apa Asia Pacific Allergy Asia Pac Allergy 2233-8276 2233-8268 Asia Pacific Association of Allergy, Asthma and Clinical Immunology 10.5415/apallergy.2020.10.e1 apa-10-e1 Original Article Anaphylaxis diagnosis and management in the Emergency Department of a tertiary hospital in the Philippines VeraMichelle Joy De 1 2 * TagaroIris Conela 1 The Medical City Hospital, Pasig, the Philippines Ateneo De Manila University School of Medicine and Public Health, Pasig, the Philippines Correspondence to Michelle Joy De Vera The Medical City Hospital, Medical Arts Tower 1119, Ortigas Ave., Pasig City, the Philippines. Tel: +63-920-950-2029, E-mail: mbdevera@themedicalcity.com deveramj@gmail.com 01 2020 04 01 2020 10 1 e1 22072019 09012020 Copyright © 2019 Asia Pacific Association of Allergy, Asthma and Clinical Immunology 2020 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background

In the Emergency Department (ED), diagnosis and management of anaphylaxis are challenging with at least 50% of anaphylaxis episodes misdiagnosed when the diagnostic criteria of current guidelines are not used.

 Objective

Objective of our study was to assess anaphylaxis diagnosis and management in patients presenting to the ED.

 Methods

Retrospective chart review conducted on patients presenting to The Medical City Hospital ED, the Philippines from 2013–2015 was done. Cases were identified based on International Statistical Classification of Diseases, 10th revision coding for either anaphylaxis or other allergic related diagnosis. Cases fitting the definition of anaphylaxis as identified by the National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network (NIAID/FAAN) were included. Data collected included demographics, signs and symptoms, triggers and management.

 Results

A total of 105 cases were evaluated. Incidence of anaphylaxis for the 3-year study period was 0.03%. Of the 105 cases, 35 (33%) were diagnosed as “urticaria” or “hypersensitivity reaction” despite fulfilling the NIAID/FAAN anaphylaxis criteria. There was a significant difference in epinephrine administration between those given the diagnosis of anaphylaxis versus misdiagnosed cases (61 [87%] vs. 12 [34%], χ2 = 30.77, p < 0.01); and a significant difference in time interval from arrival at the ED to epinephrine administration, with those diagnosed as anaphylaxis (48%) receiving epinephrine within 10 minutes, versus ≥ 60 minutes for most of the misdiagnosed group (χ2 = 52.97, p < 0.01).

 Conclusion

Despite current guidelines, anaphylaxis is still misdiagnosed in the ED. Having an ED diagnosis of anaphylaxis significantly increases the likelihood of epinephrine administration, and at a shorter time interval.

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Epinephrine administration in anaphylaxis cases. ED, Emergency Department. χ2 = 30.767, p < 0.01.

Time interval from arrival at Emergency Department (ED) to administration of epinephrine. χ2 = 2.969, p < 0.05.

Patient characteristics (n = 105)

Characteristic No. of cases (%)
Sex  
   Male 47 (44.8)
   Female 58 (55.2)
Age (yr)  
   0–5 7 (6.7)
   6–9 9 (8.6)
   10–18 36 (34.3)
   19–29 18 (17.1)
   30–39 15 (14.3)
   40–59 14 (13.3)
   ≥60 6 (5.7)
With history of anaphylaxis 12 (11.4)
History of atopic disease 81 (77.1)
   Asthma 32 (30.5)
   Food allergy 44 (41.9)
   Drug allergy 24 (22.9)
   Allergy aside from food and drugs 7 (6.7)
   Allergic rhinitis 8 (7.6)
   Atopic dermatitis 3 (2.9)
Family history of atopy 53 (50.5)
Intake of medications  
   ACE inhibitors 5 (4.8)
   Beta blockers 4 (3.8)
   NSAID 1 (0.9)
Medical comorbidity 17 (16.2)
   Hypertension 14 (13.3)
   Other cardiovascular disease 2 (1.9)

ACE, angiotensin-converting-enzyme; NSAID, nonsteroidal anti-inflammatory drug

Diagnosis of anaphylaxis in relation to history of anaphylaxis

History of anaphylaxis Anaphylaxis cases Total
Diagnosed as anaphylaxis at ED Not diagnosed as anaphylaxis at ED
No 62 (66.7) 31 (33.3) 93 (88.6)
Yes 8 (66.7) 4 (33.3) 12 (11.4)
Total 70 (66.7) 35 (33.3) 105 (100)

Values are presented as number (%).

