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Outpatient Emergencies: Anaphylaxis
Scott P Commins, MD, PhD
University of North Carolina, Department of Medicine & Pediatrics, Thurston Research Center,
Division of Rheumatology, Allergy and Immunology, 3300 Thurston Building, CB 7280, Chapel
Hill, NC 27599-7280, [email protected], 866.827.2862 (ph), 919.966.1739 (fax)
Synopsis
Anaphylactic fatalities are rare and in the vast majority of instances, patients will do well.
Nevertheless, fatalities do occur and reactions presenting with mild symptoms can rapidly progress
to cardiovascular and respiratory arrest. At the initiation of symptoms it is not possible to know
whether an episode will rapidly progress. Because the clinical course of anaphylaxis can be
unpredictable, prompt and early use of epinephrine should be considered even with mild
symptoms or single-system involvement. Any patient who has experienced an episode of
anaphylaxis should be evaluated to determine the causative agent. Most anaphylaxis episodes have
an immunologic mechanism involving immunoglobulin E (IgE). Foods are the most common
cause in children, while medications and insect stings are more common causes in adults. Any
patient who has experienced anaphylaxis when the cause is not completely avoidable or cannot be
determined should be supplied with auto-injectable epinephrine (AIE) and should be instructed in
the use of this device and told to keep their AIE with them at all times. The patient should be
taught to recognize the signs and symptoms of anaphylaxis and when to administer the injection
and be given an anaphylaxis action plan.
Keywords
IgE; mast cell; allergy; tryptase; anaphylaxis
INTRODUCTION
Anaphylaxis is a life-threatening reaction with respiratory, cardiovascular, cutaneous, or
gastrointestinal manifestations resulting from exposure to an offending agent, usually a food,
insect sting, medication, or physical factor. It causes approximately 1,500 deaths in the
United States annually.^1 ,^2 Occasionally, anaphylaxis can be confused with septic or other
forms of shock, asthma, airway foreign body, panic attack, or other entities.^3 –^5 Urinary and
serum histamine levels and plasma tryptase levels drawn after onset of symptoms may assist
in diagnosis as well as assessment of platelet activating factor.^3 ,^6 ,^7 Prompt treatment of
anaphylaxis is critical, with intramuscular epinephrine, recumbent positioning and
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Med Clin North Am. Author manuscript; available in PMC 2018 May 01.
Published in final edited form as:
Med Clin North Am. 2017 May ; 101(3): 521–536. doi:10.1016/j.mcna.2016.12.003.
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intravenous fluids remaining the mainstays of acute management.^4 ,^8 Adjunctive measures
include airway protection, antihistamines, glucocorticoids and beta-agonists.^4 Patients
should be observed for delayed or protracted anaphylaxis and instructed on how to initiate
urgent treatment for future episodes.^9 ,^10
A significant portion of the U.S. population is at risk for anaphylaxis and these reactions are
under-recognized and frequently under treated.^2 ,^11 Anaphylaxis is mediated by
immunoglobulin E (IgE), while anaphylactoid reactions are not.^4 Because of their clinical
similarities, the term anaphylaxis will be used to refer to both conditions. In keeping with
the theme of this collection, we will focus on aspects of anaphylaxis primarily related to
outpatient emergencies: symptoms, treatment and management with less discussion devoted
to diagnostic testing and consideration of differential diagnosis.
SYMPTOMS
Anaphylaxis may include any combination of common signs and symptoms (Table I).^4
Cutaneous manifestations of anaphylaxis, including urticaria and angioedema, are by far the
most common, occurring in 62% to 90% of reported cases.^12 Nonetheless, the absence of
cutaneous symptoms speaks against a diagnosis of anaphylaxis but does not rule it out.
Severe episodes characterized by rapid cardiovascular collapse and shock can occur without
cutaneous manifestations.^13 The respiratory system is also commonly involved, producing
symptoms such as dyspnea, wheezing, and upper airway obstruction from edema.^12
Gastrointestinal manifestations (e.g., nausea, vomiting, diarrhea, abdominal pain) and
cardiovascular manifestations (e.g., dizziness, syncope, hypotension) affect about one third
of patients.^14 Headache, rhinitis, substernal pain, pruritus, and seizure occur less
frequently.^12 In addition, it is important to note that anaphylaxis can present with unusual
manifestations, such as syncope without any further sign or symptom.^15 The essentials of the
history are listed in Box 1.
