ACAAI Collaboration with Emergency Physicians to Improve the Diagnosis, Treatment and Long-Term Management of Anaphylaxis

Anaphylaxis is a complex disorder associated with a variety of different mechanisms, triggers, clinical presentations, levels of severity, and rates of progression, resulting in a broad differential diagnosis. As such, it presents unique challenges for first responders and emergency physicians who may see the condition infrequently, yet must make rapid diagnostic and treatment decisions. 

The American College of Allergy, Asthma and Immunology (ACAAI) convened an expert panel of allergists and emergency physicians to address these challenges. The panel discussed:

  • Current knowledge of anaphylaxis
  • Potential strategies to improve the medical management of anaphylaxis and severe allergic reactions along the continuum of care
  • Opportunities for further collaborations between allergists and emergency providers

Results of the Panel Discussion

Original Article

Addressing barriers to emergency anaphylaxis care: from emergency medical services to emergency department to outpatient follow-up,” an original article based on the expert panel discussion, was published in the October 2015 issue of the Annals of Allergy, Asthma & Immunology. 

Highlights of the article include:

Barriers to Care

The expert panel identified three primary barriers to optimum care for anaphylaxis and other severe allergies in the emergency setting:

Complexity of diagnosing anaphylaxis: Although the NIAID/FAAN Clinical Criteria are helpful for research, education, and risk assessment by allergists, they are of limited value for emergency physicians at the onset of an anaphylactic event. Such an event may include symptoms associated with multiple differential diagnoses. The criteria also offer no guidance for identifying a patient with mild symptoms who may have impending anaphylaxis or be at risk of a future event. This adds to the complexity of decision-making around the use of epinephrine by the emergency medical services (EMS) practitioner or ED physician.

Underuse of epinephrine: Despite evidence of the safety and efficacy of epinephrine, physicians on the expert panel concurred that the potential for inappropriate dosing was the most significant barrier to the use of epinephrine in the ED, where rapid decision making is crucial and epinephrine is the recommended first-line therapy for various other medical conditions that are seen more frequently than anaphylaxis and for which the recommended doses differ. They attributed the problem primarily to the lack of autoinjectors or other strategies specifically designed to facilitate appropriate dosing in many EDs.

Inadequate post-discharge follow-up: By providing a prescription for autoinjectable epinephrine, and referral to an allergist at the time of discharge from the ED, emergency physicians play an important role in ensuring prompt treatment of future anaphylactic reactions. For patients who present with symptoms, ED physicians should consider obtaining a serum tryptase level for follow-up after the ED visit. Careful ED documentation of the anaphylactic event also can help allergists and other follow-up physicians confirm the diagnosis and may help identify the trigger responsible for the anaphylactic event.

Unresolved issues

The panel posed four questions recommended for further discussion and study.

  1. How should we define and treat mild or moderate allergic reactions?

  2. How can we promote more appropriate dosing of epinephrine?

  3. Does treatment with epinephrine early in the onset of anaphylaxis prevent or reduce the risk of a biphasic reaction?

  4. How can EDs follow up with the results of serum tryptase testing?

Opportunities for Outreach by Allergists

National and grassroots education is needed for EMS practitioners and ED physicians to improve the diagnosis and management of anaphylaxis. The panel agreed that allergists should be proactive in seeking collaborations with emergency practitioners in their hospitals and in their communities through local medical societies, grand rounds presentations and other activities.

Key Messages for Anaphylaxis Education

The panel recommended the following key messages for allergists and others to emphasize in educational outreach to emergency providers: 

  • Epinephrine in appropriate doses is safe, and there are no absolute contraindications for its use in treating anaphylaxis.
  • Delay in administration of epinephrine may lead to more severe anaphylaxis.
  • Epinephrine administration is indicated for anaphylaxis, for a severe allergic reaction or for patients at risk of anaphylaxis.
  • It is not necessary for the NIAID/FAAN criteria to be met to administer epinephrine.
  • Antihistamines and glucocorticoids are not indicated as first-line treatment for anaphylaxis.
  • Patients treated in the emergency setting for anaphylaxis should be provided with a prescription for epinephrine autoinjectors and an action plan for their use before discharge.
  • Patients should be referred to an allergist to assist with diagnosis confirmation, trigger identification, and continued outpatient management.

