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WAO Journal & July 2008, Supplement 2 FIGURE 2. Adrenergic effects of epinephrine. Adapted from Simons.40 recur 1 hour to 72 hours (most within 8 hours) after apparent The A-adrenergic properties of epinephrine cause bronchodila- resolution of the initial phase.30 The severity of the initial tion, increase myocardial output and contractility, and suppress phase of an anaphylactic reaction is not predictive of further mediator release from mast cells and basophils.41,42 either biphasic or protracted anaphylaxis, although failure to Epinephrine administered in low concentrations (eg, 0.1 Kg/kg) give an adequate dose of epinephrine initially may be paradoxically can produce vasodilation, hypotension, and associated with increased risk of biphasic anaphylaxis.
increased release of inflammatory mediators.39,43 Monitoring of patients for 24 hours or more after apparent Epinephrine administration enhances coronary blood recovery from the initial phase may be necessary in more flow. Two mechanisms are probably responsible: an increased severe cases because life-threatening manifestations of duration of diastole compared with systole and a vasodilator anaphylaxis may recur. Data are limited concerning the effect caused by increased myocardial contractility. These frequency with which 2 or more doses of epinephrine are actions usually offset the vasoconstrictor effects of epinephr- needed to treat anaphylaxis (reports range from 16% to 36%), ine on the coronary arteries.39,44 and multiple cofactors may be involved.31Y33 Rapid achievement of peak plasma and tissue epinephrine Respiratory compromise and cardiovascular collapse levels seems to optimize survival because retrospective human cause most fatalities.28,34 An analysis of 202 anaphylaxis studies demonstrate that delayed administration is associated fatalities occurring in the United Kingdom from 1992 to with poor outcomes.20,21 However, epinephrine administration 2001 ascertained that the interval between initial onset of during anaphylaxis is not always effective, and patients may still food anaphylaxis symptoms and fatal cardiopulmonary die.20Y25 Reasons may be multifactorial and include delayed arrest averaged 25 to 35 minutes, which was longer than for administration, inadequate doses, inappropriate route of admin- insect stings (10Y15 minutes) or for drugs (mean, 5 minutes istration, use of epinephrine that has passed its expiration date, in hospital; 10Y20 minutes prehospital).34 leading to inadvertent administration of an inadequate dose, or an Increased vascular permeability during anaphylaxis can underlying disease, such as poorly controlled asthma, cardiovas- shift up to 35% of intravascular fluid to the extravascular space cular disease, mastocytosis, and perhaps other serious systemic within 10 minutes.35 The intrinsic compensatory response to disorders.40,45 A study done in a canine model also demonstrates anaphylaxis (endogenous epinephrine and other catechola- that achievement of peak epinephrine plasma levels and mines, as well as angiotensin II, endothelin-1, etc) also hemodynamic recovery is not as effective when epinephrine influences the extent of clinical manifestations and, when administration is delayed until hypotension has developed.46 adequate, may be lifesaving independent of medical inter- Epinephrine has a relatively narrow therapeutic window vention, which sometimes contributes to diagnostic and (relative benefit vs risk; Fig. 3). Common pharmacological therapeutic confusion. Because mast cells accumulate at effects that occur at recommended doses via any route of sites of coronary atherosclerotic plaques and IgE antibodies administration include agitation, anxiety, tremulousness, bound to mast cells can trigger mast cell degranulation, some headache, dizziness, pallor, or palpitations.39 Rarely, and investigators have suggested that anaphylaxis may lead to usually associated with overdosage or overly rapid rate of myocardial ischemia by promoting plaque rupture.36,37 intravenous infusion, epinephrine administration might con- Stimulation of the H1 histamine receptor may also produce tribute to or cause myocardial ischemia or infarction,47Y52 coronary artery vasospasm.37,38 pulmonary edema,53,54 prolonged QTc (QTc = QT intervaldivided by the square root of the RR interval [in seconds] of PHARMACOLOGY OF EPINEPHRINE the electrocardiogram) interval,55 ventricular arrhythmias, The pharmacology of epinephrine is reviewed in detail accelerated hypertension, and intracranial hemorrhage in elsewhere (Fig. 2).39,40 At recommended dosages and routes of adults and children alike.41,56 Nonetheless, some patients administration, the >-adrenergic vasoconstrictive effects reverse have survived massive overdoses of epinephrine, with no peripheral vasodilation, which alleviates hypotension and also evidence of myocardial ischemia.57,58 Particularly vulnerable reduces erythema, urticaria, and angioedema. Local injection of populations are those individuals at the extremes of age and epinephrine may also minimize further absorption of antigen from those with hypertension, peripheral vascular disease, ischemic a sting or injection, but this has not been studied systematically.
heart disease, or untreated hyperthyroidism (increased number * 2008 World Allergy Organization Copyright @ 2008 World Allergy Organization. Unauthorized reproduction of this article is prohibited.
