Background: The Cross-Canada Anaphylaxis Registry (C-CARE) assesses the triggers and management of anaphylaxis and identifies predictors of the development of severe allergic reactions and of epinephrine use. Here, we present data from an urban adult tertiary care emergency department (ED) in Montreal, Canada. Methods: Potential anaphylaxis cases were identified using ICD-10 codes related to anaphylaxis or allergic reactions. Putative cases underwent chart review to ensure they met anaphylaxis diagnostic criteria. Demographic, clinical and management data were collected. Multivariate logistic regressions were conducted to assess the effect of demographic characteristics, triggers, and comorbidities on severity and management of reactions. Results: Among 37,730 ED visits, 0.26% (95% CI 0.21, 0.32) fulfilled the definition of anaphylaxis. Food was the suspected trigger in almost 60% of cases. Epinephrine was not administered in almost half of moderate-to-severe cases, and similar numbers of individuals with moderate-to-severe reactions were not prescribed an epinephrine autoinjector. Reaction to shellfish was associated with more severe reactions (OR 13.9; 95% CI 2.2, 89.4). Older individuals and those not receiving steroids were more likely managed without epinephrine (OR 1.04; 95% CI 1.01, 1.07 and OR 2.97; 95% CI 1.05, 8.39, respectively). Conclusions: Anaphylaxis accounted for a substantial number of ED visits in adults, and the most common trigger was food. There is non-adherence to guidelines recommending epinephrine use for all cases of anaphylaxis. We postulate that this may be related to concerns regarding the side effects of epinephrine in adults.

Keywords:
Anaphylaxis, Food allergy, Management, Epinephrine, Severe anaphylaxis
1.
Ben Shoshan M, Clarke AE: Anaphylaxis: past, present and future. Allergy 2011;66:1-14.
2.
Bock SA, Munoz-Furlong A, Sampson HA: Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol 2007;119:1016-1018.
3.
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;133:461-467.
4.
Panesar SS, Javad S, de Silva D, Nwaru BI, Hickstein L, Muraro A, Roberts G, Worm M, Bilo MB, Cardona V, Dubois AE, Dunn GA, Eigenmann P, Fernandez-Rivas M, Halken S, Lack G, Niggemann B, Santos AF, Vlieg-Boerstra BJ, Zolkipli ZQ, Sheikh A: The epidemiology of anaphylaxis in Europe: a systematic review. Allergy 2013;68:1353-1361.
5.
Sheikh A, Hippisley-Cox J, Newton J, Fenty J: Trends in national incidence, lifetime prevalence and adrenaline prescribing for anaphylaxis in England. J R Soc Med 2008;101:139-143.
6.
Lauritano EC, Novi A, Santoro MC, Casagranda I: Incidence, clinical features and management of acute allergic reactions: the experience of a single, Italian Emergency Department. Eur Rev Med Pharmacol Sci 2013;17(suppl 1):39-44.
7.
Renaudin JM, Beaudouin E, Ponvert C, Demoly P, Moneret-Vautrin DA: Severe drug-induced anaphylaxis: analysis of 333 cases recorded by the Allergy Vigilance Network from 2002 to 2010. Allergy 2013;68:929-937.
8.
Calderon E, Mendez J, Nazario S: Anaphylaxis diagnosis and treatment at an emergency department in Puerto Rico. P R Health Sci J 2013;32:170-174.
9.
Summers CW, Pumphrey RS, Woods CN, McDowell G, Pemberton PW, Arkwright PD: Factors predicting anaphylaxis to peanuts and tree nuts in patients referred to a specialist center. J Allergy Clin Immunol 2008;121:632-638.
10.
Brown SG, Stone SF, Fatovich DM, Burrows SA, Holdgate A, Celenza A, Coulson A, Hartnett L, Nagree Y, Cotterell C, Isbister GK: Anaphylaxis: clinical patterns, mediator release, and severity. J Allergy Clin Immunol 2013;132:1141-1149.
11.
Alrasbi M, Sheikh A: Comparison of international guidelines for the emergency medical management of anaphylaxis. Allergy 2007;62:838-841.
12.
Desjardins M, Clarke A, Alizadehfar R, Grenier D, Eisman H, Carr S, Vander Leek TK, Teperman L, Higgins N, Joseph L, Shand G, Ben-Shoshan M: Comparison between allergists and non-allergists on issues related to food-induced anaphylaxis. J Allergy Clin Immunol 2012;129:AB183.
13.
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;65:435-444.
14.
Khan NU, Shakeel N, Makda A, Mallick AS, Ali MM, Hashmi SH, Khan UR, Razzak JA: Anaphylaxis: incidence, presentation, causes and outcome in patients in a tertiary-care hospital in Karachi, Pakistan. QJM 2013;106:1095-1101.
15.
Beyer K, Eckermann O, Hompes S, Grabenhenrich L, Worm M: Anaphylaxis in an emergency setting - elicitors, therapy and incidence of severe allergic reactions. Allergy 2012;67:1451-1456.
16.
