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Anaphylaxis: Rapid recognition and treatment

INTRODUCTION

Anaphylaxis is a potentially fatal disorder. In industrialized countries, the lifetime prevalence from all causes has been estimated to be between 0.05 and 2 percent in the general population and the rate of occurrence is increasing [1-6]. In the United States, the lifetime prevalence of anaphylaxis is reported to be 1.6 percent, based on strict clinical diagnostic criteria [7]. Anaphylaxis is not always recognized as such because it can mimic other conditions and is variable in its presentation.

This topic will review the recognition and treatment of anaphylaxis by healthcare professionals working in settings such as an emergency department (ED), surgical unit, hemodialysis facility, hospital ward, clinic, or clinician's office [8-12]. Unique features of anaphylaxis in pregnant women and infants are presented separately, as is the pathophysiology of anaphylaxis. (See "Anaphylaxis in pregnant and breastfeeding women" and "Anaphylaxis in infants" and "Pathophysiology of anaphylaxis".)

DEFINITION AND DIAGNOSIS

Anaphylaxis is defined as a serious allergic or hypersensitivity reaction that is rapid in onset and may cause death [13,14]. The diagnosis of anaphylaxis is based primarily upon clinical symptoms and signs, as well as a detailed description of the acute episode, including antecedent activities and events occurring within the preceding minutes to hours.

Anaphylaxis is underrecognized and undertreated [1-3,5]. This may partly be due to failure to appreciate that it can present without obvious skin symptoms and signs and without shock. 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.

Diagnostic criteria — Diagnostic criteria for anaphylaxis were published by a multidisciplinary group of experts in 2005 and 2006 [13,14]. These criteria were intended to help clinicians recognize the full spectrum of symptoms and signs that comprise anaphylaxis. Recognition of the variable and atypical presentations of anaphylaxis is critical to providing effective therapy in the form of epinephrine, as well as reducing overreliance on second-line medications such as antihistamines and glucocorticoids that are not lifesaving in anaphylaxis [15]. In a retrospective cohort study of 214 emergency department (ED) patients, these criteria were found to have a sensitivity of 97 percent compared with an allergist's diagnosis upon review of the case, as well as a specificity of 82 percent, a positive-predictive value of 69 percent, and a negative-predictive value of 98 percent [16].

                                          

