What are the guideline sources, guidelines and references for Anaphylaxis ?
Guideline sources The following summarized guidelines for the evaluation and management of anaphylaxis are prepared by our editorial team based on guidelines from the Wilderness Medical Society (WMS 2022), the European Academy of Allergy and Clinical Immunology (EAACI 2022; 2014), the American Academy of Allergy, Asthma & Immunology (AAAAI/ACAAI 2020; 2014), and the American Heart Association (AHA 2020). 1 2 3 4 5 6 Guidelines 1. Screening and diagnosis Diagnostic criteria: consider using clinical criteria, including rapid onset of multiple symptoms and signs, for identifying anaphylaxis in an acute context. C https://web.pathway.md/diseases/recZK0DO9cy9R1bWR 1/7 6/23/23, 2:35 AM Anaphylaxis Pathway 2. Diagnostic investigations Serum tryptase: consider measuring serum tryptase half to two hours after the start of the reaction and baseline tryptase at least 24 hours after complete resolution of symptoms to support the diagnosis of anaphylaxis. C 3. Respiratory support Supplemental oxygen: administer high-flow oxygen by face mask in all patients with anaphylaxis. B 4. Medical management General principles: As per AAAAI 2020 guidelines, consider incorporating severity of anaphylaxis presentation and/or the administration of > 1 dose of epinephrine for the treatment of initial anaphylaxis as a guide to determining patient's risk for developing biphasic anaphylaxis. C As per EAACI 2014 guidelines: Call for help promptly and assess the patient simultaneously. B Use an anaphylaxis management plan from the time of diagnosis to prevent future reactions, and aid recognition and treatment of any further reactions. B Epinephrine, clinician-delivered: As per EAACI 2022 guidelines, administer intramuscularly epinephrine in the mid-thigh area promptly as first-line management of anaphylaxis. B As per WMS 2022 guidelines, administer epinephrine as the essential and primary treatment once anaphylaxis has been diagnosed. A Show 5 more As per ACAAI/AAAAI 2020 guidelines, administer epinephrine as first-line therapy in patients with uniphasic and/or biphasic anaphylaxis. B Show 2 more As per EAACI 2014 guidelines, administer epinephrine promptly as first-line therapy for the emergency management of patients with anaphylaxis. B Show 5 more Epinephrine, patient-delivered: As per EAACI 2022 guidelines, advise self-administering of epinephrine autoinjectors for first- line management of anaphylaxis in the community. B Show 2 more As per WMS 2022 guidelines, take into consideration cost, operator training, and safety for both patient and first responder when choosing an epinephrine delivery device. B Show 4 more https://web.pathway.md/diseases/recZK0DO9cy9R1bWR 2/7 6/23/23, 2:35 AM Anaphylaxis Pathway As per EAACI 2014 guidelines, prescribe at least one epinephrine auto-injector in patients with any of the following: previous anaphylaxis triggered by food, latex, or aeroallergens previous exercise-induced anaphylaxis previous idiopathic anaphylaxis coexisting unstable or moderate-to-severe, persistent asthma and a food allergy (excluding pollen food syndrome) venom allergy in adult patients with previous systemic reactions (not receiving maintenance hymenoptera venom immunotherapy) and pediatric patients with more than cutaneous/mucosal systemic reactions underlying mast cell disorders or elevated baseline serum tryptase concentrations together with any previous systemic allergic reactions to insect stings, even in hymenoptera venom immunotherapy-treated patients. B Show 2 more Corticosteroids and antihistamines: As per WMS 2022 guidelines: Consider administering empiric corticosteroids given the potential for benefit paired with a low side-effect profile. Administer corticosteroids for anaphylaxis with a respiratory component in asthmatic patients. B Consider administering antihistamines early with epinephrine to help blunt the overall severity of anaphylaxis. B Consider preferring nonsedating antihistamines in the field care to help keep the patient alert and potentially able to walk. C Consider adding an H2RA to an H2RA. C As per AAAAI 2020 guidelines, avoid administering corticosteroids or antihistamines for the prevention of biphasic anaphylaxis. D Show 3 more As per EAACI 2014 guidelines: Consider administering oral H1RAs and H2RAs to relieve cutaneous symptoms of anaphylaxis. B Consider administering systemic corticosteroids to reduce the risk of late-phase respiratory symptoms. Consider administering high-dose nebulized corticosteroids for upper airway obstruction. C Intravenous fluids: As per WMS 2022 guidelines, consider administering IV crystalloids with additional doses of