WAO Journal & July 2008, Supplement 2 Epinephrine: The Drug of Choice for Anaphylaxis FIGURE 3. Therapeutic window of epinephrine. Adapted from Simons.18 of A-adrenergic receptors in the vasculature of these indivi- oids for intravenous injection; and (10) vasopressors (eg, duals render the myocardium more sensitive to A-adrenergic dopamine or norepinephrine). Glucagon, an automatic defi- effects of epinephrine).59 Certain medications might also brillator, and 1-way valve face mask with oxygen inlet port are increase the risk of adverse events from drug interactions.13,18,42,59 other supplies that some clinicians might find desirable Some medications decrease the effectiveness of endogenous depending on the individual clinical setting.13 catecholamine stores or exogenously administered epinephrine Assessment and maintenance of airway, breathing, (A-adrenergic blockers), interfere with intrinsic compensatory circulation, and mentation are necessary before proceeding to responses to hypotension (angiotensin-converting enzyme inhi- other management steps. Patients are monitored continuously to bitors and possibly angiotensin II receptor blockers), or impede facilitate prompt detection of any clinical changes or treatment epinephrine metabolism and lead to increased plasma and tissue complications. Placement of a patient in the recumbent position concentrations (tricyclic antidepressants and monoamine oxidase with elevation of the lower extremities is strongly recommended inhibitors). The A-adrenergic antagonists and >-adrenergic because management in the sitting or upright position has antagonists can also potentially exaggerate pharmacological contributed to poor outcomes in some patients.34 effects of epinephrine by permitting unopposed >-adrenergic(vasoconstrictor) and A-adrenergic (vasodilator) effects, respec- When to Administer Epinephrine tively. Cocaine and amphetamines sensitize the myocardium to Epinephrine should be administered simultaneously with effects of epinephrine, thus increasing the risk of toxicity.
the above measures.12Y14 By expert consensus based on However, none of these circumstances pose an absolute anecdotal evidence, there is no absolute contraindication to contraindication to epinephrine administration for anaphylaxis.13 epinephrine administration in anaphylaxis.13 It can be adminis-tered in doses appropriate for the severity of the reaction, MANAGEMENT OF ANAPHYLAXIS regardless of the initial signs and symptoms of anaphylaxis. All Physician and other health care professionals who subsequent therapeutic interventions depend on the initial perform procedures or administer medications should have response to epinephrine. Development of toxicity or inadequate available the basic therapeutic agents used to treat anaphy- response to epinephrine injections indicates that additional laxis4,7,13: (1) stethoscope and sphygmomanometer; (2) therapeutic modalities are necessary.13 Table 1 outlines a tourniquets, syringes, hypodermic needles, large-bore needles sequential approach to anaphylaxis treatment. Modalities used (eg, 14- or 16-gauge); (3) injectable aqueous epinephrine in concert with epinephrine are reviewed in detail elsewhere.10Y14 1:1000 (1 mg in 1 mL; physicians are being urged to expressdoses in mass concentration, eg, 1 mg in mL, rather than as Epinephrine Injections ratios, eg, 1:1000, which have been identified as a source of Expert consensus and anecdotal evidence indicate dosing errors with epinephrine and other medications); (4) aqueous epinephrine 1:1000 dilution (1 mg in 1 mL), 0.2 to equipment and supplies for administering supplemental 0.5 mg (0.01 mg/kg in children; maximum dose, 0.3 mg) oxygen; (5) equipment and supplies for administering administered intramuscularly every 5 to 15 minutes or as intravenous fluids; (6) oral or laryngeal mask airway; (7) necessary, depending on the severity of the anaphylaxis, diphenhydramine or similar injectable antihistamine; (8) should be used to control symptoms and sustain or increase ranitidine or other injectable H2 antihistamine; (9) corticoster- blood pressure.12Y14 Efficacy comparisons of intramuscular * 2008 World Allergy Organization Copyright @ 2008 World Allergy Organization. Unauthorized reproduction of this article is prohibited.
WAO Journal & July 2008, Supplement 2 sponsive or severely hypotensive patients who have failed to TABLE 1. Management of Acute Anaphylaxis respond to intravenous volume replacement and several I. Immediate intervention epinephrine injections.13 One group of investigators suggest a. Assessment of airway, breathing, circulation, and adequacy of mentation b. Administer epinephrine intramuscularly every 5 to 15 minutes, in appropriate doses, as necessary, depending on the presenting signs andsymptoms of anaphylaxis, to control signs and symptoms and prevent TABLE 2. Clinical Scenarios for Epinephrine Use Outside of a progression to more severe symptoms, such as respiratory distress, hypotension, shock, and unconsciousness.
For Discussion Purposes II. Possibly appropriate subsequent measures depending on response Clinical Findings Use of Epinephrine? a. Place patient in recumbent position and elevate lower extremities Generalized urticaria develops in a Pro: inject immediately; past b. Establish and maintain airway 28-yr-old fire antYallergic anaphylaxis and current c. Administer oxygen individual stung by ant while findings away from medical playing in the yard. Currently d. Establish venous access receives ant immunotherapy based Con: do not inject immediately; e. Isotonic sodium chloride solution intravenously for fluid replacement on positive skin test response to wait for symptoms involving III. Specific measures to consider after epinephrine injections, fire ant whole body extract but another organ system where appropriate is not yet at maintenance dosage a. Consider epinephrine infusion (6 wk of therapy on conventional buildup schedule).