Symptom onset varies widely but generally occurs within seconds or minutes of exposure.^2 ,^5
A novel IgE antibody to a mammalian oligosaccharide has been discovered that is associated
with 2 distinct forms of anaphylaxis, an immediate onset of an event to cetuximab and a
delayed onset of anaphylaxis, usually occurring 3 to 6 hours after the ingestion of
mammalian food products (eg, beef and pork).^16 ,^17 This red meat allergy has been
associated with tick bites and appears to have significant and expanding regional prevalence
in the southern and eastern U.S.^18 Anaphylaxis can be protracted, lasting for more than 24
hours, or recur after initial resolution.^10
OUTPATIENT-BASED TREATMENT
Plan for appropriate office response to anaphylaxis by (1) educating staff and patients, (2)
preparing an anaphylaxis emergency cart (Table II), and (3) developing an office action plan
for anaphylaxis management to maintain proficiency in anaphylaxis management.^4 At the
onset of anaphylaxis, (1) administer epinephrine intramuscularly in the mid-outer thigh; (2)
remove the inciting allergen, if possible (eg, stop an infusion); (3) quickly assess airway,
breathing, circulation, and mentation and summon appropriate assistance from staff
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office and with the emergency supplies for ready access. The successful management of
anaphylaxis requires that office staff must immediately activate the response team and
expeditiously deliver appropriate treatment. This can be accomplished with frequent (eg,
periodic), organized, mock anaphylaxis drills in which all staff members, clerical and
medical, are required to participate.^19 Maintaining clinical proficiency with anaphylaxis
management involves certification in basic cardiopulmonary resuscitation and, ideally,
advanced life support to insure the proper skillset for treatment of refractory anaphylaxis,
including airway management, cardiac compressions, venous and intraosseous access, and
parental medication calculation and delivery.^19 ,^22
The initial assessment and treatment of the patient in anaphylaxis involves several critical
steps that should be started concomitantly (Table III).^4 ,^19 ,^22 Urgent treatment is based on the
finding that there is often a very short time (eg, 5 minutes for an iatrogenic intravenously
administered allergen such as an antibiotic and 30 minutes for food-induced anaphylaxis)
from the onset of mild symptoms to respiratory or cardiac arrest.^23 –^27 Although removal of
the inciting allergen is ideal, this will rarely apply in the office setting because parental or
ingestion will usually have been completed before the onset of symptoms. However, with
medication infusions or oral challenges with food or medications, the procedure should be
stopped as soon as signs and symptoms of even mild anaphylaxis are noted.^28 ,^29
The first member of the office staff to recognize that the patient is experiencing anaphylaxis
must be prepared to evaluate the airway, breathing, circulation, and mentation.^19 If the
patient has moderate to severe anaphylaxis or is showing signs and symptoms of impending
cardiopulmonary arrest, EMS must be summoned immediately in addition to all available
office medical staff.^4 ,^12 Cardiopulmonary resuscitation should be started immediately in the
event of cardiopulmonary arrest, with emphasis on adequate chest compressions without
interruption (Table IV).^19 ,^22 Ventilations can be given once there are 2 medical staff
members at the patient’s side.^22
For imminent or established cardiopulmonary arrest, rapidly establish venous access and
administer an intravenous bolus dose of epinephrine because ventricular arrhythmias have
been reported after epinephrine administration.^19 ,^22 ,^30 For adults, the dose is 1 mg
intravenously (as a 1:10,000 dilution).^31 ,^32 This can be repeated every 3 to 5 minutes as
cardiopulmonary resuscitation is continued.^22 ,^31 –^33 If the intravenous route is not available,
epinephrine can be given by endotracheal administration if the advanced airway is in place
(adult dose is 2–2.5 mg of 1:1,000 diluted in 5–10 mL of sterile water).^19 ,^22 The treatment
of anaphylaxis is, at best, based on indirect and observational studies and primarily on
consensus.^12 Observational studies and analysis of near-fatal and fatal reactions have shown
that prompt and decisive treatment of any systemic reaction, even a mild one, with
epinephrine prevents progression to more severe symptoms.^5 ,^34 In contrast, delayed
administration of epinephrine is often believed to be the major contributing factor to
fatalities.^5 ,^34 Anaphylaxis guidelines are in agreement that epinephrine should be
administered intramuscularly into the lateral thigh.^4 ,^5 ,^14 Published studies on epinephrine
pharmacokinetics in patients not in anaphylaxis have shown that intramuscular
