Managing Anaphylaxis In Adults: A Review Of All Cases Presenting In A Single Year At An Emergency Department Dr. Yarden Yanishevsky, MD1, Dr. Ann Elaine Clarke, MD, MSc2,3, Dr. Sebastian La Vieille, MD4, Dr. Scott Delaney, MD5, Dr. Reza Alizadehfar, MD1, Mr. Christopher Mill, BSc3, Dr. Lawrence Joseph, PhD3, Dr. Judy Morris, MD, MSc6, Dr. Yuka Asai, MD3,7, Dr. Moshe Ben-Shoshan, MD, MSc1; 1Division of Paediatric Allergy and Clinical Immunology, Department of Paediatrics, McGill University Health Center, Montreal, QC, Canada, 2Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada, 3Division of Clinical Epidemiology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada, 4 Food Directorate, Health Canada, Ottawa, ON, Canada, 5Department of Emergency Medicine, McGill University Health Center, Montreal, QC, Canada, 6Department of Emergency Medicine, H^opital du SacreCœur, Montreal, QC, Canada, 7Division of Dermatology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada. RATIONALE: To assess anaphylaxis rate and management in adults presenting to an emergency department (ED). METHODS: As part of the Cross-Canada Anaphylaxis REgistry (CCARE), charts of all ED visits to the Montreal General Hospital between March 2011 and February 2012 were reviewed to identify anaphylaxis cases. Cases were identified based on ICD 10 coding for either anaphylaxis or allergic reaction and only cases fitting the definition of anaphylaxis were included. Multivariate logistic regressions were used to identify factors associated with epinephrine use for moderate/severe cases. RESULTS: Among 37,730 ED visits, 98 anaphylaxis cases [0.26 %, (95% CI 0.21%, 0.32%)] were identified. Median age was 31.5 years (IQR 26.4, 44.0) and 33.7% (95% CI 24.6%, 44.0%) were males. Food was responsible for 63.3% (52.9%, 72.6%) of reactions, drugs for 18.4% (11.5%, 27.7%) and venom for 4.1% (1.3%, 10.7%). In 14.3% (8.3%, 23.1%), the trigger was unidentified. Among all cases 95.9% (89.3%, 98.7%) were moderate (difficulty breathing/stridor/wheezing) or severe (hypoxia/cyanosis/circulatory collapse/incontinence/neurological symptoms). Prior to ED arrival, 25% (1.3%, 78.1%) of mild and 20.2% (12.9%, 30.0%) of moderate/severe reactions received epinephrine compared to 25% (1.3%, 78.1%) and 39.4% (22.9%, 42.4%) after arrival. In 51.1% (40.6%, 61.4%) of moderate/severe reactions, no epinephrine was given. In non-drug induced anaphylaxis, epinephrine auto-injectors (EAI) were prescribed in 52.5 % (41.1%, 63.7%). Older individuals presenting with moderate/severe reactions were less likely to receive epinephrine [Odds ratio5 0.96 (0.92, 0.99)]. CONCLUSIONS: Given the striking underuse of epinephrine in anaphylaxis management, especially in older individuals, educational programs are required to better implement current guidelines.
Anaphylaxis Cases Presenting To Primary Care Paramedics In Quebec Ms. Nofar Kimchi1, Dr. Ann Elaine Clarke, MD, MSc2,3, Jocelyn Moisan4, Colette Lachaine5, Dr. Sebastian La Vieille, MD6, Dr. Yuka Asai, MD3,7, Dr. Lawrence Joseph, PhD3,8, Mr. Christopher Mill, BSc3, Dr. Moshe Ben-Shoshan, MD, MSc9,10; 1Technion American Medical Students Program, Israel, 2McGill University Health Centre, Montreal, Canada, 3Division of Clinical Epidemiology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada, 4Services prehospitaliers d’urgence de l’Outaouais, Quebec, Canada, QC, Canada, 5 Direction adjointe de services prehospitaliers d’urgence, MSSS, Quebec, Canada, QC, Canada, 6Food Directorate, Health Canada, Ottawa, ON, Canada, 7Division of Dermatology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada, 8Departments of Epidemiology and Biostatistics, McGill University, Montreal, Canada, 9 Division of Paediatric Allergy and Clinical Immunology, Department of Paediatrics, McGill University Health Center, Montreal, QC, Canada, 10 Montreal Children’s Hospital, Montreal, Canada. RATIONALE: To assess the percentage of anaphylaxis cases among all emergency medical services (EMS) calls in Outaouais, Quebec, Canada and characterize their triggers and management.