ED, Emergency Department.

χ2 = 0.0, p > 0.05.

Identified triggers of anaphylaxis

Trigger of anaphylaxis Child (n = 52) Adult (n = 53) Total (n = 105)
Food 19 (18) 17 (16.1) 36 (34.3)
  Crustacean 7 (6.6) 9 (8.6) 16 (15.2)
  Fish 3 (2.8) 3 (2.8) 6 (5.7)
  Peanut 5 (4.8) 0 (0) 5 (4.8)
  Chicken 1 (1) 3 (2.8) 4 (3.8)
  Sesame seed 0 (0) 1 (1) 1 (1)
  Raisin 0 (0) 1 (1) 1 (1)
  Fried rice 1 (1) 0 (0) 1 (1)
  Chocolate 1 (1) 0 (0) 1 (1)
  Noodles 1 (1) 0 (0) 1 (1)
Drugs 10 (9.5) 11 (10.5) 21 (20)
  NSAID 5 (4.8) 6 (5.7) 11 (10.4)
  Paracetamol 1 (1) 1 (1) 2 (1.9)
  Amoxicillin 1 (1) 1 (1) 2 (1.9)
  Coamoxiclav (amoxicillin + clavulanic acid) 2 (1.9) 1 (1) 3 (2.8)
  Cefalexin 0 (0) 1 (1) 1 (1)
  Probiotics 1 (1) 0 (0) 1 (1)
  Hyoscine 0 (0) 1 (1) 1 (1)
  Radiocontrast media 1 (1) 1 (1) 2 (1.9)
  Rabies vaccine 0 (0) 1 (1) 1 (1)
Insect bite/sting 1 (1) 4 (3.8) 5 (4.8)
Unknown 21 (2) 19 (18.1) 40 (38.1)

Values are presented as number (%).

NSAID, nonsteroidal anti-inflammatory drug.

χ2 = 3.788, p > 0.05.

Chief complaint and signs and symptoms of anaphylaxis cases

Variable No. of cases (n = 105)
Chief complaints  
    Difficulty of breathing 51 (48.6)
    Rashes 31 (29.5)
    Eye swelling 11 (10.5)
    Chest pain/tightness 3 (2.9)
    Throat discomfort 2 (1.9)
    Generalized body weakness 3 (2.9)
    Loss of consciousness 1 (1)
    Abdominal pain 1 (1)
    Nausea 1 (1)
    Dizziness 1 (1)
Signs and symptoms  
    Respiratory  
        Difficulty of breathing 95 (90.5)
        Wheezing 68 (64.8)
        O2 saturation < 95% 22 (21)
        Cough 14 (13.3)
        Rhinorrhea 11 (10.5)
        Choking 4 (3.8)
        Stridor 1 (1)
    Skin  
        Pruritus 90 (85.7)
        Urticaria 61 (58.1)
        Flushing 43 (41)
        Periorbital edema 37 (35.2)
        Erythema 12 (11.4)
        Conjunctival redness 9 (8.6)
        Lip swelling 8 (7.6)
        Tearing 7 (6.7)
    Cardiovascular  
        Tachycardia 55 (52.4)
        Hypotension 17 (16.2)
        Chest pain 17 (16.2)
        Syncope 6 (5.7)
        Arrhythmia 3 (2.9)
        Palpitation 4 (3.8)
    Gastrointestinal  
        Abdominal pain 17 (16.2)
        Vomiting 15 (14.3)
        Diarrhea 4 (3.8)
        Nausea 2 (1.9)
    Central nervous system  
        Dizziness 7 (6.7)
        Weakness 5 (4.8)
        Headache 1 (1)

Values are presented as number (%).

