tree nuts, and the other 2 cases were probably due to milk and fish (1 [9%]each). The sexes were equally affected; most victims were adolescents or young adults, and all but 1 subject were known to have food allergy before the fatal event. In those subjects for whom data were available, all but 1 was known to have asthma, and most of these individuals did not have epinephrine available at the time of their fatal reaction. Fatalities due to ingestion of allergenic foods in susceptible individuals remain a major health problem. In this series, peanuts and tree nuts accounted for more than 90% of the fatalities. Improved education of the profession, allergic individuals, and the public will be necessary to stop these tragedies.
AD
Department of Pediatrics, National Jewish Medical and Research Center, Denver, CO, USA.
PMID
4
TI
Further fatalities caused by anaphylactic reactions to food, 2001-2006.
AU
Bock SA, Muñoz-Furlong A, Sampson HA
SO
J Allergy Clin Immunol. 2007;119(4):1016.
 
AD
PMID
5
TI
Anaphylaxis: can we tell who is at risk of a fatal reaction?
AU
Pumphrey R
SO
Curr Opin Allergy Clin Immunol. 2004;4(4):285.
 
PURPOSE OF REVIEW: Anaphylaxis is frightening and patients commonly fear their next reaction will be fatal. This review looks at the characteristics of fatal reactions to find if a fatal recurrence is predictable.
RECENT FINDINGS: Most publications on fatal anaphylaxis are case reports that do not help predict risks. Most epidemiological studies focus on non-fatal reactions. The UK fatal anaphylaxis register demonstrates that over two-thirds of those dying from sting reactions and over four-fifths dying from drug anaphylaxis had no previous indication of their allergy, whereas those dying from food allergy had usually had previous reactions but these were typically not severe. Recent reports of anaphylaxis epidemiology based on diagnostic coding or attendance for treatment may be biased by differences in health service resource utilization according to the cause and course of the reaction.
SUMMARY: Most fatal anaphylactic reactions are unpredictable. The appropriate management after recovery from a severe reaction may be protective against a fatal recurrence. An accurate identification of the cause and effective avoidance is a crucial part of this management, together with effective treatment of asthma for those with food allergy, immunotherapy for sting allergy, the avoidance of drugs that potentiate anaphylaxis, and effective training in self-treatment.
AD
Department of Immunology, St Mary's Hospital, Manchester, UK. richard.pumphrey@cmmc.nhs.uk
PMID
6
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Further fatal allergic reactions to food in the United Kingdom, 1999-2006.
AU
Pumphrey RS, Gowland MH
SO
J Allergy Clin Immunol. 2007;119(4):1018. Epub 2007 Mar 8.
 
AD
PMID
7
TI
Fatal anaphylaxis: postmortem findings and associated comorbid diseases.
AU
Greenberger PA, Rotskoff BD, Lifschultz B
SO
Ann Allergy Asthma Immunol. 2007;98(3):252.
 
BACKGROUND: Anaphylaxis is an infrequent cause of sudden death. Death often results from circulatory collapse, respiratory arrest, or both.
OBJECTIVE: To investigate the causes of death, anatomical findings, and comorbid diseases in cases of fatal anaphylaxis.
METHODS: This is a retrospective case review of 25 unselected cases of documented fatal anaphylaxis. Each case report contained details of the fatal reaction, a review of the medical record, and laboratory and autopsy findings. Serum tryptase concentrations were measured in 7 cases.
RESULTS: The anaphylactic deaths included 7 reactions to medications, 6 to radiocontrast material, 6 to Hymenoptera stings, and 4 to foods. The mean age was 59 years. The anaphylactic reaction began within 30 minutes of exposure in 21 of 25 cases, with death occurring within 60 minutes in 13 of 25 cases. Urticaria occurred in only 1 of 25 cases. Anatomical findings consistent with anaphylaxis were present in 18 of 23 patients undergoing autopsy. At least 1 significant comorbid disease was identified in 22 of 25 cases.
CONCLUSIONS: (1) Elderly patients with substantial comorbid conditions constituted a significant number of the anaphylactic fatalities; (2) the onset of severe anaphylaxis occurred in less than 30 minutes in nearly every case; (3) 18 of 23 cases were associated with specific anatomical findings of anaphylaxis; (4) self-administered epinephrine was used in just 1 of 5 cases; and (5) serum total tryptase concentrations were elevated markedly in 4 of 7 cases tested.
AD
Division of Allergy-Immunology, Departments of Medicine and Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 14018, USA. p-greenberger@northwestern.edu
PMID
8
TI
Anaphylactic deaths in Maryland (United States) and Shanghai (China): a review of forensic autopsy cases from 2004 to 2006.
AU
Shen Y, Li L, Grant J, Rubio A, Zhao Z, Zhang X, Zhou L, Fowler D
SO
Forensic Sci Int. 2009;186(1-3):1.
 