1 and H2 antihistamines c. Consider nebulized A A 45-yr-old yellow jacketYallergic Pro: inject immediately in view 2 agonist (eg, albuterol [salbutamol]) for bronchospasm resistant to epinephrine farmer has just been stung after of past severe anaphylaxis; low disturbing nest with tractor. History risk of serious side effects from d. Consider systemic corticosteroids of hypotension and rapid syncope in injected epinephrine; some risk e. Consider vasopressor (eg, dopamine) past stings. Currently receives of severe symptoms because he f. Consider glucagon for patient taking A-blocker venom immunotherapy but is not has not reached maintenance g. Consider atropine for symptomatic bradycardia yet at maintenance (last dose was Con: do not inject immediately; 1 mL [L]). No current symptoms.
h. Consider transportation to an emergency department or an intensive wait for symptoms A 17-yr-old individual develops Pro: inject immediately; rapid onset i. For cardiopulmonary arrest during anaphylaxis, high-dose epinephrine paroxysmal sneezing within of symptoms may be associated and prolonged resuscitation efforts are encouraged, if necessary 5 min of receiving allergen with severe anaphylaxis; (see reference for specific details) immunotherapy injection low risk of serious sideeffects from injected epinephrine; Adapted from Lieberman et al.13 antihistamines are second-lineagents in anaphylaxis injections to subcutaneous injections have not been done Con: do not inject immediately; during acute anaphylaxis. However, absorption is complete wait for other symptoms if and more rapid and plasma levels are higher in asymptomatic suspect sneezing could be dueto transient respiratory irritant adults and children who receive epinephrine intramuscularly exposure or seasonal allergy in the anterolateral thigh (vastus lateralis).60,61 In overweight exacerbation if it occurs during and obese individuals, the thickness of the subcutaneous fat pollen season of a pollen-allergic pad may preclude intramuscular access.62Y64 Table 2 provides some examples of clinical scenarios where the pros and cons A 7-yr-old child with mild Pro: inject immediately; history is of epinephrine use might be weighed.65,66 persistent asthma and clinical strongly suggestive of past history of peanut allergy anaphylaxis; safety of cookie Epinephrine autoinjectors, which are easy to use and (wheeze, hives that Bget is uncertain; signs and severity will inject through clothing, are currently available in 2 better after vomiting[) of anaphylaxis can vary from fixed doses: 0.15 mg and 0.3 mg. The potential exists for experiences sudden cough and episode to episode in the same overdosage in infants receiving the 0.15 mg, overdosage in wheeze while playing outside individual; delayed treatment or 15 min after eating a cookie in treating anaphylaxis with some small children receiving the 0.3 mg dose, and for school cafeteria; has no other salbutamol (albuterol) alone underdosage in many adolescents receiving the 0.15 mg symptoms; has albuterol could have adverse outcome; dose.17,40 The relative benefits and risks of dosage might vary metered-dose inhaler and low risk of serious side effects with each individual, but autoinjectors with 0.15 mg of epinephrine autoinjector available from injected epinephrine epinephrine are recommended for otherwise healthy children Con: do not inject immediately; who weigh 10 to 25 kg (22Y55 lb) and autoinjectors with for possible asthma (eg,exercise-induced or pollen 0.3 mg of epinephrine for children who weigh approxi- exposure), assess response mately 25 kg (55 lb) or more.17,40 Providing parents with to salbutamol first.
an epinephrine ampule, syringe, and needle is not an ap- Anaphylaxis occurs as part of a continuum, and delaying treatment until multiorgan propriate option unless autoinjectors are not available for dysfunction is present is risky. The recommendations in this table apply regardless of comorbid conditions because there is no absolute contraindication to epinephrineadministration during anaphylaxis. Physicians and other health care professionals should Intravenous Epinephrine instruct patients at risk for anaphylaxis outside of a medical facility to err on the side ofcaution and self-administer epinephrine if there is any doubt anaphylaxis is either present Epinephrine (1:10,000 or 1:100,000 dilutions) should be or imminent.
administered by infusion during cardiac arrest or to unre- Adapted from Sicherer and Simons.65 * 2008 World Allergy Organization Copyright @ 2008 World Allergy Organization. Unauthorized reproduction of this article is prohibited.
WAO Journal & July 2008, Supplement 2 Epinephrine: The Drug of Choice for Anaphylaxis that the early use of intravenous epinephrine is safe, effective, For example, a questionnaire based on the clinical scenario of and well tolerated when the rate is titrated to clinical response, a child with peanut-induced anaphylaxis was used in a random but this has not been evaluated systematically in a cohort study sample of 468 pediatricians in the United States.74 About half comparing this modality to epinephrine intramuscular (56%) agreed that the scenario represented anaphylaxis and that treatment with epinephrine was indicated. Most (81%)correctly chose to discharge the child home with self- Inhaled Epinephrine injectable epinephrine and either to refer to an allergist or to Some physicians recommend inhalation of epinephrine recommend further diagnostic testing (86%). Similar surveys as an alternative to injection during anaphylaxis, but perioral have been done in other countries (several studies are cited in paresthesias, bad taste, and gastrointestinal effects are dose- Pongracic and Kim75).
limiting, and it may not achieve prompt significant increases in Studies have also demonstrated that many health care plasma epinephrine concentrations.68,69 No direct comparisons professionals are uncertain about how to use an epinephrine have been made between the inhaled and the intramuscular autoinjector and thus cannot properly instruct their routes of epinephrine administration.
patients.76,77 Available resources may help physicians developtreatment plans and resolve any therapeutic quandaries.17,18,65 FOLLOW-UP AND OBSERVATION Examples of written action plans can be downloaded over the AFTER ANAPHYLAXIS Internet (see Additional Educational Resources).