Vetander M, Helander D, Flodstrom C, Ostblom E, Alfven T, Ly DH, Hedlin G, Lilja G, Nilsson C, Wickman M: Anaphylaxis and reactions to foods in children - a population-based case study of emergency department visits. Clin Exp Allergy 2012;42:568-577.
17.
Sampson HA, Munoz-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;47:373-380.
18.
Muraro A, Roberts G, Clark A, Eigenmann PA, Halken S, Lack G, Moneret-Vautrin A, Niggemann B, Rance F: The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology. Allergy 2007;62:857-871.
19.
Campbell RL, Hagan JB, Li JT, Vukov SC, Kanthala AR, Smith VD, Manivannan V, Bellolio MF, Decker WW: Anaphylaxis in emergency department patients 50 or 65 years or older. Ann Allergy Asthma Immunol 2011;106:401-406.
20.
Tejedor Alonso MA, Moro MM, Hernandez JE, Mugica Garcia MV, Albelda CV, Ingelmo AR, Encinas MP, Lorena W, Abreu A: Incidence of anaphylaxis in hospitalized patients. Int Arch Allergy Immunol 2011;156:212-220.
21.
Ben-Shoshan M, La VS, Eisman H, Alizadehfar R, Mill C, Perkins E, Joseph L, Morris J, Clarke A: Anaphylaxis treated in a Canadian pediatric hospital: incidence, clinical characteristics, triggers, and management. J Allergy Clin Immunol 2013;132:739-741.
22.
Chen W, Mempel M, Schober W, Behrendt H, Ring J: Gender difference, sex hormones, and immediate type hypersensitivity reactions. Allergy 2008;63:1418-1427.
23.
Wuthrich B: Lethal or life-threatening allergic reactions to food. J Investig Allergol Clin Immunol 2000;10:59-65.
24.
Pumphrey RS, Gowland MH: Further fatal allergic reactions to food in the United Kingdom, 1999-2006. J Allergy Clin Immunol 2007;119:1018-1019.
25.
Bailey S, Albardiaz R, Frew AJ, Smith H: Restaurant staff's knowledge of anaphylaxis and dietary care of people with allergies. Clin Exp Allergy 2011;41:713-717.
26.
Ross MP, Ferguson M, Street D, Klontz K, Schroeder T, Luccioli S: Analysis of food-allergic and anaphylactic events in the National Electronic Injury Surveillance System. J Allergy Clin Immunol 2008;121:166-171.
27.
Soller L, Ben-Shoshan M, Harrington DW, Fragapane J, Joseph L, St Pierre Y, Godefroy SB, La VS, Elliott SJ, Clarke AE: Overall prevalence of self-reported food allergy in Canada. J Allergy Clin Immunol 2012;130:986-988.
28.
Hassaine A, Clarke A, Alizadehfar R, Joseph L, Shand G, Ben-Shoshan M: Initial allergic reactions to fish and shellfish in children: clinical characteristics and treatment. J Allergy Clin Immunol 2012;129:AB169.
29.
Lee AJ, Gerez I, Shek LP, Lee BW: Shellfish allergy - an Asia-Pacific perspective. Asian Pac J Allergy Immunol 2012;30:3-10.
30.
Dewachter P, Mouton-Faivre C: Possible link between apical ballooning syndrome during anaphylaxis and inappropriate administration of epinephrine. Mayo Clin Proc 2010;85:396-397.
31.
Kumar A, Qureshi A: Possible link between apical ballooning syndrome during anaphylaxis and inappropriate administration of epinephrine-1. Mayo Clin Proc 2010;85:397-398.
32.
Park HJ, Kim SH: Factors associated with shock in anaphylaxis. Am J Emerg Med 2012;30:1674-1678.
33.
Simons FE, Ardusso LR, Bilo MB, El-Gamal YM, Ledford DK, Ring J, Sanchez-Borges M, Senna GE, Sheikh A, Thong BY: World Allergy Organization anaphylaxis guidelines: summary. J Allergy Clin Immunol 2011;127:587-593.
34.
Sheikh A, Ten B, V, Brown SG, Simons FE: H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2007;62:830-837.
35.
Choo KJ, Simons FE, Sheikh A: Glucocorticoids for the treatment of anaphylaxis. Cochrane Database Syst Rev 2012;4:CD007596.
36.
Simons FE, Ardusso LR, Dimov V, Ebisawa M, El-Gamal YM, Lockey RF, Sanchez-Borges M, Senna GE, Sheikh A, Thong BY, Worm M: World Allergy Organization Anaphylaxis Guidelines: 2013 update of the evidence base. Int Arch Allergy Immunol 2013;162:193-204.
37.
Zadnik K, Mannis MJ, Kim HS, Miller M, Marquez M: Inter-clinician agreement on clinical data abstracted from patients' medical charts. Optom Vis Sci 1998;75:813-816.
38.
Sayre EC, Bunting PS, Kopec JA: Reliability of self-report versus chart-based prostate cancer, PSA, DRE and urinary symptoms. Can J Urol 2009;16:4463-4471.
© 2014 S. Karger AG, Basel
2014
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.