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Literature review current through: Aug 2014. | This topic last updated: Jun 11, 2014.
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References
Top
  1. Lieberman P, Camargo CA Jr, Bohlke K, et al. Epidemiology of anaphylaxis: findings of the American College of Allergy, Asthma and Immunology Epidemiology of Anaphylaxis Working Group. Ann Allergy Asthma Immunol 2006; 97:596.
  2. Decker WW, Campbell RL, Manivannan V, et al. The etiology and incidence of anaphylaxis in Rochester, Minnesota: a report from the Rochester Epidemiology Project. J Allergy Clin Immunol 2008; 122:1161.
  3. Lin RY, Anderson AS, Shah SN, Nurruzzaman F. Increasing anaphylaxis hospitalizations in the first 2 decades of life: New York State, 1990 -2006. Ann Allergy Asthma Immunol 2008; 101:387.
  4. Poulos LM, Waters AM, Correll PK, et al. Trends in hospitalizations for anaphylaxis, angioedema, and urticaria in Australia, 1993-1994 to 2004-2005. J Allergy Clin Immunol 2007; 120:878.
  5. Sheikh A, Hippisley-Cox J, Newton J, Fenty J. Trends in national incidence, lifetime prevalence and adrenaline prescribing for anaphylaxis in England. J R Soc Med 2008; 101:139.
  6. Liew WK, Williamson E, Tang ML. Anaphylaxis fatalities and admissions in Australia. J Allergy Clin Immunol 2009; 123:434.
  7. Wood RA, Camargo CA Jr, Lieberman P, et al. Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States. J Allergy Clin Immunol 2014; 133:461.
  8. Ewan PW, Dugué P, Mirakian R, et al. BSACI guidelines for the investigation of suspected anaphylaxis during general anaesthesia. Clin Exp Allergy 2010; 40:15.
  9. Chacko T, Ledford D. Peri-anesthetic anaphylaxis. Immunol Allergy Clin North Am 2007; 27:213.
  10. Harboe T, Benson MD, Oi H, et al. Cardiopulmonary distress during obstetrical anaesthesia: attempts to diagnose amniotic fluid embolism in a case series of suspected allergic anaphylaxis. Acta Anaesthesiol Scand 2006; 50:324.
  11. Ebo DG, Bosmans JL, Couttenye MM, Stevens WJ. Haemodialysis-associated anaphylactic and anaphylactoid reactions. Allergy 2006; 61:211.
  12. Oswalt ML, Kemp SF. Anaphylaxis: office management and prevention. Immunol Allergy Clin North Am 2007; 27:177.
  13. 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.
  14. Sampson HA, Muñoz-Furlong A, Bock SA, et al. Symposium on the definition and management of anaphylaxis: summary report. J Allergy Clin Immunol 2005; 115:584.
  15. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000; 30:1144.
  16. Campbell RL, Hagan JB, Manivannan V, et al. Evaluation of national institute of allergy and infectious diseases/food allergy and anaphylaxis network criteria for the diagnosis of anaphylaxis in emergency department patients. J Allergy Clin Immunol 2012; 129:748.
  17. Simons FE. Anaphylaxis. J Allergy Clin Immunol 2010; 125:S161.
  18. Kemp SF, Lockey RF. Anaphylaxis: a review of causes and mechanisms. J Allergy Clin Immunol 2002; 110:341.
  19. Simons FE. Anaphylaxis, killer allergy: long-term management in the community. J Allergy Clin Immunol 2006; 117:367.
  20. 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.
  21. Simons FE, Ardusso LR, Bilò MB, et al. World Allergy Organization anaphylaxis guidelines: summary. J Allergy Clin Immunol 2011; 127:587.
  22. Soar J, Pumphrey R, Cant A, et al. Emergency treatment of anaphylactic reactions--guidelines for healthcare providers. Resuscitation 2008; 77:157.
  23. Brown SG, Mullins RJ, Gold MS. Anaphylaxis: diagnosis and management. Med J Aust 2006; 185:283.
  24. 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.
  25. Muraro A, Roberts G, Worm M, et al. Anaphylaxis: Guidelines from the European Academy of Allergy and Clinical Immunology (in preparation). Allergy 2014.
  26. 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.
  27. Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol 2001; 107:191.
  28. Bock SA, Muñoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol 2007; 119:1016.
  29. Pumphrey R. Anaphylaxis: can we tell who is at risk of a fatal reaction? Curr Opin Allergy Clin Immunol 2004; 4:285.
  30. Pumphrey RS, Gowland MH. Further fatal allergic reactions to food in the United Kingdom, 1999-2006. J Allergy Clin Immunol 2007; 119:1018.
  31. Greenberger PA, Rotskoff BD, Lifschultz B. Fatal anaphylaxis: postmortem findings and associated comorbid diseases. Ann Allergy Asthma Immunol 2007; 98:252.
  32. 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.
  33. 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.
  34. Rohacek M, Edenhofer H, Bircher A, Bingisser R. Biphasic anaphylactic reactions: occurrence and mortality. Allergy 2014; 69:791.
  35. Mehr S, Liew WK, Tey D, Tang ML. Clinical predictors for biphasic reactions in children presenting with anaphylaxis. Clin Exp Allergy 2009; 39:1390.
  36. Simons FE. Anaphylaxis in infants: can recognition and management be improved? J Allergy Clin Immunol 2007; 120:537.
  37. Simons FE, Schatz M. Anaphylaxis during pregnancy. J Allergy Clin Immunol 2012; 130:597.