Observation periods should be individualized and based on such factors as comorbid conditions and distance from the UNDERUTILIZATION OF EPINEPHRINE BY patient's home to the closest emergency facility, particularlybecause there are no reliable predictors of biphasic anaphy- PATIENTS, PARENTS, AND CAREGIVERS laxis.13 After resolution of the acute episode, patients should Fatalities during witnessed anaphylaxis, most of which be discharged with an epinephrine autoinjector and properly occur outside of a medical facility, usually result from delayed instructed on how to self-administer it in case of a subsequent administration of epinephrine. In a retrospective review of 6 episode. They should receive an individualized Anaphylaxis fatal and 7 nonfatal episodes of food-induced anaphylaxis in Emergency Action Plan.18 Patients should also have ready children and adolescents, all subjects who survived had access to emergency medical services to facilitate prompt received epinephrine before or within 5 minutes of developing transportation to the closest emergency department (ED) for severe respiratory symptoms. None of the subjects with fatal treatment after injecting the additional epinephrine.
attacks received epinephrine before the onset of severerespiratory symptoms.20 Analysis of data from a nationalcase registry of fatal food anaphylaxis in the United States USE OF EPINEPHRINE BY HEALTH indicates that very few individuals (7/63) had epinephrine CARE PROFESSIONALS autoinjectors available at the time of fatal reaction.23,25 Numerous guidelines on anaphylaxis have been pub- Similarly, Pumphrey21 determined that although epinephrine lished, but physicians and other health care professionals often was administered in 62% of the fatal anaphylactic reactions in do not follow them. For example, investigators determined by the United Kingdom that he reviewed, in only 14% was it questionnaire that only 4 (5%) of 78 senior house officers given before cardiac arrest. In a follow-up analysis of 48 beginning ED responsibilities in the United Kingdom would cases of fatal food anaphylaxis from 1999 to 2006, Pumphrey administer epinephrine appropriately and with the proper dose and Gowland24 reported that 19 (40%) had received and route of administration, as outlined in the UK Resuscita- epinephrine autoinjectors, but more than one half of the tion Council guidelines on anaphylaxis.70 Other reports have fatalities occurred in patients whose previous clinical reactions examined treatment patterns in the ED settings of civilian71 had been so mild that, in the opinion of the investigators, it was and military hospitals72 in the United States and observed unlikely that a physician would have prescribed a precau- that epinephrine injections were administered during acute tionary epinephrine syringe.
anaphylaxis to 16% and 50% of patients, respectively, as Multiple factors may contribute to the lack of available recommended by consensus anaphylaxis guidelines. Retro- epinephrine for administration during anaphylaxis that occurs spective analysis of a national reporting database on ED visits outside of a medical facility. An international survey in the United States from 1993 to 2004 revealed 12.4 million conducted under the auspices of the World Allergy Organiza- allergy-related visits to the ED, approximately 1% of all ED tion determined that epinephrine autoinjectors were available visits based on International Classification of Diseases, Ninth in about half of surveyed countries, and that the cost of an Revision, Clinical Modification coding. Anaphylaxis coding autoinjector in some countries was equivalent to the monthly was rare (0.01% of all ED visits), although epinephrine was salary of an average citizen.78 Of 39 countries, autoinjectors administered in 50% of those coded with anaphylaxis.
containing 0.15-mg and 0.3-mg doses were available in 17 Epinephrine administration documented in patients with (44%) and 22 (56%), respectively.
acute allergic conditions was infrequent (11%), and the trend Adherence to an action plan to keep epinephrine available of use declined over the period of interest from 19% to 7% at all times and to inject it during anaphylaxis is another concern.
Kemp and colleagues79 determined in a follow-up survey of Primary care physicians have demonstrated similar patients that 32 (47%) of 68 did not have the recommended knowledge gaps in their knowledge pertaining to anaphylaxis.
epinephrine autoinjector with them when they again * 2008 World Allergy Organization Copyright @ 2008 World Allergy Organization. Unauthorized reproduction of this article is prohibited.
WAO Journal & July 2008, Supplement 2 TABLE 3. Preventive Measures to Reduce the Risk Based on available evidence, the benefit of using appropriate doses of intramuscular epinephrine in anaphylaxis I. General measures far exceeds the risk (evidence category IV). Consensus Obtain thorough history to diagnose life-threatening food or drug allergy opinion and anecdotal evidence recommend epinephrine Identify cause of anaphylaxis and those individuals at risk for future attacks administration Bsooner rather than later,[ that is, when the Provide instruction on proper reading of food and medication labels, where initial signs and symptoms of anaphylaxis occur, regardless of their severity, because fatalities in anaphylaxis usually result Avoidance of exposure to antigens and cross-reactive substances from delayed or inadequate administration of epinephrine.