Resources for Physicians

Anaphylaxis in the ED: A Reference for Physicians

Based on the recommendations of the expert panel, ACAAI created the Anaphylaxis in the ED: A Reference for Physicians pocket card for use by emergency physicians in outreach to their hospital EDs and other local and regional emergency providers.

The 8 ½ X 11” document may be printed as a single sheet for use as an educational handout, or folded into a pocket-size flyer for use as a handy reference in care settings.

Sample Anaphylaxis Action Plans

The expert panel recommended that patients and/or caretakers be given a simple anaphylaxis action plan before they leave the ED that includes instructions on how and when to self-administer epinephrine, when to call 911 and/or return to the ED, and a referral to an allergist. Of the anaphylaxis action plans currently recognized by major professional organizations and patient advocacy support groups and reviewed by panel members, the following most closely align with the recommendations made by the panel. Hospitals and other emergency treatment centers may wish to use these plans as a guide to developing action plans tailored to their individual needs.

Related Links

National professional organizations of emergency providers also offer opportunities for participation in educational programs, including:

The Anaphylaxis Roundtable Expert Panel

Steven H. Bowman, MD, FACEP, is an attending physician and program director, department of emergency medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago; and associate professor of emergency medicine, Rush Medical College, Chicago. Dr. Bowman received his medical degree from Washington University School of Medicine, St. Louis, and completed his residency in emergency medicine at Cook County Hospital. He is an examiner for the American Board of Emergency Medicine; a member of the EM-Residency Review Committee of the Accreditation Council on Graduate Medical Education; and past president of the Council of Emergency Medicine Residency Directors (CORD). An expert on the education and training of emergency medicine physicians, Dr. Bowman lectures widely both nationally and internationally and is the author of numerous book chapters, peer-reviewed articles and abstracts.

Ronna L. Campbell, MD, PhD, received both her MD and PhD (Immunology) degrees from the University of Pittsburgh School of Medicine. She completed her residency training at the Mayo School of Graduate Medical Education and joined the faculty of the department of emergency medicine in 2007. Dr. Campbell was a member of the multinational and multidisciplinary Second Symposium on the Definition and Management of Anaphylaxis convened by the National Institute of Allergy and Infectious Diseases (NIAID) and Food Allergy and Anaphylaxis Network (FAAN) in 2005. She was a coauthor of the recently published “Emergency department diagnosis and treatment of anaphylaxis: a practice parameter” and has published numerous other peer-reviewed manuscripts related to the emergency department management of anaphylaxis.

Paul J Dowling, MD, is a practicing allergist and director of the allergy/immunology training program, University of Missouri, Children’s Mercy Hospitals and Clinics, Kansas City. A graduate of Albany Medical College, Albany, NY, Dr. Dowling completed a residency in pediatrics at Michigan State University/Hurley Medical Center, Flint; and a fellowship in allergy/immunology at Creighton University, Omaha. He served as chair of the ACAAI Drug and Anaphylaxis Committee and is the ACAAI allergy/ immunology representative to the Council of Pediatric Subspecialists (CoPS). He has served on the board of directors of the Joint Council of Asthma, Allergy and Immunology, and as a reviewer for the Council’s Drug Allergy Practice Parameter and Anaphylaxis Practice Parameter. 

Stanley M. Fineman, MD, MBA, is a practicing allergist and adjunct associate professor in the department of pediatrics, allergy division at Emory University School of Medicine, Atlanta. He earned his medical degree from Emory University; completed his internship and residency in pediatrics at the University of Cincinnati and a fellowship in allergy and immunology at Harvard University School of Medicine, Boston. He earned his MBA at Kennesaw State University in Boston. Dr. Fineman currently serves on the boards of the World Allergy Organization and the Allergy & Asthma Network Mothers of Asthmatics and is a past president of ACAAI. He has authored numerous scientific papers and several book chapters in the field of allergy and immunology, is a contributing editor for the publication Allergy Watch, and serves on the editorial boards of the journals Annals of Allergy, Asthma & Immunology and Allergy & Asthma Proceedings.

