Journal List > Asia Pac Allergy > v.10(1) > 1148389

Vera and Tagaro: Anaphylaxis diagnosis and management in the Emergency Department of a tertiary hospital in the Philippines

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.

References

1. Sampson HA, Muñoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, Branum A, Brown SG, Camargo CA Jr, Cydulka R, Galli SJ, Gidudu J, Gruchalla RS, Harlor AD Jr, Hepner DL, Lewis LM, Lieberman PL, Metcalfe DD, O'Connor R, Muraro A, Rudman A, Schmitt C, Scherrer D, Simons FE, Thomas S, Wood JP, Decker WW. 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. Ann Emerg Med. 2006; 47:373–80.
crossref
2. Neugut AI, Ghatak AT, Miller RL. Anaphylaxis in the United States: an investigation into its epidemiology. Arch Intern Med. 2001; 161:15–21.
3. Simons FE, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK, Lockey RF, El-Gamal YM, Brown SG, Park HS, Sheikh A. 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines. World Allergy Organ J. 2015; 8:32.
crossref
4. Campbell RL, Hagan JB, Manivannan V, Decker WW, Kanthala AR, Bellolio MF, Smith VD, Li JT. 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; 129:748–52.
crossref
5. Sicherer SH, Simons FE. Section on Allergy and Immunology, American Academy of Pediatrics. Self-injectable epinephrine for first-aid management of anaphylaxis. Pediatrics. 2007; 119:638–46.
crossref
6. Alvarez-Perea A, Tomás-Pérez M, Martínez-Lezcano P, Marco G, Pérez D, Zubeldia JM, Baeza ML. Anaphylaxis in adolescent/adult patients treated in the Emergency Department: differences between initial impressions and the definitive diagnosis. J Investig Allergol Clin Immunol. 2015; 25:288–94.
7. Russell WS, Farrar JR, Nowak R, Hays DP, Schmitz N, Wood J, Miller J. Evaluating the management of anaphylaxis in US emergency departments: Guidelines vs. practice. World J Emerg Med. 2013; 4:98–106.
crossref
8. Khan NU, Shakeel N, Makda A, Mallick AS, Ali Memon M, Hashmi SH, Khan UR, Razzak JA. Anaphylaxis: incidence, presentation, causes and outcome in patients in a tertiary-care hospital in Karachi, Pakistan. QJM. 2013; 106:1095–101.
crossref
9. Techapornroong M, Akrawinthawong K, Cheungpasitporn W, Ruxrungtham K. Anaphylaxis: a ten years inpatient retrospective study. Asian Pac J Allergy Immunol. 2010; 28:262–9.
10. Simons FE, Ardusso LR, Bilò MB, El-Gamal YM, Ledford DK, Ring J, Sanchez-Borges M, Senna GE, Sheikh A, Thong BY. World Allergy Organization. World Allergy Organization anaphylaxis guidelines: summary. J Allergy Clin Immunol. 2011; 127:587–93.
crossref
11. Klein JS, Yocum MW. Underreporting of anaphylaxis in a community emergency room. J Allergy Clin Immunol. 1995; 95:637–8.
crossref
12. Tanno LK, Ganem F, Demoly P, Toscano CM, Bierrenbach AL. Undernotification of anaphylaxis deaths in Brazil due to difficult coding under the ICD-10. Allergy. 2012; 67:783–9.
crossref
13. Trojan T, Ma Y, Khan DA. Anaphylaxis identification using direct and combined ICD-9 methods. J Allergy Clin Immunol. 2013; 131(2 Suppl):AB224. https://www.jacionline.org/article/S0091-6749(12)03466-5/abstract.
crossref
14. Lieberman P. Epidemiology of anaphylaxis. Curr Opin Allergy Clin Immunol. 2008; 8:316–20.
crossref
15. Kastner M, Harada L, Waserman S. Gaps in anaphylaxis management at the level of physicians, patients, and the community: a systematic review of the literature. Allergy. 2010; 65:435–44.