  38. Simons FE, Frew AJ, Ansotegui IJ, et al. Risk assessment in anaphylaxis: current and future approaches. J Allergy Clin Immunol 2007; 120:S2.
  39. González-Pérez A, Aponte Z, Vidaurre CF, Rodríguez LA. Anaphylaxis epidemiology in patients with and patients without asthma: a United Kingdom database review. J Allergy Clin Immunol 2010; 125:1098.
  40. Iribarren C, Tolstykh IV, Miller MK, Eisner MD. Asthma and the prospective risk of anaphylactic shock and other allergy diagnoses in a large integrated health care delivery system. Ann Allergy Asthma Immunol 2010; 104:371.
  41. Mulla ZD, Simons FE. Concomitant chronic pulmonary diseases and their association with hospital outcomes in patients with anaphylaxis and other allergic conditions: a cohort study. BMJ Open 2013; 3.
  42. Westfall TC, Westfall DP. Adrenergic agonists and antagonists. In: Goodman and Gilman's the pharmacological basis of therapeutics, 11th ed, Brunton LL (Ed), McGraw-Hill, New York 2006. p.215.
  43. Triggiani M, Patella V, Staiano RI, et al. Allergy and the cardiovascular system. Clin Exp Immunol 2008; 153 Suppl 1:7.
  44. Watson A. Alpha adrenergic blockers and adrenaline. A mysterious collapse. Aust Fam Physician 1998; 27:714.
  45. Ruëff F, Przybilla B, Biló MB, et al. Predictors of severe systemic anaphylactic reactions in patients with Hymenoptera venom allergy: importance of baseline serum tryptase-a study of the European Academy of Allergology and Clinical Immunology Interest Group on Insect Venom Hypersensitivity. J Allergy Clin Immunol 2009; 124:1047.
  46. Mueller UR. Cardiovascular disease and anaphylaxis. Curr Opin Allergy Clin Immunol 2007; 7:337.
  47. Lee S, Hess EP, Nestler DM, et al. Antihypertensive medication use is associated with increased organ system involvement and hospitalization in emergency department patients with anaphylaxis. J Allergy Clin Immunol 2013; 131:1103.
  48. Schwartz LB. Diagnostic value of tryptase in anaphylaxis and mastocytosis. Immunol Allergy Clin North Am 2006; 26:451.
  49. Komarow HD, Hu Z, Brittain E, et al. Serum tryptase levels in atopic and nonatopic children. J Allergy Clin Immunol 2009; 124:845.
  50. Lieberman PL. Anaphylaxis. In: Middleton's allergy: Principles and practice, 7th ed, Adkinson NF Jr, Bochner BS, Busse WW, et al (Eds), St. Louis 2009. p.1027.
  51. Vadas P, Perelman B, Liss G. Platelet-activating factor, histamine, and tryptase levels in human anaphylaxis. J Allergy Clin Immunol 2013; 131:144.
  52. Belhocine W, Ibrahim Z, Grandné V, et al. Total serum tryptase levels are higher in young infants. Pediatr Allergy Immunol 2011; 22:600.
  53. Sala-Cunill A, Cardona V, Labrador-Horrillo M, et al. Usefulness and limitations of sequential serum tryptase for the diagnosis of anaphylaxis in 102 patients. Int Arch Allergy Immunol 2013; 160:192.
  54. Summers CW, Pumphrey RS, Woods CN, et al. Factors predicting anaphylaxis to peanuts and tree nuts in patients referred to a specialist center. J Allergy Clin Immunol 2008; 121:632.
  55. Vadas P, Gold M, Perelman B, et al. Platelet-activating factor, PAF acetylhydrolase, and severe anaphylaxis. N Engl J Med 2008; 358:28.
  56. Mochizuki A, McEuen AR, Buckley MG, Walls AF. The release of basogranulin in response to IgE-dependent and IgE-independent stimuli: validity of basogranulin measurement as an indicator of basophil activation. J Allergy Clin Immunol 2003; 112:102.
  57. Izikson L, English JC 3rd, Zirwas MJ. The flushing patient: differential diagnosis, workup, and treatment. J Am Acad Dermatol 2006; 55:193.
  58. Erem C, Kocak M, Onder Ersoz H, et al. Epinephrine-secreting cystic pheochromocytoma presenting with an incidental adrenal mass: a case report and a review of the literature. Endocrine 2005; 28:225.
  59. Ueda T, Oka N, Matsumoto A, et al. Pheochromocytoma presenting as recurrent hypotension and syncope. Intern Med 2005; 44:222.
  60. Becker K, Southwick K, Reardon J, et al. Histamine poisoning associated with eating tuna burgers. JAMA 2001; 285:1327.
  61. Daschner A, Alonso-Gómez A, Cabañas R, et al. Gastroallergic anisakiasis: borderline between food allergy and parasitic disease-clinical and allergologic evaluation of 20 patients with confirmed acute parasitism by Anisakis simplex. J Allergy Clin Immunol 2000; 105:176.
  62. Bork K, Hardt J, Witzke G. Fatal laryngeal attacks and mortality in hereditary angioedema due to C1-INH deficiency. J Allergy Clin Immunol 2012; 130:692.
  63. Greenberger PA. Idiopathic anaphylaxis. Immunol Allergy Clin North Am 2007; 27:273.
  64. Brown SG. Cardiovascular aspects of anaphylaxis: implications for treatment and diagnosis. Curr Opin Allergy Clin Immunol 2005; 5:359.
  65. 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.
  66. Simons FE. First-aid treatment of anaphylaxis to food: focus on epinephrine. J Allergy Clin Immunol 2004; 113:837.
  67. Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol 2001; 108:871.
  68. Simons FE, Roberts JR, Gu X, Simons KJ. Epinephrine absorption in children with a history of anaphylaxis. J Allergy Clin Immunol 1998; 101:33.