W. Scott Russell, MD, is assistant professor, department of pediatrics, College of Medicine, Medical University of South Carolina (MUSC), Charleston. He was appointed as medical director of the pediatric emergency department in 2011, and most recently was named the medical director of the MUSC Children’s Hospital Service Line. Dr. Russell received his MD from the Medical College of Georgia, Augusta, and completed his pediatric residency and pediatric emergency medicine fellowship training at University of Alabama, Birmingham. His research interests include anaphylaxis, trauma, asthma, minimizing diagnostic radiation exposure in children and high risk sexual behaviors in teenagers. He is co-investigator on 4 funded projects and is author of 11 manuscripts, including 3 articles on anaphylaxis management, guidelines and best practices.

J. Wesley Sublett, MD, MPH, a practicing allergist in Louisville, Ky., is a graduate of St. Louis University (MPH) and the University of Louisville School of Medicine. Board certified in both pediatrics and allergy/immunology, Dr. Sublett completed his internship and residency in pediatrics at the University of Louisville – Kosair Children’s Hospital. He completed his fellowship in allergy, asthma and immunology at the University of Cincinnati. He played a crucial role in getting a Kentucky House Bill passed that allows schools to purchase and store epinephrine auto-injectors and use them on children who experience a life-threatening anaphylactic event. 

Dana V. Wallace, MD, is a practicing allergist and associate clinical professor at Nova Southeastern University in Davie, Fla., and Florida Atlantic University in Boca Raton. A graduate of the University of Tennessee College of Medicine, Dr. Wallace completed a residency at Lenox Hill Hospital and a fellowship in allergy and immunology at Roosevelt Hospital. Dr. Wallace is on the board of the World Allergy Organization and a past president of ACAAI, and has received the ACAAI Distinguished Service Award and Woman in Allergy Award. She has been on the Joint Task Force on Practice Parameters since 2005, and is past chairman and active member of the drugs and anaphylaxis committee; and is ACAAI’s representative on the Health Level 7 (HL7) Clinical Interoperability Council. Dr. Wallace serves on the Annals of Allergy, Asthma and Immunology manuscript review committee and on the Allergy and Asthma Proceedings editorial review board.

Selected References

Complexity of Diagnosing Anaphylaxis: Selected References

  1. Boyce JA, Assa’ad A, Burks AW, et al. 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 Suppl):S1-S58.
  2. Lieberman P, Nicklas RA, Oppenheimer J. The diagnosis and management of anaphylaxis practice parameter: 2010 Update. J Allergy Clin Immunol. 2010;126(3):477-80.
  3. Simons FE, Ardusso LR, Bilo MB, et al. 2012 Update: World Allergy Organization Guidelines for the assessment and management of anaphylaxis. Curr Opin Allergy Clin Immunol. 2012;12:389–99.
  4. Campbell, RL, Li JTC, Nicklas RA, Sadosty AT. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014;113:599-608.

Underuse of Epinephrine: Selected References

  1. 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(8):1061-70.
  2.  Anchor J, Settipane RA. Appropriate use of epinephrine in anaphylaxis. Am J Emerg Med. 2004;22(6):488-90.
  3. Wood JP, Traub SJ, Lipinski C. Safety of epinephrine for anaphylaxis in the emergency setting. World J Emerg Med. 2013;4(4):245.
  4. Kanwar M, Irvin CB, Frank JJ, Weber K, Rosman H. Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution. Ann Emerg Med 2010;55:341-4.

Inadequate Post-Discharge Follow-Up: Selected References

  1. Campbell RL, Park MA, Kueber MA Jr, Lee S, Hagan JB. Outcomes of allergy/immunology follow-up after an emergency department evaluation for anaphylaxis. J Allergy Clin Immunol Pract. 2015;3(1):88-93.
  2. Kanwar M, Irvin CB, Frank JJ, Weber K, Rosman H. Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution. Ann Emerg Med 2010;55:341-4.
Provide Feedback