Diagnosis of anaphylaxis in relation to presence of symptoms

Symptom Anaphylaxis cases χ2 (p value)
Diagnosed as anaphylaxis at ED Not diagnosed as anaphylaxis at ED Total
Difficulty of breathing       1.382 (>0.05)
  Absent 5 (50) 5 (50) 10 (9.5)  
  Present 65 (68.4) 30 (31.6) 95 (90.5)  
  Total 70 (66.7) 35 (33.3) 105 (100)  
Wheezing       4.090 (<0.05*)
  Absent 20 (54.1) 17 (45.9) 37 (35.2)  
  Present 50 (73.5) 18 (26.5) 68 (64.8)  
  Total 70 (66.7) 35 (33.3) 105 (100)  
O2 saturation < 95%       4.859 (<0.05*)
  Absent 51 (61.4) 32 (38.6) 83 (79)  
  Present 19 (86.4) 3 (13.6) 22 (21)  
  Total 70 (66.7) 35 (33.3) 105 (100)  
Urticaria       2.367 (>0.05)
  Absent 33 (75) 11 (25) 44 (41.9)  
  Present 37 (60.7) 24 (39.3) 61 (58.1)  
  Total 70 (66.7) 35 (33.3) 105 (100)  
Flushing       0.020 (>0.05)
  Absent 41 (66.1) 21 (33.9) 62 (59)  
  Present 29 (67.4) 14 (32.6) 43 (41)  
  Total 70 (66.7) 35 (33.3) 105 (100)  
Periorbital edema       1.022 (>0.05)
  Absent 43 (63.2) 25 (36.8) 68 (64.8)  
  Present 27 (73) 10 (27) 37 (35.2)  
  Total 70 (66.7) 35 (33.3) 105 (100)  
Tachycardia       0.019 (>0.05)
  Absent 33 (66) 17 (34) 50 (47.6)  
  Present 37 (67.3) 18 (32.7) 55 (52.4)  
  Total 70 (66.7) 35 (33.3) 105 (100)  
Hypotension       4.246 (<0.05*)
  Absent 55 (62.5) 33 (37.5) 88 (83.8)  
  Present 15 (88.2) 2 (11.8) 17 (16.2)  
  Total 70 (66.7) 35 (33.3) 105 (100)  
Chest pain       0.561 (>0.05)
  Absent 60 (68.2) 28 (31.8) 88 (83.8)  
  Present 10 (58.8) 7 (41.2) 17 (16.2)  
  Total 70 (66.7) 35 (33.3) 105 (100)  
Abdominal pain       12.669 (<0.01*)
  Absent 65 (73.9) 23 (26.1) 88 (83.8)  
  Present 5 (29.4) 12 (70.6) 17 (16.2)  
  Total 70 (66.7) 35 (33.3) 105 (100)  
Vomiting       0.350 (>0.05)
  Absent 59 (65.6) 31 (34.4) 90 (85.7)  
  Present 11 (73.3) 4 (26.7) 15 (14.3)  
  Total 70 (66.7) 35 (33.3) 105 (100)  

Values are presented as number (%).

ED, Emergency Department.

Management care plan

Variable Diagnosed as Anaphylaxis at ED (n = 70) Not diagnosed as Anaphylaxis at ED (n = 35) Total (n = 105)
Other drugs administered aside from epinephrine
  Corticosteroid 66 (94.3) 34 (97.1) 100 (95.2)
  Antihistamine 64 (91.4) 34 (97.1) 98 (93.3)
  Bronchodilator 48 (68.6) 18 (51.4) 66 (62.8)
  H2 blocker/proton pump inhibitor 27 (38.6) 25 (71.4) 52 (49.5)
Referral to an allergist      
  With referral 32 (45.7) 17 (48.6) 49 (46.7)
  Without referral 38 (54.3) 18 (51.4) 56 (53.3)
Disposition      
  Admitted to regular room 56 (80) 24 (68.6) 80 (76.2)
  Admitted to ICU 13 (18.6) 1 (2.9) 14 (13.3)
  Discharged from ED 1 (1.4) 9 (25.7) 10 (9.5)
  DAMA from ED 0 (0) 1 (2.9) 1 (1)

Values are presented as number (%).

ED, Emergency Department; ICU, intensive care unit; DAMA, discharged against medical advice.