Anaphylaxis - 2020 National Practice Parameter UpdateThe guidelines for systematic review, and grading of
recommendations, assessment, development
and evaluation (GRADE) analysis of anaphylaxis have been updated.
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Today’s Guideline Knowledge Check question comes from the desk of Med-Challenger Emergency Medicine Editor-in-Chief, Andrea Eberly, MD, FAAEM.
As many as 5% of people experience anaphylaxis in their lifetime, with medications and stinging insects being the leading causes of anaphylaxis in adults, and foods and stings being the leading causes in children. Although overall risk for death from anaphylaxis is quite low (0.3% of emergency visits or hospitalizations for anaphylaxis end with fatalities), comorbid conditions, such as uncontrolled asthma, cardiovascular disease, or advanced age, are associated with excess risk.
As many as 20% of patients experience biphasic reactions that can occur as long as 72 hours later, with potentially life-threatening symptoms. Patients with severe anaphylaxis, those who require multiple doses of epinephrine, or those with delayed administration of epinephrine are at greatest risk. Negative predictive values for a biphasic reaction after discharge are 95% and 97% for patients who are watched for 1 and 6 hours, respectively. A set of 2020 National Anaphylaxis Practice Parameters addresses biphasic anaphylaxis (recurrent anaphylaxis after first resolution)
A set of 2020 National Anaphylaxis Practice Parameters addresses biphasic anaphylaxis (recurrent anaphylaxis after first resolution). What role do antihistamines, glucocorticoids, and observation play in the prevention/early management of biphasic anaphylaxis?
A 43-year-old, healthy female without known allergies presents to the hospital with acute, generalized urticaria and wheezing. Two hours earlier she took her 3rd dose of sulfamethoxazole-trimethoprim for a urinary tract infection (UTI).
What do the American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma, and Immunology (ACAAI) recommend in their just published 2020 allergy practice parameter with regards to the further management of the above patient?
Give antihistamines and glucocorticoids after the second dose of epinephrine to significantly reduce incidence of biphasic anaphylaxis; discharge after resolution of anaphylaxis plus 1 hour observation of asymptomatic patient.
After resolution of symptoms, observe the asymptomatic patient for at least 6 hours; antihistamines and glucocorticoids do not reliably decrease risk of biphasic anaphylaxis and are not recommended for this purpose.
Give antihistamines and glucocorticoids to reduce incidence of biphasic anaphylaxis; admit for 24 hours to monitor for return of anaphylaxis.
Give antihistamines and glucocorticoids before or immediately after the first dose of epinephrine to significantly decrease rate of return visits for recurrent (biphasic) anaphylaxis; optimal observation time after resolution of anaphylaxis is not known, but might be as short as 1 hour.
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About the Author:
Andrea Eberly, MD, FAAEM graduated from the David Geffen Medical School of Los Angeles (UCLA) and completed her residency in Emergency Medicine at the University Medical Center, Tucson, Arizona. After working as an attending physician in Tucson, she followed a recruiting call to the island of Guam, where she served in various roles, including as the director of the emergency department, the EMS Medical Director of Guam, and the Director of the 911 Call System. She has maintained her emergency medicine board certification through three cycles of American Board of Emergency Medicine Board Exams (last in 2014), all three with the help of Med-Challenger.
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