Optimal management of asthma and coronary artery disease Experts may differ on how they define the clinical threshold by Implement a waiting period of 20 to 30 min after injections of drugs or other which they define and treat anaphylaxis. However, they have no disagreement whatsoever that appropriate doses of In the physician's office, consider a waiting period of 2 h if a patient receives an oral medication he/she has never previously taken intramuscular epinephrine should be administered rapidly II. Specific measures for high-risk patients once that threshold is reached. There is no absolute contra- Individuals at high risk for anaphylaxis should carry self-injectable syringes indication to epinephrine administration in anaphylaxis, and of epinephrine at all times and receive instruction on proper use with all subsequent therapeutic interventions depend on the initial response to epinephrine. Development of toxicity or inade- MedicAlert (MedicAlert Foundation, Turlock, Calif) or similar warning quate response to epinephrine injections indicates that bracelets or chains additional therapeutic modalities are necessary. All individuals Substitute other agents for A-adrenergic blockers, angiotensin-converting at increased risk of anaphylaxis should have an anaphylaxis enzyme inhibitors, tricyclic antidepressants, and monoamine oxidaseinhibitors, whenever possible action plan and carry epinephrine autoinjectors for self- Agents suspected of causing anaphylaxis should be given orally if possible; administration. Such individuals (and their caregivers, as if the intravenous route is needed, a slow supervised rate of administration appropriate) should be assessed regularly for adherence with these recommendations and for the ability to demon- Where appropriate, use specific preventive strategies, including pharmaco- strate proper epinephrine administration technique with a logical prophylaxis, short-term challenge and desensitization, and placebo device.
Modified from Kemp.88 ADDITIONAL EDUCATIONAL RESOURCES experienced anaphylaxis from a previously identified culprit.
In contrast, 31 (91%) of 34 patients with idiopathic anaphylaxis(that is, no culprit could be identified) had epinephrine available at the time of a subsequent episode. Implementation of an World Allergy Organization (www.worldallergy.org) educational protocol with emphasis on carrying epinephrine increased the frequency of adherence from 53% to 92% over the American Academy of Allergy, Asthma, and Immunol- ensuing 10 years.80 Other studies have similarly reported that ogy (AAAAI) (www.aaaai.org) 50% to 75% of patients prescribed epinephrine carry it with American College of Allergy, Asthma, and Immunology them, of whom 30% to 40% can demonstrate proper adminis- tration technique.81Y84 Still others carry epinephrine but choose Joint Council of Allergy, Asthma, and Immunology not to use it during anaphylaxis32,85Y87 or prefer to seek emergency medical assistance.21 Food Allergy and Anaphylaxis Network (FAAN) (www.
Few studies thus far have examined management of anaphylaxis in school or day care settings. These are reviewed Allergy UK (www.allergyuk.org) in detail elsewhere.75 Protection of children at risk for Anaphylaxis Canada (www.anaphylaxis.org) anaphylaxis in school, day care, or other settings requires an The Web sites of other national and regional allergy/ interdisciplinary approach.9 Several resources are available immunology organizations also provide useful perspectives.
for help in the school or day care setting (see AdditionalEducational Resources).
Action Plans for Health Care Professionals PRECAUTIONS FOR THE PATIENT AT RISK Spanish language versions of the following AAAAI Optimizing prevention (Table 3) is crucial because anaphylaxis materials are now available: The AAAAI Anaphy- future anaphylaxis may be fatal despite appropriate manage- laxis Emergency Action Plan, Killer Allergy information page, ment. An allergist-immunologist can provide comprehensive AAAAI Anaphylaxis Tips to Remember brochure, and AAAAI professional advice on these matters and should be consulted Anaphylaxis Easy Reader page.
if he/she is not already involved in the anaphylaxis plan of FAAN (English language version: www.foodallergy.org/ care. All patients at risk for future anaphylaxis should carry at actionplan.pdf; Spanish language version: www.foodallergy.
least 1 epinephrine syringe and know how to administer it.
* 2008 World Allergy Organization Copyright @ 2008 World Allergy Organization. Unauthorized reproduction of this article is prohibited.
WAO Journal & July 2008, Supplement 2 Epinephrine: The Drug of Choice for Anaphylaxis School, Child Care, or Camp Settings 17. Sicherer SH, Simons FER. Section on Allergy and Immunology, American Academy of Pediatrics. Self-injectable epinephrine for first-aid New South Wales Department of Health, Anaphylaxis management of anaphylaxis. Pediatrics. 2007;119;638Y646. IV Guidelines for Schools (www.health.nsw.gov.au/pubs/a/pdf/ 18. Simons FER. Anaphylaxis, killer allergy: long-term management in the community. J Allergy Clin Immunol. 2006;117:367Y377. IV 19. Brown AFT. Anaphylaxis: quintessence, quarrels, and quandaries. Emerg Med J. 2001;18:328. IV 20. Sampson HA, Mendelson L, Rosen JP. Fatal and near-fatal anaphylactic Information for Patients and Their Families reactions to food in children and adolescents. N Engl J Med.
1992;327:380Y384. III Anaphylaxis Campaign (www.anaphylaxis.org.uk) 21. Pumphrey RSH. Lessons for the management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000;30:1144Y1150. III Global Allergy and Anaphylaxis Links (www.world 22. Yunginger JW, Sweeney KG, Sturner WQ, Giannandrea LA, et al. Fatal food-induced anaphylaxis. JAMA. 1988;260:1450Y1452. III 23. Bock SA, Mun˜oz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001;107:191 24. Pumphrey RSH, Gowland MH. Further fatal allergic reactions to food in 1. The American Academy of Pediatrics Committee on Drugs. Anaphylaxis.
the United Kingdom, 1999Y2006. J Allergy Clin Immunol.
