UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Medline ® Abstracts for References 10,12-15,22-26,43

of 'Anaphylaxis: Emergency treatment'

10
TI
Epinephrine and its use in anaphylaxis: current issues.
AU
Simons KJ, Simons FE
SO
Curr Opin Allergy Clin Immunol. 2010;10(4):354.
 
PURPOSE OF REVIEW: Epinephrine is a life-saving medication in the treatment of anaphylaxis, in which it has multiple beneficial pharmacologic effects. Here, we examine the evidence base for its primary role in the treatment of anaphylaxis episodes in community settings.
RECENT FINDINGS: We review the practical pharmacology of epinephrine in anaphylaxis, its intrinsic limitations, and the pros and cons of different routes of administration. We provide a new perspective on the adverse effects of epinephrine, including its cardiac effects. We describe the evidence base for the use of epinephrine in anaphylaxis. We discuss the role of epinephrine auto-injectors for treatment of anaphylaxis in community settings, including identification of patients who need an auto-injector prescription, current use of auto-injectors, and advances in auto-injector design. We list reasons why physicians fail to prescribe epinephrine auto-injectors for patients with anaphylaxis, and reasons why patients fail to self-inject epinephrine in anaphylaxis. We emphasize the primary role of epinephrine in the context of emergency preparedness for anaphylaxis in the community.
SUMMARY: Epinephrine is the medication of choice in the first-aid treatment of anaphylaxis in the community. For ethical reasons, it is not possible to conduct randomized, placebo-controlled trials of epinephrine in anaphylaxis; however, continued efforts are needed towards improving the evidence base for epinephrine injection in this potentially fatal disease.
AD
Faculty of Pharmacy and Department of Pediatrics&Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
PMID
12
TI
Adrenaline for the treatment of anaphylaxis: cochrane systematic review.
AU
Sheikh A, Shehata YA, Brown SG, Simons FE
SO
Allergy. 2009;64(2):204.
 
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.
AD
Allergy&Respiratory Research Group, Division of Community Health Sciences: GP Section, The University of Edinburgh, Edinburgh, UK.
PMID
13
TI
Emergency treatment of anaphylaxis.
AU
Simons FE
SO
BMJ. 2008;336(7654):1141.
 
AD
PMID
14
TI
Adrenaline in the treatment of anaphylaxis: what is the evidence?
AU
McLean-Tooke AP, Bethune CA, Fay AC, Spickett GP
SO
BMJ. 2003;327(7427):1332.
 
AD
Regional Department of Immunology and Allergy, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP. andrew.mclean-tooke@nuth.northy.nhs.uk
PMID
15
TI
Pharmacologic treatment of anaphylaxis: can the evidence base be strengthened?
AU
Simons FE
SO
Curr Opin Allergy Clin Immunol. 2010;10(4):384.
 
PURPOSE OF REVIEW: To evaluate the evidence base for the pharmacologic treatment of anaphylaxis.
RECENT FINDINGS: In this review, we focus on four classes of medications (the alpha/beta-agonist epinephrine (adrenaline), H1-antihistamines, H2-antihistamines, and glucocorticoids) that are used in healthcare settings for the initial treatment of anaphylaxis. Epinephrine and many H1-antihistamines and glucocorticoids were introduced before the era of randomized controlled trials and before the era of evidence-based medicine. In anaphylaxis, no randomized controlled trials that are free from methodological problems and meet current standards have been performed with these medications, or with H2-antihistamines. The evidence base for epinephrine injection is stronger than the evidence base for use of other medications in anaphylaxis. Guidelines unanimously recommend prompt injection of epinephrine as the life-saving first-line medication in anaphylaxis; however, they differ in their recommendations for H1-antihistamines, H2-antihistamines, and glucocorticoids. Epinephrine is the only medication that is universally available for anaphylaxis treatment in healthcare settings worldwide. Paradoxically, it is underused in anaphylaxis treatment.
SUMMARY: For ethical reasons, there should never be a placebo-controlled trial of epinephrine in anaphylaxis. We discuss why the possibility of conducting randomized placebo-controlled trials with H1-antihistamines, H2-antihistamines, and particularly with glucocorticoids in anaphylaxis should be considered in order to improve the evidence base for treatment and guide clinical decision-making. We also describe the precautions that will be needed if randomized controlled trials are conducted in anaphylaxis.
AD
Department of Pediatrics&Child Health, Department of Immunology, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. lmcniven@hsc.mb.ca
PMID
22
TI
Anaphylaxis--a practice parameter update 2015.
AU
Lieberman P, Nicklas RA, Randolph C, Oppenheimer J, Bernstein D, Bernstein J, Ellis A, Golden DB, Greenberger P, Kemp S, Khan D, Ledford D, Lieberman J, Metcalfe D, Nowak-Wegrzyn A, Sicherer S, Wallace D, Blessing-Moore J, Lang D, Portnoy JM, Schuller D, Spector S, Tilles SA
SO
Ann Allergy Asthma Immunol. 2015;115(5):341.
 