administration in the vastus lateralis muscle produces a more rapid rate of increase in blood
epinephrine levels than subcutaneous or intramuscular administration in the deltoid
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muscle.^35 ,^36 Unfortunately, there are no studies evaluating the pharmacokinetics of a
subcutaneous injection in the lateral thigh. The adult dose of 1:1,000 epinephrine is 0.2 to
0.5 mL, whereas the pediatric dose is 0.01 mg/kg, with a maximum of 0.3 mg.^19 A higher
dose (eg, 0.5 mL) within the recommended dose range should be considered in patients with
severe anaphylaxis.^4 ,^12 ,^19 If there has not been significant improvement in symptoms, then
the dose can be repeated approximately every 5 to 15 minutes, as the physician deems to be
necessary. It has been shown that a repeat dose is required up to 35% of the time.^37 ,^38
Monitor and record the patient’s blood pressure, cardiac rate and function, respiratory status,
and oxygenation at frequent and regular intervals.^19 Start frequent oxygen saturation
measurement, start continuous noninvasive monitoring, and obtain an electrocardiogram, if
available.
There is universal agreement that most patients should be placed in a supine position during
anaphylaxis.^4 ,^5 ,^12 ,^14 ,^19 ,^39 ,^40 However, whether to elevate the legs is controversial.^4 ,^41 ,^42
Although some guidelines continue to recommend the Trendelenburg position (feet are
elevated 15–30° higher than the head) for the management of shock, the American Heart
Association and the American Red Cross in a 2010 consensus document concluded that
there is insufficient evidence to support routine use of the Trendelenburg position in patients
with shock.^30 ,^43 If the patient is having respiratory difficulty, consider having the patient sit
up.^30 In a retrospective study of 10 anaphylactic fatalities, there appeared to be an
association with fatality when there was a change in position from a supine to an upright or
standing position during anaphylaxis.^44 Although the investigators recommended
maintaining a supine position during anaphylaxis, they did not recommend the
Trendelenburg position.^44
Administration of oxygen is the second most important therapeutic intervention, second only
to epinephrine administration, for the treatment of anaphylaxis and should be considered for
all patients experiencing anaphylaxis regardless of their respiratory status.^4 ,^5 ,^12 ,^14 ,^20 ,^40 It is
imperative to administer oxygen for any patient with respiratory or cardiovascular
compromise and to patients who do not respond to the initial treatment with epinephrine.^19
Oxygen up to 100% should be administered at a flow rate of 6 to 10 L/min through a
facemask. Ideally, oxygen saturation should be monitored and kept at 94% to 96% by
oximetry.^19 In most office settings, bag-valve-mask ventilation will be the method of choice
to support ventilation in the event of respiratory failure or arrest.^4 ,^12 It is most effective
when 2 individuals can support the airway.^22 One person opens the airway with the head-tilt
and chin-lift maneuver and seals the mask to the face, covering the nose and mouth.^22 The
second person squeezes the bag and the 2 rescuers look for adequate chest rise.^22 It is
recommended that approximately 600 mL of tidal volume for 1 second using an adult (1–
L) bag be delivered.^22 ,^30 Supplementary oxygen at a flow rate of 10 to 12 L/min should be
used.^30 Two breaths are delivered during a 3- to 4-second pause after every 30 chest
compressions.^22 An oropharyngeal airway can aid in the delivery of adequate ventilation in
an unconscious patient with no cough or gag reflex.^30 The training, skill, and experience of
the physician should guide the selection of the most appropriate airway for the patient.^22
When the provider can adequately ventilate the patient using the bag-valve-mask, there is no
evidence that the use of advanced airway measures improves survival rates of out-of-hospital
cardiac arrest.^22 ,^30 ,^43 The incidence of complications is unacceptably high when
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because beta 1 - and beta 2 -antagonists can inhibit the beta-adrenergic receptor.^12 If
epinephrine is ineffective in treating anaphylaxis in patients taking beta-blockers, then
glucagon administration might be necessary. Glucagon can reverse refractory bronchospasm
and hypotension during anaphylaxis in patients on beta-blockers by activating adenyl cyclase
directly and bypassing the beta-adrenergic receptor. The recommended dosage for glucagon
is 1 to 5 mg administered intravenously over 5 minutes and followed by an infusion at 5 to
15 mg/min titrated to clinical response.^4 ,^12 ,^30 Protection of the airway is important because
glucagon can cause emesis and risk aspiration in severely drowsy or obtunded patients.