Pediatrics. 1973;51:136Y140. IV 2007;119:1018Y1019. III 2. NIH Consensus Development Conference. Emergency treatment of insect 25. Bock SA, Mun˜oz-Furlong A, Sampson HA. Further fatalities caused by sting allergy. J Allergy Clin Immunol. 1979;63:77Y79. IV anaphylactic reactions to food, 2001Y2006. J Allergy Clin Immunol.
3. American Academy of Allergy and Immunology Board of Directors. The 2007;119:1016Y1018. III use of epinephrine in the treatment of anaphylaxis. Position statement.
26. Johansson SGO, Bieber T, Dahl R, et al. Revised nomenclature for allergy J Allergy Clin Immunol. 1994;94;666Y668. IV for global use: report of the Nomenclature Review Committee of the 4. American Academy of Allergy and Immunology Board of Directors.
World Allergy Organization, October 2003. J Allergy Clin Immunol.
Guidelines to minimize the risk from systemic reactions caused by 2004;113:832Y836. IV immunotherapy with allergenic extracts. Position statement. J Allergy Clin 27. Shekelle PG, Soolf SH, Eccles M, Grimshaw J. Clinical guidelines: Immunol. 1994;93:811Y812. IV developing guidelines. BMJ. 1999;318:593Y596. NR 5. Simons FER, Chad ZH, Dean JM, Watson WTA for the Canadian 28. Kemp SF, Lockey RF. Anaphylaxis: a review of causes and mechanisms.
Pediatric Society Allergy Section. Fatal anaphylactic reactions to food in J Allergy Clin Immunol. 2002;110:341Y48. IV children. Position statement. Can Med Assoc J. 1994;150:337Y339. IV 29. Gupta R, Sheikh A, Strachan DP, Anderson HR. Time trends in allergic 6. Joint Task Force on Practice Parameters. The diagnosis and management disorders in the UK. Thorax. 2007;62:91Y96. III of anaphylaxis. J Allergy Clin Immunol. 1998;101:S465YS528. IV 30. Lieberman P. Biphasic anaphylactic reactions. Ann Allergy Asthma 7. Bousquet J, Lockey RF, Malling H-J, eds. World Health Organization Immunol. 2005;95:217Y226. IV Position Paper. Allergen immunotherapy: therapeutic vaccines for allergic 31. Oren E, Banderji A, Clark S, Camargo CA Jr. Food-induced anaphylaxis diseases. Allergy. 1998;53:S1YS42. IV and repeated epinephrine treatments. Ann Allergy Asthma Immunol.
8. Gavalas M, Sedana A, Metcalf S. Guidelines for the management of anaphylaxis in the emergency department. J Accid Emerg Med.
32. Uguz A, Lack G, Pumphrey R, Ewan P, et al. Allergic reactions in the 1998;15:96Y98. IV community: a questionnaire survey of members of the anaphylaxis 9. American Academy of Allergy, Asthma, and Immunology Board of campaign. Clin Exp Allergy. 2005;35:746Y750. IV Directors. Anaphylaxis in schools and other child care settings. Position 33. Kelso JM. A second dose of epinephrine for anaphylaxis: how statement. J Allergy Clin Immunol. 1998;102:173Y176. IV often needed and how to carry. J Allergy Clin Immunol. 2006;117: 10. Project Team of the Resuscitation Council (UK). Emergency medical treatment of anaphylactic reactions. J Accid Emerg Med. 1999;16: 34. Pumphrey R. Anaphylaxis: can we tell who is at risk of a fatal reaction? Curr Opin Allergy Clin Immunol. 2004;4:285Y290. III 11. Cummins RO, Hazinski MR, Baskett PJF, et al, eds. Guidelines 2000 for 35. Fisher MM. Clinical observations on the pathophysiology and treatment cardiopulmonary resuscitation and emergency cardiovascular care: an of anaphylactic cardiovascular collapse. Anaesth Intensive Care.
international consensus on science. American Heart Association in 1986;14:17Y21. III collaboration with the International Liaison Committee on Resuscitation 36. Kovanen PT, Kaartinen M, Paavonen T. Infiltrates of activated mast cells (ILCOR). Part 8: Advanced Challenges in Resuscitation. Section 3: at the site of coronary atheromatous erosion or rupture in myocardial Special Challenges in ECC. Anaphylaxis. Circulation. 2000; infarction. Circulation. 1995;92:1084Y1088. III 102(suppl I):I241YI243. IIb 37. Kounis NG. Kounis syndrome (allergic angina and allergic myocardial 12. American Heart Association in collaboration with International Liaison infarction): a natural paradigm? Int J Cardiol. 2006;110:7Y14. IV Committee on Resuscitation. 2005 American Heart Association guidelines 38. Steffel J, Akhmedov A, Greutert H, et al. Histamine induces tissue factor for cardiopulmonary resuscitation and emergency cardiovascular care.
expression: implications for acute coronary syndromes. Circulation.
Anaphylaxis. Circulation. 2005;112(suppl IV):IV143YIV145. IIb 2005;112:341Y349. III 13. Lieberman P, Kemp SF, Oppenheimer J, Lang DM, Bernstein IL, Nicklas 39. Westfall TC, Westfall DP. Adrenergic agonists and antagonists.