AD
PMID
23
TI
World Allergy Organization anaphylaxis guidelines: summary.
AU
Simons FE, Ardusso LR, BilòMB, El-Gamal YM, Ledford DK, Ring J, Sanchez-Borges M, Senna GE, Sheikh A, Thong BY, World Allergy Organization
SO
J Allergy Clin Immunol. 2011;127(3):587.
 
AD
Department of Pediatrics and Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Canada. lmcniven@hsc.mb.ca
PMID
24
TI
Emergency treatment of anaphylactic reactions--guidelines for healthcare providers.
AU
Soar J, Pumphrey R, Cant A, Clarke S, Corbett A, Dawson P, Ewan P, Foëx B, Gabbott D, Griffiths M, Hall J, Harper N, Jewkes F, Maconochie I, Mitchell S, Nasser S, Nolan J, Rylance G, Sheikh A, Unsworth DJ, Warrell D, Working Group of the Resuscitation Council (UK)
SO
Resuscitation. 2008;77(2):157. Epub 2008 Mar 20.
 
*The UK incidence of anaphylactic reactions is increasing. *Patients who have an anaphylactic reaction have life-threatening airway and, or breathing and, or circulation problems usually associated with skin or mucosal changes. *Patients having an anaphylactic reaction should be treated using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. *Anaphylactic reactions are not easy to study with randomised controlled trials. There are, however, systematic reviews of the available evidence and a wealth of clinical experience to help formulate guidelines. *The exact treatment will depend on the patient's location, the equipment and drugs available, and the skills of those treating the anaphylactic reaction. *Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction. *Despite previous guidelines, there is still confusion about the indications, dose and route of adrenaline. *Intravenous adrenaline must only be used in certain specialist settings and only by those skilled and experienced in its use. *All those who are suspected of having had an anaphylactic reaction should be referred to a specialist in allergy. *Individuals who are at high risk of an anaphylactic reaction should carry an adrenaline auto-injector and receive training and support in its use. *There is a need for further research about the diagnosis, treatment and prevention of anaphylactic reactions.
AD
Southmead Hospital, North Bristol NHS Trust, Bristol, UK. Jasmeet.soar@nbt.nhs.uk
PMID
25
TI
Anaphylaxis: diagnosis and management.
AU
Brown SG, Mullins RJ, Gold MS
SO
Med J Aust. 2006;185(5):283.
 