Placement in the lateral recumbent position provides sufficient airway protection for most of
these patients.^4 ,^12 ,^19
Antihistamines, H1 and H2, should be considered second-line drugs in the management of
anaphylaxis because there is no direct evidence to support their use in the treatment of
anaphylaxis.^3 –^5 ,^12 ,^14 ,^40 The use of the H1 antihistamines is extrapolated mainly from their
use in other allergic diseases (eg, urticaria or allergic rhinitis) in which they relieve itching,
urticaria, flushing, sneezing, and rhinorrhea.^12 However, they do not prevent or treat upper
airway obstruction or hypotension. The frequent and at times fatal error that is made by
professionals and patients is to delay the administration of epinephrine while waiting for the
antihistamines to relieve symptoms.^8 ,^20 ,^22 ,^39 ,^51 –^54 When administered as adjunctive
treatment for severe anaphylaxis, only sedating antihistamines (eg, diphenhydramine) are
available for intravenous administration. The dose for diphenhydramine is 25 to 50 mg in
adults administered intravenously over 10 to 15 minutes.^19 When given orally, a low or
nonsedating antihistamine (eg, fexofenadine) is preferred over a sedating antihistamine (eg,
diphenhydramine or chlorpheniramine) to avoid somnolence and impairment of cognitive
function and the decreased ability to describe symptoms.^19 If administered parentally, then
the dose of the H2 antihistamine ranitidine is 1 mg/kg for adults and can be administered
intramuscularly or intravenously (with slow infusion) because these administration methods
have the same onset of action.^12 ,^19
The use of corticosteroids has no role in the acute management of anaphylaxis.^22 ,^30 The
purported evidence that they produce a decrease of biphasic or prolonged reactions is not
supported by strong evidence.^8 –^10 Their use and dosage are extrapolated from those used for
acute asthma. When administered, the intravenous or oral dosage often recommended is 1 to
2 mg/kg per dose up to 125 mg of methylprednisolone or an equivalent formulation.^19
Patients who have complete resolution of symptoms after treatment with epinephrine do not
need to be prescribed antihistamines or corticosteroids thereafter.^4
The duration of direct observation and monitoring after an episode of anaphylaxis must be
individualized and based on the severity and duration of the anaphylactic event, response to
treatment, pattern of previous anaphylactic reactions (eg, history of protracted or biphasic
reactions), medical comorbidities, patient reliability, and access to medical care.^2 ,^4 ,^12 ,^19 ,^20 ,^40
Patients with moderate to severe anaphylaxis should be observed for a minimum of 4 to 8
hours.^4 ,^12 ,^19 Mild anaphylactic symptoms that occur in a medical setting (eg, office-based
allergy injection) and that rapidly resolve with treatment usually will require a relatively
shorter period of observation. A longer observation, including possible hospital admission,
should be considered when (1) risk factors for more severe anaphylaxis (eg, history of severe
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asthma) are present, (2) the allergens have been ingested, (3) more than 1 dose of
epinephrine is required, (4) pharyngeal edema is present, and (5) severe or prolonged
symptoms (eg, prolonged wheezing or hypotension) are noted.^4 ,^12 ,^14 ,^19 ,^40 ,^55 ,^56
FOLLOW-UP EDUCATION
As in many diseases, patient education is vital; however, due to the potential for rapidly
progressing, life-threatening reactions, proper and through patient education is a critical
component in the management of anaphylaxis. Auto-injectable epinephrine should be
prescribed for patients who have experienced an anaphylactic reaction and for those at
increased risk for anaphylaxis. The patient must be instructed in the administration of
epinephrine. Patients should be encouraged to fill this prescription immediately because up
to 23% can experience a return of symptoms as a biphasic reaction, usually within 10 hours
after the resolution of the presenting symptoms of anaphylaxis.^10 Two auto-injectors should
be provided because up to 30% of patients who develop anaphylaxis will require more than
1 dose of epinephrine.^2 ,^8 ,^9 ,^34 In the U.S., auto-injectors are available in only 2 doses, 0.
