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

Michelle Joy De Vera; Iris Conela Tagaro

doi:10.5415/apallergy.2020.10.e1

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

Original Article

Asia Pac Allergy 2020;10(1):e1.

Published online: 4 January 2020

DOI: https://doi.org/10.5415/apallergy.2020.10.e1

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

Michelle Joy De Vera^1,^2,^*, Iris Conela Tagaro¹

¹The Medical City Hospital, Pasig, the Philippines

²Ateneo 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

Received 22 July 2019 Accepted 9 January 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.

Keywords: Anaphylaxis, Epinephrine, Emergency Department

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Fig. 1.

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

Fig. 2.

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

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
History of anaphylaxis	Diagnosed as anaphylaxis at ED	Not diagnosed as anaphylaxis at ED	Total
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)
Symptom	Diagnosed as anaphylaxis at ED	Not diagnosed as anaphylaxis at ED	Total	χ² (p value)
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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