crossref
16. Campbell RL, Li JT, Nicklas RA, Sadosty AT. Members of the Joint Task Force. Practice Parameter Workgroup. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014; 113:599–608.
crossref
17. Bansal PJ, Marsh R, Patel B, Tobin MC. Recognition, evaluation, and treatment of anaphylaxis in the child care setting. Ann Allergy Asthma Immunol. 2005; 94:55–9.
crossref
18. Clark S, Bock SA, Gaeta TJ, Brenner BE, Cydulka RK, Camargo CA. Multicenter Airway Research Collaboration-8 Investigators. Multicenter study of emergency department visits for food allergies. J Allergy Clin Immunol. 2004; 113:347–52.
crossref
19. 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; 98:360–5.
crossref
20. Gompels LL, Bethune C, Johnston SL, Gompels MM. Proposed use of adrenaline (epinephrine) in anaphylaxis and related conditions: a study of senior house officers starting accident and emergency posts. Postgrad Med J. 2002; 78:416–8.
crossref
21. Haymore BR, Carr WW, Frank WT. Anaphylaxis and epinephrine prescribing patterns in a military hospital: underutilization of the intramuscular route. Allergy Asthma Proc. 2005; 26:361–5.
22. Krugman SD, Chiaramonte DR, Matsui EC. Diagnosis and management of food-induced anaphylaxis: a national survey of pediatricians. Pediatrics. 2006; 118:e554–60.
crossref
23. Bernstein DI, Wanner M, Borish L, Liss GM. Immunotherapy Committee, American Academy of Allergy, Asthma and Immunology. Twelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001. J Allergy Clin Immunol. 2004; 113:1129–36.
crossref
24. Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001; 107:191–3.
crossref
25. de Silva IL, Mehr SS, Tey D, Tang ML. Paediatric anaphylaxis: a 5 year retrospective review. Allergy. 2008; 63:1071–6.
26. Lee JM, Greenes DS. Biphasic anaphylactic reactions in pediatrics. Pediatrics. 2000; 106:762–6.
crossref
27. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000; 30:1144–50.
crossref
28. Wood RA, Camargo CA Jr, Lieberman P, Sampson HA, Schwartz LB, Zitt M, Collins C, Tringale M, Wilkinson M, Boyle J, Simons FE. Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States. J Allergy Clin Immunol. 2014; 133:461–7.
crossref
29. Jose R, Clesham GJ. Survey of the use of epinephrine (adrenaline) for anaphylaxis by junior hospital doctors. Postgrad Med J. 2007; 83:610–1.
crossref
30. Mehl A, Wahn U, Niggemann B. Anaphylactic reactions in children–a questionnaire-based survey in Germany. Allergy. 2005; 60:1440–5.
31. Thain S, Rubython J. Treatment of anaphylaxis in adults: results of a survey of doctors at Dunedin Hospital, New Zealand. N Z Med J. 2007; 120:U2492.
32. Sheikh A, Shehata YA, Brown SG, Simons FE. Adrenaline for the treatment of anaphylaxis: cochrane systematic review. Allergy. 2009; 64:204–12.
crossref
33. Ben-Shoshan M, Clarke AE. Anaphylaxis: past, present and future. Allergy. 2011; 66:1–14.
crossref
34. Ma L, Danoff TM, Borish L. Case fatality and population mortality associated with anaphylaxis in the United States. J Allergy Clin Immunol. 2014; 133:1075–83.
crossref
35. McBride D, Keil T, Grabenhenrich L, Dubakiene R, Drasutiene G, Fiocchi A, Dahdah L, Sprikkelman AB, Schoemaker AA, Roberts G, Grimshaw K, Kowalski ML, Stanczyk-Przyluska A, Sigurdardottir S, Clausen M, Papadopoulos NG, Mitsias D, Rosenfeld L, Reche M, Pascual C, Reich A, Hourihane J, Wahn U, Mills EN, Mackie A, Beyer K. The EuroPrevall birth cohort study on food allergy: baseline characteristics of 12,000 newborns and their families from nine European countries. Pediatr Allergy Immunol. 2012; 23:230–9.