  69. Pumphrey RS. Fatal posture in anaphylactic shock. J Allergy Clin Immunol 2003; 112:451.
  70. Brown SG. The pathophysiology of shock in anaphylaxis. Immunol Allergy Clin North Am 2007; 27:165.
  71. Brown SG. Anaphylaxis: clinical concepts and research priorities. Emerg Med Australas 2006; 18:155.
  72. Simons KJ, Simons FE. Epinephrine and its use in anaphylaxis: current issues. Curr Opin Allergy Clin Immunol 2010; 10:354.
  73. Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2013; 2:CD000567.
  74. Sheikh A, Ten Broek V, Brown SG, Simons FE. H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2007; 62:830.
  75. Sheikh A, Shehata YA, Brown SG, Simons FE. Adrenaline for the treatment of anaphylaxis: cochrane systematic review. Allergy 2009; 64:204.
  76. Simons FE. Emergency treatment of anaphylaxis. BMJ 2008; 336:1141.
  77. McLean-Tooke AP, Bethune CA, Fay AC, Spickett GP. Adrenaline in the treatment of anaphylaxis: what is the evidence? BMJ 2003; 327:1332.
  78. Simons FE. Pharmacologic treatment of anaphylaxis: can the evidence base be strengthened? Curr Opin Allergy Clin Immunol 2010; 10:384.
  79. Vadas P, Perelman B. Effect of epinephrine on platelet-activating factor-stimulated human vascular smooth muscle cells. J Allergy Clin Immunol 2012; 129:1329.
  80. 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.
  81. 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.
  82. Kounis NG. Coronary hypersensitivity disorder: the Kounis syndrome. Clin Ther 2013; 35:563.
  83. Hegenbarth MA, American Academy of Pediatrics Committee on Drugs. Preparing for pediatric emergencies: drugs to consider. Pediatrics 2008; 121:433.
  84. 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.
  85. Stecher D, Bulloch B, Sales J, et al. Epinephrine auto-injectors: is needle length adequate for delivery of epinephrine intramuscularly? Pediatrics 2009; 124:65.
  86. Brown SG, Stone SF, Fatovich DM, et al. Anaphylaxis: clinical patterns, mediator release, and severity. J Allergy Clin Immunol 2013; 132:1141.
  87. 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.
  88. 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.
  89. Anchor J, Settipane RA. Appropriate use of epinephrine in anaphylaxis. Am J Emerg Med 2004; 22:488.
  90. Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol 2011; 127:S1.
  91. Scranton SE, Gonzalez EG, Waibel KH. Incidence and characteristics of biphasic reactions after allergen immunotherapy. J Allergy Clin Immunol 2009; 123:493.
  92. 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.
  93. Biteker M, Duran NE, Biteker FS, et al. Allergic myocardial infarction in childhood: Kounis syndrome. Eur J Pediatr 2010; 169:27.
  94. 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.
  95. Clark S, Bock SA, Gaeta TJ, et al. Multicenter study of emergency department visits for food allergies. J Allergy Clin Immunol 2004; 113:347.
  96. 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.
  97. 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.
  98. Banerji A, Long AA, Camargo CA Jr. Diphenhydramine versus nonsedating antihistamines for acute allergic reactions: a literature review. Allergy Asthma Proc 2007; 28:418.
  99. 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.
  100. Ellis BC, Brown SG. Parenteral antihistamines cause hypotension in anaphylaxis. Emerg Med Australas 2013; 25:92.
  101. Simons FE, Simons KJ. Histamine and H1-antihistamines: celebrating a century of progress. J Allergy Clin Immunol 2011; 128:1139.
  102. 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.
  103. 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.
  104. Fedorowicz Z, van Zuuren EJ, Hu N. Histamine H2-receptor antagonists for urticaria. Cochrane Database Syst Rev 2012; 3:CD008596.
  105. Choo KJ, Simons FE, Sheikh A. Glucocorticoids for the treatment of anaphylaxis. Cochrane Database Syst Rev 2012; 4:CD007596.
  106. Dewachter P, Mouton-Faivre C, Emala CW. Anaphylaxis and anesthesia: controversies and new insights. Anesthesiology 2009; 111:1141.
  107. Jang DH, Nelson LS, Hoffman RS. Methylene blue for distributive shock: a potential new use of an old antidote. J Med Toxicol 2013; 9:242.
  108. Puttgen HA, Mirski MA. The level of evidence 5 blues: investigating medicine when experience trumps equipoise. Crit Care Med 2013; 41:359.
  109. Simons FE, Clark S, Camargo CA Jr. Anaphylaxis in the community: learning from the survivors. J Allergy Clin Immunol 2009; 124:301.
  110. 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).
  111. 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.
  112. Simons FE, Edwards ES, Read EJ Jr, et al. Voluntarily reported unintentional injections from epinephrine auto-injectors. J Allergy Clin Immunol 2010; 125:419.
  113. The American College of Allergy, Asthma and Immunology. www.acaai.org (Accessed on August 13, 2009).
  114. The American Academy of Allergy, Asthma and Immunology. www.aaaai.org (Accessed on August 13, 2009).