and 0.30 mg. The preferred adult dose is 0.30 mg. Although the initial anaphylaxis action
plan can be provided at the point of care (eg, emergency department or primary care office),
the permanent anaphylaxis action plan should be developed by the allergist working with the
patient, the primary care physician, other members of the interdisciplinary clinical team, and
the school, when appropriate. Education on the triggers and early signs and symptoms of
anaphylaxis must be a structured, reoccurring, and scheduled process for all office staff,
medical and clerical, and patients. The patient’s education on anaphylaxis should start at the
time of the new patient visit for all patients who present with signs and symptoms of
anaphylaxis and for all patients who will be undergoing a diagnostic or treatment procedure
that could result in anaphylaxis (eg, chemotherapy infusion).
FUTURE CONSIDERATIONS/SUMMARY
Patients with anaphylaxis should be assessed and treated as rapidly as possible, as
respiratory or cardiac arrest and death can occur within minutes. Anaphylaxis appears to be
most responsive to treatment in its early phases, before shock has developed, based on the
observation that delayed epinephrine injection is associated with fatalities. Epinephrine is
life-saving in anaphylaxis. It should be injected as early as possible in the episode in order to
prevent progression of symptoms and signs. There are no absolute contraindications to
epinephrine use, and it is the treatment of choice for anaphylaxis of any severity. Patients
successfully treated for anaphylaxis should be discharged with a personalized written
anaphylaxis emergency action plan, an AIE, written information about anaphylaxis and its
treatment, and a plan for further evaluation. Consultation with an allergist can help (1)
confirm the diagnosis of anaphylaxis; (2) identify the anaphylactic trigger through history,
skin testing, and RAST; (3) educate the patient in the prevention and initial treatment of
future episodes; and (4) aid in desensitization and pretreatment when indicated as well as,
for some allergens, immunomodulation is also available to reduce the risk.^4 ,^12
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Box 1
Pertinent history taking in evaluation of a patient presenting with
anaphylaxis
- Detailed history of ingestants (foods, drinks/medications) taken within 8 h
before the event
- Activity in which the patient was engaged at the time of the event - Location of the event (home, school, work, indoors/outdoors) - Exposure to heat or cold - Any related sting or bite (significant tick or chigger bites within prior 4
weeks)
- Time of day or night - Duration of event - Recurrence of symptoms after initial resolution - Exact nature of symptoms (eg, if cutaneous, determine whether flush,
pruritus, urticaria, or angioedema)
- In a woman, the relation between the event and her menstrual cycle - Was medical care given and what treatments were administered - How long before recovery occurred and was there a recurrence of symptoms
after a symptom-free period
- The perceived level of stress by the patient prior to the episode - Any recent illness or infection - Pertinent travel history - Description of any prior similar episodes - Return of mild symptoms with exposure to heat, exercise or alcohol ingestion
Adapted from Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis--a practice
parameter update 2015. Ann Allergy Asthma Immunol 2015;115(5):341–84; with
permission.
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Table I
Signs and symptoms of anaphylaxis
Signs and Symptoms Frequency (%) Urticaria, angioedema 60– Upper airway edema 50– Flush 45– Dyspnea, wheeze 45– Dizziness, syncope, hypotension 30– Nausea, vomiting, diarrhea, cramping abdominal pain
Rhinitis 15– Headache 10– Chest pain 3– Pruritus without rash 2– *Palmar erythema and pruritus 35–
Specifically related to patients with IgE to galactose-alpha-1,3-galactose mammalian meat allergy.