Anaphylaxis is a serious, rapid-onset, allergic reaction that may cause death. Severe anaphylaxis is characterised by life-threatening upper airway obstruction, bronchospasm and/or hypotension. Anaphylaxis in children is most often caused by food. Bronchospasm is a common symptom, and there is usually a background of atopy and asthma. Venom- and drug-induced anaphylaxis are more common in adults, in whom hypotension is more likely to occur. Diagnosis can be difficult, with skin features being absent in up to 20% of people. Anaphylaxis must be considered as a differential diagnosis for any acute-onset respiratory distress, bronchospasm, hypotension or cardiac arrest. The cornerstones of initial management are putting the patient in the supine position, administering intramuscular adrenaline into the lateral thigh, resuscitation with intravenous fluid, support of the airway and ventilation, and giving supplementary oxygen. If the response to initial management is inadequate, intravenous infusion of adrenaline should be commenced. Use of vasopressors should be considered if hypotension persists. The patient should be observed for at least 4 hours after symptom resolution and referred to an allergist to assist with diagnosis, allergen avoidance measures, risk assessment, preparation of an action plan and education on the use of self-injectable adrenaline. Provision of a MedicAlert bracelet should also be arranged.
AD
University of Western Australia, Fremantle Hospital, Fremantle, WA, Australia. simon.brown@uwa.edu.au
PMID
26
TI
The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology.
AU
Muraro A, Roberts G, Clark A, Eigenmann PA, Halken S, Lack G, Moneret-Vautrin A, Niggemann B, RancéF, EAACI Task Force on Anaphylaxis in Children
SO
Allergy. 2007;62(8):857. Epub 2007 Jun 21.
 
Anaphylaxis is a growing paediatric clinical emergency that is difficult to diagnose because a consensus definition was lacking until recently. Many European countries have no specific guidelines for anaphylaxis. This position paper prepared by the EAACI Taskforce on Anaphylaxis in Children aims to provide practical guidelines for managing anaphylaxis in childhood based on the limited evidence available. Intramuscular adrenaline is the acknowledged first-line therapy for anaphylaxis, in hospital and in the community, and should be given as soon as the condition is recognized. Additional therapies such as volume support, nebulized bronchodilators, antihistamines or corticosteroids are supplementary to adrenaline. There are no absolute contraindications to administering adrenaline in children. Allergy assessment is mandatory in all children with a history of anaphylaxis because it is essential to identify and avoid the allergen to prevent its recurrence. A tailored anaphylaxis management plan is needed, based on an individual risk assessment, which is influenced by the child's previous allergic reactions, other medical conditions and social circumstances. Collaborative partnerships should be established, involving school staff, healthcare professionals and patients' organizations. Absolute indications for prescribing self-injectable adrenaline are prior cardiorespiratory reactions, exercise-induced anaphylaxis, idiopathic anaphylaxis and persistent asthma with food allergy. Relative indications include peanut or tree nut allergy, reactions to small quantities of a given food, food allergy in teenagers and living far away from a medical facility. The creation of national and European databases is expected to generate better-quality data and help develop a stepwise approach for a better management of paediatric anaphylaxis.
AD
Centre for Food Allergy Diagnosis and Treatment Veneto Region, Department of Pediatrics, University of Padua, Padua, Italy.
PMID
43
TI
Epinephrine: the drug of choice for anaphylaxis. A statement of the World Allergy Organization.
AU
Kemp SF, Lockey RF, Simons FE, World Allergy Organization ad hoc Committee on Epinephrine in Anaphylaxis
SO
Allergy. 2008;63(8):1061.
 
Anaphylaxis is an acute and potentially lethal multi-system allergic reaction. Most consensus guidelines for the past 30 years have held that epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis. Some state that properly administered epinephrine has no absolute contraindication in this clinical setting. A committee of anaphylaxis experts assembled by the World Allergy Organization has examined the evidence from the medical literature concerning the appropriate use of epinephrine for anaphylaxis. The Committee strongly believes that epinephrine is currently underutilized and often dosed suboptimally to treat anaphylaxis, is under-prescribed for potential future self-administration, that most of the reasons proposed to withhold its clinical use are flawed, and that the therapeutic benefits of epinephrine exceed the risk when given in appropriate i.m. doses.
AD
Department of Medicine, The University of Mississippi Medical Center, Jackson, MS, USA.
PMID