Anaphylaxis is a life threatening allergic reaction that is rapid in onset and may cause sudden death. A retrospective study was performed using the database from the Office of the Chief Medical Examiner (OCME) in the State of Maryland and the Department of Forensic Medicine in Shanghai Medical College (DFM-SMC) to examine the etiology and forensic investigation findings of anaphylactic deaths from 2004 to 2006. Details of the medical history, agent responsible for the allergic reaction, death scene investigation and postmortem examination findings were reviewed for all cases. A total of 28 cases of anaphylactic death were identified for the study period, 17 from Maryland and 11 from Shanghai. Of the 17 Maryland cases, 6 (35%) involved allergic reaction to food, 5 (25%) to drugs, 2 to bee stings, 1 to hair dye, and 3 to unknown allergens. Investigation revealed that 9 of 17 cases had a history of asthma and 8 had previous allergic reactions to certain foods and / or drugs. In Shanghai, all 11 deaths resulted from anaphylactic reaction to antibiotics, 10 of which occurred in clinics illegally operated by unlicensed physicians. The interval between the onset of symptoms and death ranged from less than 1 min to 3 days after initially contacting the allergen. In the majority (68%) of cases, death occurred within 8h after the onset of symptoms. Postmortemfindings were relatively non-specific, and included pharyngeal/laryngeal edema 14/28 (50%), mucus plugging in the airways 11/28 (39%), and pulmonary congestion and edema 28/28 (100%). Serum tryptase concentrations were measured in 14 cases in Maryland and the concentration ranged from 3.3 ng/ml to 200 ng/ml. There were significant differences with regards to allergen type and the circumstances of death between these two regions. Inappropriate use of antibiotics and illegal medical practices were the main causes of identified anaphylactic death in Shanghai. In Maryland anaphylactic deaths were mainly caused by food reactions. This study indicates that the postmortem diagnosis of anaphylactic death is usually based on exclusion and circumstantial evidence. Knowledge of the patient's history and circumstances of death is of major importance for the forensic pathologist when investigating suspected anaphylactic death.
AD
Office of Chief Medical Examiner, State of Maryland, 111 Penn Street, Baltimore, MD 21201, USA.
PMID
9
TI
Postmortem findings after anaphylactic reactions to drugs in Turkey.
AU
Yilmaz R, Yuksekbas O, Erkol Z, Bulut ER, Arslan MN
SO
Am J Forensic Med Pathol. 2009;30(4):346.
 
AIMS: To determine the frequency of anaphylactic deaths at autopsies performed in Turkey between January 2001 and June 2006 and to review the circumstances of death and autopsy findings.
METHODS: The Council of Forensic Medicine database in Istanbul was searched for anaphylactic deaths. Postmortem reports and medical records were reviewed to determine the circumstances of death. Data about basic demographics, medical history, drugs responsible for allergic reactions, and pathologic findings at autopsy were collected.
RESULTS: A total of 36 anaphylactic deaths from drugs were identified for the study period. Death was due to antibiotics in 26 cases, analgesics in 7 cases, an intraoperative drug in 1 case, an H2 receptor in 1 case, and intravenous contrast medium in 1 case. Out of 36 cases, 19 were male and 17 female. They were aged between 1 and 74 years with the median age of 26.7 years. Death occurred within 1 hour of the onset of anaphylaxis in 27 cases. Findings at autopsy included nonspecific pulmonary edema and congestion, upper airway edema, cerebral hypoxia, and cutaneous edema. Serum tryptase levels were not measured in all cases.
CONCLUSION: Anaphylactic reaction is an uncommon cause of sudden death. In many cases, no specific macroscopic or microscopic findings were detected at autopsy. When serum tryptase levels cannot be determined, in the presence of typical clinical records, eye witness reports and autopsy findings can be useful diagnostic aids.
AD
Council of Forensic Medicine, Istanbul, Turkey. dr_riza_yilmaz@yahoo.com
PMID