RA, eds. Joint Task Force on Practice Parameters. The diagnosis and In: Brunton LL, ed. Goodman and Gilman's The Pharmacological management of anaphylaxis: an updated practice parameter. J Allergy Clin Basis of Therapeutics. 9th ed. New York, NY: McGraw-Hill; 2006: Immunol. 2005;115:S483YS523. IV 14. Soar J, Deakin CD, Nolan JP, et al. European Resuscitation Council 40. Simons FER. First-aid treatment of anaphylaxis to food: focus on guidelines for resuscitation 2005. Section 7. Cardiac arrest in special epinephrine. J Allergy Clin Immunol. 2004;113:837Y844. IV circumstances. Resuscitation. 2005;67(suppl 1):S135YS170. IIb 41. Barach EM, Nowak RM, Lee TG, Tomanovich MC. Epinephrine for 15. Sampson HA, Mun˜oz-Furlong A, Bock SA, et al. Symposium on the treatment of anaphylactic shock. JAMA. 1984;251:2118Y2122. IV definition and management of anaphylaxis: summary report. J Allergy 42. Lieberman P. Use of epinephrine in the treatment of anaphylaxis. Curr Clin Immunol. 2005;115:584Y591. IV Opin Allergy Clin Immunol. 2003;3:313Y318. IV 16. Sampson HA, Mun˜oz-Furlong A, Campbell RL, et al. Second symposium 43. Austen KF. Systemic anaphylaxis in the human being. N Engl J Med.
on the definition and management of anaphylaxis: summary 1974;291:661Y664. IV reportVSecond National Institute of Allergy and Infectious 44. Lin RY, Curry A, Pitsios VI, Morgan JP, et al. Cardiovascular responses in Diseases/Food Allergy and Anaphylaxis Network Symposium. J Allergy patients with acute allergic reactions treated with parenteral epinephrine.
Clin Immunol. 2006;117:391Y397. IV Am J Emerg Med. 2005;23:266Y272. III * 2008 World Allergy Organization Copyright @ 2008 World Allergy Organization. Unauthorized reproduction of this article is prohibited.
WAO Journal & July 2008, Supplement 2 45. Simons FER, Gu X, Simons KJ. Outdated EpiPen and Epi Pen Jr auto- 67. Brown SGA, Blackman KE, Stenlake V, Heddle RJ. Insect sting injectors: past their prime? J Allergy Clin Immunol. 2000;105:1025Y1030. III anaphylaxis: prospective evaluation of treatment with intravenous 46. Bautista E, Simons FE, Simons KJ, et al. Epinephrine fails to hasten the adrenaline and volume resuscitation. Emerg Med J. 2004;21:149Y154. IIa hemodynamic recovery in fully developed canine anaphylactic shock. Int 68. Heilborn H, Heemdahl P, Daleskog M, Adamsson U. Comparison of Arch Allergy Immunol. 2002;128:151Y164. III subcutaneous injection and high-dose inhalation of 47. Horak A, Raine R, Opie LH, Lloyd EA. Severe myocardial ischaemia epinephrineVimplications for self-treatment to prevent anaphylaxis.
induced by intravenous adrenaline. BMJ. 1983;286:519. IV J Allergy Clin Immunol. 1986;78:1174Y1179. III 48. Sullivan TJ. Cardiac disorders in penicillin-induced anaphylaxis.
69. Simons FER, Gu X, Johnston L, Simons KJ. Can epinephrine inhalations Association with intravenous epinephrine therapy. JAMA.
be substituted for epinephrine injection in children at risk for systemic 1982;248:2161Y2162. IV anaphylaxis? Pediatrics. 2000;106:1040Y1044. III 49. Butte MJ, Nguyen BX, Hutchison TJ, Wiggins JW, Ziegler JW. Pediatric 70. Gompels LL, Bethune C, Johnston SL, Gompels MM. Proposed use of myocardial infarction after racemic epinephrine administration.
adrenaline (epinephrine) in anaphylaxis and related conditions: a study of Pediatrics. 1999;104:9Y11. IV senior house officers starting accident and emergency posts. Postgrad 50. Saff R, Nahhas A, Fink JN. Myocardial infarction induced by coronary Med J. 2002;78:416Y418. III vasospasm after self-administration of epinephrine. Ann Allergy.
71. Clark S, Bock SA, Gaeta TH, et al. Multicenter study of emergency 1993;70:396Y398. IV department visits for food allergies. J Allergy Clin Immunol.
51. Davis CO, Wax PM. Prehospital epinephrine overdose in a child resulting 2004;113:347Y352. III in ventricular dysrhythmias and myocardial ischemia. Pediatr Emerg 72. Haymore BR, Carr WW, Frank WT. Anaphylaxis and epinephrine Care. 1999;15:116Y118. IV prescribing patterns in a military hospital: underutilization of the 52. Goldhaver-Fiebert S, Grecu L. Postoperative ST-segment elevation: was intramuscular route. Allergy Asthma Proc. 2005;26:361Y365. III vasospasm caused by anaphylaxis or by its treatment with epinephrine? 73. Gaeta JT, Clark S, Pelletier AJ, Camargo CA. National study of US Ann Allergy Asthma Immunol. 2006;97:449Y453. IV emergency department visits for acute allergic reactions, 1993 to 2004.
