Improving Diagnostic Accuracy of Anaphylaxis in the Acute Care Setting

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Abstract

The identification and appropriate management of those at highest risk for life-threatening anaphylaxis remains a clinical enigma. The most widely used criteria for such patients were developed in a symposium convened by National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network. In this paper we review the current literature on the diagnosis of acute allergic reactions as well as atypical presentations that clinicians should recognize. Review of case series reveals significant variability in definition and approach to this common and potentially life-threatening condition. Series on fatal cases of anaphylaxis indicate that mucocutaneous signs and symptoms occur less frequently than in milder cases. Of biomarkers studied to aid in the work-up of possible anaphylaxis, drawing blood during the initial six hours of an acute reaction for analysis of serum tryptase has been recommended in atypical cases. This can provide valuable information when a definitive diagnosis cannot be made by history and physical exam.

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Most cited references 36

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Fatalities due to anaphylactic reactions to foods.

S A Bock, A Muñoz-Furlong, H Sampson (2001)

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.

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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.

Gabriela A C G Camargo, Stephen J. Galli, Andrew S. Bock … (2006)

There is no universal agreement on the definition of anaphylaxis or the criteria for diagnosis. In July 2005, the National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network convened a second meeting on anaphylaxis, which included representatives from 16 different organizations or government bodies, including representatives from North America, Europe, and Australia, to continue working toward a universally accepted definition of anaphylaxis, establish clinical criteria that would accurately identify cases of anaphylaxis with high precision, further review the evidence on the most appropriate management of anaphylaxis, and outline the research needs in this area.

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Anaphylaxis fatalities and admissions in Australia.

Woei Kang Liew, Elizabeth Mae Williamson, Mimi Tang (2009)

Detailed data on fatal anaphylaxis are limited, with national anaphylaxis fatality data for the United Kingdom and food-induced anaphylaxis fatality data for the United States. Time trends for anaphylaxis fatalities are not available. We examined causes, demographics, and time trends for anaphylaxis fatalities in Australia between January 1997 and December 2005 and compared these with findings for anaphylaxis admissions. Data on anaphylaxis deaths and hospital admissions were extracted from a national database. Death certificate codes were analyzed to determine the likely cause and associated comorbidities. There were 112 anaphylaxis fatalities in Australia over 9 years. Causes were as follows: food, 7 (6%); drugs, 22 (20%); probable drugs, 42 (38%); insect stings, 20 (18%); undetermined, 15 (13%); and other, 6 (5%). All food-induced anaphylaxis fatalities occurred between 8 and 35 years of age with female preponderance, despite the majority of food-induced anaphylaxis admissions occurring in children less than 5 years of age. Most insect sting-induced anaphylaxis deaths occurred between 35 and 84 years almost exclusively in male subjects, although bee sting-induced admissions peak between 5 and 9 years of age with a male/female ratio of 2.7. However, most drug-induced anaphylaxis deaths occurred between 55 and 85 years with equal sex distribution similar to drug-induced anaphylaxis admissions. There was no evidence of an increase in death rates for food-induced anaphylaxis, despite food-induced anaphylaxis admissions increasing approximately 350%. In contrast, drug-induced anaphylaxis deaths increased approximately 300% compared with an approximately 150% increase in drug-induced anaphylaxis admissions. The demographics for anaphylaxis deaths are different to those for anaphylaxis presentations. Anaphylaxis mortality rates remain low and stable, despite increasing anaphylaxis prevalence, with the exception of drug-induced anaphylaxis deaths, which have increased.

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Author and article information

Journal

Journal ID (nlm-ta): West J Emerg Med

Journal ID (publisher-id): WestJEM

Title: Western Journal of Emergency Medicine

Publisher: Department of Emergency Medicine, University of California, Irvine School of Medicine

ISSN (Print): 1936-900X

ISSN (Electronic): 1936-9018

Publication date (Print): December 2010

Volume: 11

Issue: 5

Pages: 456-461

Affiliations

Eastern Virginia Medical School, Department of Emergency Medicine, Norfolk, VA

Author notes

Address for Correspondence: Charles S Graffeo MD, Department of Emergency Medicine, Eastern Virginia Medical School, Raleigh Building, Room 304, 600 Gresham Drive, Norfolk, VA 23507 Email: graffecs@ 123456evms.edu

Supervising Section Editor: Gene Hern Jr., MD

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Publisher ID: wjem11_5p456

PMC ID: 3027438

PubMed ID: 21293765

SO-VID: 1637306e-da5a-458c-afbb-5d6d8986b635

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This is an Open Access article distributed under the terms of the Creative Commons Non-Commercial Attribution License, which permits its use in any digital medium, provided the original work is properly cited and not altered. For details, please refer to http://creativecommons.org/licenses/by-nc-nd/3.0/. Authors grant Western Journal of Emergency Medicine a nonexclusive license to publish the manuscript.

Improving Diagnostic Accuracy of Anaphylaxis in the Acute Care Setting

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Irish Journal of Paramedicine

Most cited references 36

Fatalities due to anaphylactic reactions to foods.

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.

Anaphylaxis fatalities and admissions in Australia.

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