Data from Refs^2 ,^4 ,^12 ,^14 ,^51
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Table III
Treatment of anaphylaxis in the physician’s office
Immediate measures 1 Allergen Remove the inciting allergen, if possible 2 Airway Assess airway, breathing, circulation, and orientation; if needed, support the airway using the least invasive but effective method (eg, bag-valve-mask) 3 Cardiopulmonary resuscitation
Start chest compressions (100/min) if cardiovascular arrest occurs at any time 4 Epinephrine Inject epinephrine 0.3–0.5 mg intramuscularly in the vastus lateralis (lateral thigh) 5 Get help Summon appropriate assistance in office 6 Position Place adults and adolescents in recumbent position; place pregnant patient on left side 7a Oxygen Give 8–10 L/min through facemask or up to 100% oxygen as needed; monitor by pulse oximetry if available 7b Epinephrine Repeat intramuscular epinephrine every 5–15 min for up to 3 injections if the patient is not responding 7c EMS Activate EMS (call 911 or local rescue squad) if no immediate response to first dose of IM epinephrine or if anaphylaxis is moderate to severe 7d IV fluids Establish intravenous line for venous access and fluid replacement; keep open with 0.9 NL saline, push fluids for hypotension or failure to respond to epinephrine using 5–10 mg/kg as quickly as possible and up to 1–2 L in the first hour Additional measures 8 Albuterol Consider administration of 2.5–5 mg of nebulized albuterol in 3 mL of saline for lower airway obstruction; repeat as necessary every 15 min 9 Glucagon Patients on beta-blockers who are not responding to epinephrine should be given 1–5 mg of glucagon IV slowly over 5 min because rapid administration of glucagon can induce vomiting 10 Epinephrine (infusion)
For patients with inadequate response to IM epinephrine and IV saline, give epinephrine by continuous infusion by micro-drip in office setting (infusion pump in hospital setting); add 1 mg (1 mL of 1:1,000) of epinephrine to 1,000 mL of 0.9 NL saline; start infusion at 2 mg/min ( mL/min = 120 mL/h) and increase up to 10 mg/min (10 mL/min = 600 mL/h); titrate dose continuously according to blood pressure, cardiac rate and function, and oxygenation 11 Intraosseous access
If IV access is not readily available in patients experiencing refractory anaphylaxis, obtain intraosseous access for administration of IV fluids and epinephrine infusion Refractory anaphylaxis 12 Advanced airway management
Use supraglottic airway, endotracheal intubation, or cricothyroidotomy for marked stridor, severe laryngeal edema, or when ventilation using the bag-valve-mask is inadequate and EMS has not arrived 13 Vasopressors Consider administration of dopamine (in addition to epinephrine infusion) if patient is unresponsive to above treatment; this will likely be in the hospital setting where cardiac monitoring is available Optional treatment (efficacy not established) 14 H 1 anti-histamine Consider giving 25–50 mg of diphenhydramine intravenously; use 10 mg of cetirizine if an oral antihistamine is administered; once there is full recovery, there is no evidence that this medication needs to be continued 15 Corticosteroids Administer 1–2 mg/kg up to 125 mg per dose, IV or PO, of methylprednisolone or an equivalent formulation; once there is full
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recovery, there is no evidence that this medication needs to be continued Observation and monitoring 16 Observation in hospital
Transport to emergency department by EMS for further treatment and observation for ~8 h 17 Observation in office
Observe in office until full recovery + additional 30–60 min for all patients who are not candidates for EMS transport to emergency department Discharge management 18 Education Educate patient and family on how to recognize and how to treat anaphylaxis 19 Auto-injectable epinephrine
Prescribe 2 doses of auto-injectable epinephrine for patients who have experienced an anaphylactic reaction and for those at risk for severe anaphylaxis; train patient, patient provider, and family on how to use the auto-injector 20 Anaphylaxis action plan
Provide patients with an action plan instructing them on how and when to administer epinephrine
EMS - emergency medical services; IV – intravenous; IM – intramuscular; PO – oral; NL – normal
Adapted from Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis--a practice parameter update 2015. Ann Allergy Asthma Immunol 2015;115(5):341–84; with permission.
