Drug-induced anaphylaxis in the emergency room

Abstract

Anaphylaxis is a life-threatening, systemic allergic reaction that presents unique challenges for emergency care practitioners. Anaphylaxis occurs more frequently than previously believed. Therefore, proper knowledge regarding the epidemiology, mechanisms, symptoms, diagnosis, and treatment of anaphylaxis is essential. In particular, the initial treatment strategy, followed by correct diagnosis, in the emergency room is critical for preventing fatal anaphylaxis, although making a diagnosis is not easy because of the broad and often atypical presentation of anaphylaxis. To this end, the clinical criteria proposed by the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network are useful, which, together with a differential diagnosis, could enable a more accurate diagnosis. Additional in vitro tests, such as plasma histamine and tryptase measurements, are also helpful. It should be emphasized that adrenaline is the only drug recommended as first-line therapy in all published national anaphylaxis guidelines. Most international anaphylaxis guidelines recommend injecting adrenaline by the intramuscular route in the mid-anterolateral thigh, whereas i.v. adrenaline is an option for patients with severe hypotension or cardiac arrest unresponsive to intramuscular adrenaline and fluid resuscitation. In addition to the route of administration, choosing the appropriate dose of adrenaline is essential, because serious adverse effects can potentially occur after an overdose of adrenaline. Furthermore, to avoid future recurrence of anaphylaxis, providing adrenaline auto-injectors and making an etiological diagnosis, including confirmation of the offending trigger, are recommended for patients at risk of anaphylaxis before their discharge from the emergency room.

Keywords: Cardiopulmonary arrest; emergency room; shock.

Figure 1

Time trends of hospital admissions (A) and fatalities (B) for all‐cause anaphylaxis in the UK between 1992 and 2012. Vertical bars represent standard error of the means.6

Figure 2

Age‐standardized rates of admission (1998–2012; A) and fatalities (1992‐2012; B) due to food‐related anaphylaxis relative to other causes (iatrogenic causes and insect stings).6

Figure 3

Pathogenesis of anaphylaxis: mechanisms and triggers, cells, mediators, and organ systems affected.16 CNS, central nervous system; Ig, immunoglobulin.

Figure 4

Emergency anaphylaxis management algorithm.14 ER, emergency room; FAAN, Food Allergy and Anaphylaxis Network; NIAID, National Institute of Allergy and Infectious Diseases; SIE, self‐injecting epinephrine.

Figure 5

Drugs used for emergency treatment of anaphylaxis, according to age.37 The dashed lines indicate the proportion of patients who received only inhalation (adrenaline) or oral (antihistamine or corticoid) treatment. Error bars indicate 95% confidence intervals.