53. Ersoz N, Firestone SC. Adrenaline-induced pulmonary edema and its Ann Allergy Asthma Immunol. 2007;98:360Y365. III treatment: a report of two cases. Br J Anaesth. 1971;43:709Y712. IV 74. Krugman SD, Chiaramonte DR, Matsui EC. Diagnosis and management 54. Freedman BJ. Accidental adrenaline overdosage and its treatment with of food-induced anaphylaxis: a national survey of pediatricians.
piperoxan. Lancet. 1955;2:575Y578. IV Pediatrics. 2006;118:e554Ye560. III 55. Ackerman MJ, Khositseth A, Tester DJ, Hejlik JB, Shen WK, Porter CB.
75. Pongracic JA, Kim JS. Update on epinephrine for the treatment of Epinephrine induced QT interval prolongation: a gene specific anaphylaxis. Curr Opin Pediatr. 2007;19:94Y98. IV paradoxical response in congenital long QT syndrome. Mayo Clin Proc.
76. Grouhi M, Alshehri M, Hummel D, Roifman CM. Anaphylaxis and 2002;77:413Y421. IV epinephrine auto-injector training: who will teach the teachers? J Allergy 56. Horowitz BZ, Jadallah S, Derlet RW. Fatal intracranial bleeding Clin Immunol. 1999;104:190Y193. III associated with prehospital use of epinephrine. Ann Emerg Med.
77. Sicherer SH, Forman JA, Noone SA. Use assessment of self-administered 1996;28:725Y727. IV epinephrine among food-allergic children and pediatricians. Pediatrics.
57. Lewis MA. Treatment and survival after massive overdose of adrenaline.
2000;105:359Y362. III BMJ. 1967;4:38. IV 78. Simons FER. Lack of worldwide availability of epinephrine autoinjectors 58. Novey HS, Meleyco LN. Alarming reaction after intravenous for outpatients at risk of anaphylaxis. Ann Allergy Asthma Immunol.
administration of 30 ml of epinephrine. JAMA. 1969;207:2435Y2436. IV 2005;94:534Y538. IV 59. McLean-Tooke APC, Bethune CA, Fay AC, Spickett GP. Adrenaline in 79. Kemp SF, Lockey RF, Wolf BL, Lieberman P. Anaphylaxis: a review of the treatment of anaphylaxis: what is the evidence? BMJ. 2003;327: 266 cases. Arch Intern Med. 1995;155:1749Y1754. III 80. Webb LM, Lieberman P. Anaphylaxis: a review of 601 cases. Ann Allergy 60. Simons FER, Roberts JR, Gu X, Simons KJ. Epinephrine absorption in Asthma Immunol. 2006;97:39Y43. III children with a history of anaphylaxis. J Allergy Clin Immunol.
81. Huang SW. A survey of Epi-PEN use in patients with a history of 1998;101:33Y37. IIa anaphylaxis. J Allergy Clin Immunol. 1998;102:525Y526. III 61. Simons FER, Gu X, Simons KJ. Epinephrine absorption in adults: 82. Gold MS, Sainsbury R. First aid anaphylaxis management in children who Intramuscular versus subcutaneous injection. J Allergy Clin Immunol.
were prescribed an epinephrine autoinjector device (EpiPen). J Allergy 2001;108:871Y873. IIa Clin Immunol. 2000;106:171Y176. III 62. Song TT, Nelson MR, Chang JH, et al. Adequacy of the epinephrine 83. Goldberg A, Confino-Cohen R. Insect sting-inflicted systemic reactions: autoinjector needle length in delivering epinephrine to the intramuscular attitudes of patients with insect venom allergy regarding after-sting tissues. Ann Allergy Asthma Immunol. 2005;94:539Y542. III behavior and proper administration of epinephrine. J Allergy Clin 63. Chowdhury BA, Meyer RJ. Intramuscular versus subcutaneous injection Immunol. 2000;106:1184Y1189. III of epinephrine in the treatment of anaphylaxis. J Allergy Clin Immunol.
84. Arkwright PD, Farragher AJ. Factors determining the ability of parents to 2002;109:720Y721. IV effectively administer intramuscular adrenaline to food allergic children.
64. Zuckerman JN. The importance of injecting vaccines into muscle: Pediatr Allergy Immunol. 2006;17:227Y229. III different patients need different needle sizes. BMJ. 2000;321: 85. Pouessel G, Deschildre A, Castelain C, et al. Parental knowledge and use of epinephrine auto-injector for children with food allergy. Pediatr Allergy 65. Sicherer SH, Simons FER. Quandaries in prescribing an emergency action Immunol. 2006;17:221Y226. III plan and self-injectable epinephrine for first-aid management of 86. Kim JS, Sinacore JM, Pongracic JA. Parental use of EpiPen for children anaphylaxis in the community. J Allergy Clin Immunol.
with food allergies. J Allergy Clin Immunol. 2005;116:164Y168. III 2005;115:575Y583. IV 87. Rosen JP. Empowering patients with a history of anaphylaxis to use an 66. Simons FER, Chan ES, Gu X, Simons KJ. Epinephrine for the epinephrine autoinjector without fear. Ann Allergy Asthma Immunol.
out-of-hospital (first aid) treatment of anaphylaxis in infants: is the ampule/syringe/needle method practical? J Allergy Clin Immunol.
88. Kemp SF. Anaphylaxis: current concepts in pathophysiology, diagnosis, 2001;108:1040Y1044. III and management. Immunol Allergy Clin North Am. 2001;21:611Y634. IV * 2008 World Allergy Organization Copyright @ 2008 World Allergy Organization. Unauthorized reproduction of this article is prohibited.

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