Medline ® Abstracts for References 71-74
of 'Anaphylaxis: Emergency treatment'
Multicenter study of emergency department visits for food allergies.
Clark S, Bock SA, Gaeta TJ, Brenner BE, Cydulka RK, Camargo CA, Multicenter Airway Research Collaboration-8 Investigators
J Allergy Clin Immunol. 2004;113(2):347.
BACKGROUND: Relatively little is known about the characteristics of patients who visit the emergency department (ED) for an acute allergic reaction. Although anaphylaxis guidelines suggest treatment with epinephrine, teaching about self-injectable epinephrine, and referral to an allergist, current ED management remains uncertain.
OBJECTIVE: The objective of this study was to describe the management of food-related acute allergic reactions.
METHODS: The Multicenter Airway Research Collaboration performed a chart review study in 21 North American EDs. Investigators reviewed a random sample of 678 charts of patients who presented with food allergy (International Classification of Diseases-ninth revision codes 693.1, 995.0, 995.3, and 995.60-995.69).
RESULTS: Patients had an average age of 29 years; the cohort was 57% female and 40% white. A variety of foods provoked the allergic reaction, including nuts (21%), crustaceans (19%), fruit (12%), and fish (10%). Although exposure to these foods can be life threatening, only 18% of patients came to the ED by ambulance. In the ED, 72% of patients received antihistamines, 48% received systemic corticosteroids, and 16% received epinephrine; 33% received respiratory treatments such as inhaled albuterol. Among patients with severe reactions (55% of total), 24% received epinephrine. Overall, 97% of patients were discharged to home. At ED discharge, 16% of patients were prescribed self-injectable epinephrine, and 12% were referred to an allergist.
CONCLUSIONS: Although guidelines suggest specific approaches for the management of acute allergic reactions, ED concordance for food allergy appears low. These findings support a new collaboration between professional organizations in allergy and emergency medicine and the development of educational programs and materials for ED patients and staff.
Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass, USA.
Multicenter study of emergency department visits for insect sting allergies.
Clark S, Long AA, Gaeta TJ, Camargo CA Jr
J Allergy Clin Immunol. 2005;116(3):643.
BACKGROUND: An earlier study of food-related anaphylaxis in the emergency department (ED) suggested low concordance with national guidelines for anaphylaxis management.
OBJECTIVE: To extend these findings, we performed a chart review study to describe current ED management of insect sting allergy.
METHODS: The Multicenter Airway Research Collaboration performed a chart review study in 15 North American EDs. Investigators reviewed 617 charts of patients with insect sting allergy. Patients were identified by using International Classification of Diseases, 9th Revision, codes 989.5 (toxic effect of venom), 995.0 (other anaphylactic shock), and 995.3 (allergy, unspecified).
RESULTS: The cohort was 42% female and 61% white, with a mean age of 36+/-19 years. In this cohort, 58% had local reactions, 11% had mild systemic reactions, and 31% had anaphylactic reactions, as defined by multisystem organ involvement or hypotension. Among patients with systemic reactions (mild or anaphylaxis), most (75%) were stung within 6 hours of ED arrival. While in the ED, 69% of systemic reaction patients received antihistamines, 50% systemic corticosteroids, and 12% epinephrine. Almost all systemic reaction patients (95%) were discharged to home. At ED discharge, 27% (95% CI, 22% to 33%) of systemic reaction patients received a prescription for self-injectable epinephrine. Only 20% (95% CI, 15% to 26%) had documentation of referral to an allergist.
CONCLUSIONS: Although guidelines suggest specific approaches for the emergency management of insect sting allergy, concordance with these guidelines appears low in patients with a severe insect sting reaction.
Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA 02114, USA. firstname.lastname@example.org
National study of US emergency department visits for acute allergic reactions, 1993 to 2004.
Gaeta TJ, Clark S, Pelletier AJ, Camargo CA
Ann Allergy Asthma Immunol. 2007;98(4):360.
BACKGROUND: The clinical epidemiology of acute allergic reactions in the emergency department (ED) is uncertain.
OBJECTIVES: To characterize ED visits for acute allergic reactions and to evaluate national trends in ED management.
METHODS: The National Hospital Ambulatory Medical Care Survey was used to identify a nationally representative sample of ED visits between 1993 and 2004. Cases with a diagnosis of acute allergic reaction were identified by International Classification of Diseases, Ninth Revision (ICD-9) codes (9950, 9951, 9952, 9953, 9956).
RESULTS: A total of 12.4 million allergy-related ED visits occurred from 1993 to 2004, representing 1.0% (95% confidence interval, 0.93%-1.10%) of all ED visits or 1.03 million ED visits per year. The number of allergy-related ED visits remained relatively stable, averaging 3.8 per 1,000 US population per year (95% confidence interval, 3.4-4.1; P for trend = .39). Although 63% of all visits were coded as urgent, only 4% required hospitalization. Anaphylaxis coding was rare (1%). EDstaff prescribed medications in 87% of visits, especially histamine, blockers (62%; P for trend = .29). Increases were noted from 1993 to 2004 for corticosteroids (22% to 50%; P<.001), histamine2 blockers (7% to 18%; P<.001), and inhaled beta-agonists (2% to 6%; P = .008). Epinephrine use was infrequent and declining (19% to 7%; P = .04).
CONCLUSION: Between 1993 and 2004, significant variability has occurred in ED management of acute allergic reactions.
New York Methodist Hospital, Brooklyn, New York, USA.
Diphenhydramine versus nonsedating antihistamines for acute allergic reactions: a literature review.
Banerji A, Long AA, Camargo CA Jr
Allergy Asthma Proc. 2007;28(4):418.
First-generation antihistamines can have adverse effects on the central nervous system and thereby complicate discharge planning from the emergency department (ED). Newer antihistamines are potentially safer, causing less sedation with similar efficacy. The aim of this study was to review the literature to better define which antihistamines are good options for the treatment of acute allergic reactions. A Medline search was conducted to identify English language articles published between January 1975 and March 2006 on antihistamines, sedation, and acute allergic reactions. Bibliographies from included studies were further investigated. We focused on sedative potential, effect on cognitive function, efficacy, onset of clinical activity, and cost of antihistamines. Diphenhydramine impairs psychomotor performance and cognitive function. Loratadine and desloratadine are nonsedating but less efficacious than cetirizine or fexofenadine. The incidence of sedation with cetirizine is less than that of first-generation antihistamines but is greater than placebo. Cetirizine has the fastest onset of action among the newer antihistamines. Fexofenadine does not impair psychomotor or cognitive skills and shows no dose-related increase in sedation but has a slower onset of action than diphenhydramine and cetirizine. Newer antihistamines cost approximately $0.52-2.39 more per dose than diphenhydramine ($0.37). Newer antihistamines provide similar efficacy as first-generation antihistamines but with less sedation. We believe this benefit outweighs the small increase in cost and that newer antihistamines should be considered in the management of acute allergic reactions. Although comparative ED-based trials are not available, newer antihistamines are an option for management of acute allergic reactions when sedation is a concern.
Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA. email@example.com