crossref
36. Roehr CC, Edenharter G, Reimann S, Ehlers I, Worm M, Zuberbier T, Niggemann B. Food allergy and non-allergic food hypersensitivity in children and adolescents. Clin Exp Allergy. 2004; 34:1534–41.
crossref
37. Woods RK, Stoney RM, Raven J, Walters EH, Abramson M, Thien FC. Reported adverse food reactions overestimate true food allergy in the community. Eur J Clin Nutr. 2002; 56:31–6.
crossref
38. Nurmatov U, Worth A, Sheikh A. Anaphylaxis management plans for the acute and long-term management of anaphylaxis: a systematic review. J Allergy Clin Immunol. 2008; 122:353–61.
crossref
39. 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; 63:1061–70.
crossref
40. NIAID-Sponsored Expert Panel. Boyce JA, Assa'ad A, Burks AW, Jones SM, Sampson HA, Wood RA, Plaut M, Cooper SF, Fenton MJ, Arshad SH, Bahna SL, Beck LA, Byrd-Bredbenner C, Camargo CA Jr, Eichenfield L, Furuta GT, Hanifin JM, Jones C, Kraft M, Levy BD, Lieberman P, Luccioli S, McCall KM, Schneider LC, Simon RA, Simons FE, Teach SJ, Yawn BP, Schwaninger JM. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010; 126(6 Supp):S1–58.
41. Lieberman P, Nicklas RA, Randolph C, Oppenheimer J, Bernstein D, Bernstein J, Ellis A, Golden DB, Greenberger P, Kemp S, Khan D, Ledford D, Lieberman J, Metcalfe D, Nowak-Wegrzyn A, Sicherer S, Wallace D, Blessing-Moore J, Lang D, Portnoy JM, Schuller D, Spector S, Tilles SA. Anaphylaxis–a practice parameter update 2015. Ann Allergy Asthma Immunol. 2015; 115:341–84.
crossref
42. Simons FE, Ardusso LR, Bilò MB, Cardona V, Ebisawa M, El-Gamal YM, Lieberman P, Lockey RF, Muraro A, Roberts G, Sanchez-Borges M, Sheikh A, Shek LP, Wallace DV, Worm M. International consensus on (ICON) anaphylaxis. World Allergy Organ J. 2014; 7:9.
crossref
43. Kaplan MS, Jung SY, Chiang ML. Epinephrine autoinjector refill history in an HMO. Curr Allergy Asthma Rep. 2011; 11:65–70.
crossref
44. Song TT, Worm M, Lieberman P. Anaphylaxis treatment: current barriers to adrenaline autoinjector use. Allergy. 2014; 69:983–91.
crossref
45. Simons FE, Chan ES, Gu X, Simons KJ. Epinephrine for the out-of-hospital (first-aid) treatment of anaphylaxis in infants: is the ampule/syringe/needle method practical? J Allergy Clin Immunol. 2001; 108:1040–4.
crossref
46. Rawas-Qalaji M, Simons FE, Collins D, Simons KJ. Long-term stability of epinephrine dispensed in unsealed syringes for the first-aid treatment of anaphylaxis. Ann Allergy Asthma Immunol. 2009; 102:500–3.
crossref

Fig. 1.
Epinephrine administration in anaphylaxis cases. ED, Emergency Department. χ2 = 30.767, p < 0.01.
apa-10-e1f1.tif
Fig. 2.
Time interval from arrival at Emergency Department (ED) to administration of epinephrine. χ2 = 2.969, p < 0.05.
apa-10-e1f2.tif
Table 1.
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

Table 2.
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.

Table 3.
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.

Table 4.
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 (%).

Table 5.
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.

Table 6.
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.

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