METHODS: As part of the Cross-Canada Anaphylaxis REgistry (C-CARE), a software program was developed to record all cases of suspected allergic reactions treated by primary care paramedics. Data on demographics, reaction characteristics and management was collected for cases meeting the definition of anaphylaxis between May and August 2013. RESULTS: Among 7, 950 ambulance calls of which 5,893 required transport, 31 anaphylaxis cases were identified [0.4%, 95%CI (0.3%, 0.6%), and 0.5% (0.4%, 0.8%), respectively]. Median age was 42.3 years (IQR 15. 9, 58.3) and 56.1% (95% CI 33.4%, 69.4%) were females. The most common triggers included venom [45.2% (31.0%, 62.4%)], food [25.8% (12.5%, 44.9%)], and drugs [16.1% (6.1%, 34.5%)]. The majority of reactions occurred at home [71.0% (51.8%, 85.1%)]. Among all reactions, 38.7% (22.4%, 57.7%) were severe and 51.6% (33.4%, 69.4%) were moderate. Epinephrine was administered in 29.0% (14.9%, 48.2%) of cases before and 58.0% (39.3%, 74.9%) after ambulance arrival. In 17.8% (6.8%, 37.6%) of moderate/severe reactions, epinephrine was not administered. CONCLUSIONS: This is the first prospective study evaluating anaphylaxis cases presenting to EMS. Anaphylaxis accounts for a substantial number of calls in Outaouais, Quebec. Most reactions are moderate or severe and almost one fifth of moderate/severe do not receive epinephrine. Although we have reported elsewhere that food is the major anaphylaxis trigger in Quebec emergency departments, venom is the major culprit in cases contacting the Quebec EMS during summer.
Anaphylaxis Management In A Pediatric Emergency Department Natasha Sidhu, MD1,2, Stacie M. Jones, MD3,4, Elizabeth Storm, MD1,2, Maria Melguizo castro1,5, Todd Nick1,2, Tonya Thompson, MD1,2; 1University of Arkansas for Medical Sciences, Little Rock, AR, 2 Arkansas Children’s Hospital, 3University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR, 4Arkansas Children’s Hospital Research Institute, Little Rock, AR, 5Arkansas Children’s Hospital, Little Rock, AR. RATIONALE: In 2006 the National Institute of Allergy and Infectious Disease established evidence-based treatment guidelines for anaphylaxis. The purpose of our study was to evaluate provider adherence to guidelinesbased management for anaphylaxis in a pediatric emergency-department (ED). METHODS: Retrospective chart-review conducted of patients (0-18 years) presenting to the Arkansas Children Hospital ED from 20042011 for the treatment of anaphylaxis using ICD9-codes. Multiple variables including demographics, allergen-source, and anaphylaxismanagement were collected. Fisher’s exact test used to compare patients treated with intramuscular (IM) epinephrine in the pre- versus post-guideline period. Relative risk (RR) computed for the likelihood that patients received self-injectable epinephrine prescription and allergy follow-up. RESULTS: Total of 187 patients evaluated; median age 7 years (range 1-18 years), 67% male, 48% African-American. Food (44%) and insect-stings (22%) were common allergens, while 29% had no identifiable allergen. Only 47% (n587) received epinephrine in the ED; 31% (n527) via the preferred IM-route. Comparing pre- (n561) versus post-guideline (n5126) period demonstrated increase in the usage of the IM-route (6% versus 46%, p<0.001). Overall 61% (n5115) received epinephrine prescription (56% pre versus 64% post, p50.3). Post-guideline patients were 1.24 times as likely to receive the prescription (RR 1.24, 95% CI 0.86-1.79). Only 45% (n585) received an allergy-referral (41% pre versus 48% post, p50.4). ). Post-guideline patients were 1.13 times as likely to receive an allergy-referral (RR 1.13, 95% CI 0.86-1.47). CONCLUSIONS: Provider utilization of IM epinephrine has improved since anaphylaxis-guidelines were published. However, more provider education is needed to improve overall adherence of guidelines in a pediatric ED.
J ALLERGY CLIN IMMUNOL VOLUME 133, NUMBER 2