intramuscularly epinephrine for hypotension after epinephrine administration. B As per EAACI 2014 guidelines, administer IV fluids (crystalloids, boluses of 20 ml/kg) in patients experiencing cardiovascular instability. B Inhaled beta-2 agonists: As per WMS 2022 guidelines, consider administering inhaled -agonists as adjunctive treatment for wheezing, especially in patients with a history of asthma. B https://web.pathway.md/diseases/recZK0DO9cy9R1bWR 3/7 6/23/23, 2:35 AM Anaphylaxis Pathway As per EAACI 2014 guidelines, administer inhaled short-acting -2 agonists additionally to relieve symptoms of bronchoconstriction. B Glucagon: As per WMS 2022 guidelines, consider administering glucagon in patients on long-term - blockers with refractory hypotension. C As per EAACI 2014 guidelines, consider administering parenteral glucagon in patients with anaphylaxis unresponsive to epinephrine, particularly in patients taking -blockers. C 5. Nonpharmacologic interventions Removal of allergen: As per WMS 2022 guidelines, separate the patient from the inciting allergen, if possible, but do not induce vomiting to eliminate a food-based allergen. B As per EAACI 2014 guidelines, remove the trigger of the anaphylaxis episode. B Patient positioning: Keep patients with anaphylaxis still and position them according to their clinical condition: Situation Guidance Supine position with elevated lower extremities Circulatory instability Sitting up Respiratory distress Recovery position Unconscious Semirecumbent on the left side with elevated lower extremities. B Pregnancy Avoid sudden abrupt change to a more upright posture. D Evacuation: proceed to medical evacuation In the field after treatment of anaphylaxis. Consider deciding on the evacuation (also on the timing and method of evacuation) based on case-specific factors, such as geography, weather, field capabilities, and patient characteristics and response to treatment. B 6. Specific circumstances Patients with food-dependent exercise-induced anaphylaxis: Suspect food-dependent exercise-induced anaphylaxis when ingestion of causal food and tempPO related exercise result in symptoms of anaphylaxis. Recognize that symptoms only occur with ingestion of the causal food proximate to exercise and that ingestion of the food in the absence of exercise will not result in anaphylaxis. B https://web.pathway.md/diseases/recZK0DO9cy9R1bWR 4/7 6/23/23, 2:35 AM Anaphylaxis Pathway Advise avoiding food ingestion within 2-4 hours of exercise for the prevention of symptoms in patients with food-dependent exercise-induced anaphylaxis, and initiate prompt treatment with the onset of symptoms. B Patients in cardiac arrest: undertake standard resuscitative measures and administer immediate epinephrine in patients in cardiac arrest secondary to anaphylaxis. B Show 7 more 7. Patient education Patient education: As per EAACI 2022 guidelines, provide structured, comprehensive training to improve knowledge and use of epinephrine autoinjectors in people at risk of anaphylaxis, in addition to basic instructions about autoinjector use. B As per AAAAI 2020 guidelines, educate all patients with anaphylaxis regarding anaphylaxis, including avoidance of identified triggers, presenting signs and symptoms, biphasic anaphylaxis, treatment with epinephrine, and the use of epinephrine autoinjectors. B As per EAACI 2014 guidelines, offer training for the recognition and management of anaphylaxis in all patients and caregivers of pediatric patients at risk of anaphylaxis, ideally from the time of diagnosis. B Show 6 more 8. Preventative measures Premedication: Insufficient evidence to recommend for or against the use of premedication with antihistamines to prevent anaphylaxis. I Consider administering premedication with SC epinephrine to prevent anaphylaxis when snake bite anti-venom is given to a patient. C Allergen immunotherapy: offer SC venom immunotherapy in patients with venom-allergy with a previous episode of anaphylaxis and in adult patients with systemic cutaneous reactions. A Desensitization: consider offering desensitization to Hymenoptera venom and peanuts in patients with a history of anaphylactic reactions to these antigens. B 9. Follow-up and surveillance Clinical observation: As per WMS 2022 guidelines, obtain clinical observation after treatment of anaphylaxis with a length of observation depending on the severity of the initial reaction and risk factors for a biphasic reaction. B Show 2 more https://web.pathway.md/diseases/recZK0DO9cy9R1bWR 5/7 6/23/23, 2:35 AM Anaphylaxis Pathway As per AAAAI 2020 guidelines: Keep all patients under observation after diagnosis and treatment of anaphylaxis in a setting capable of managing anaphylaxis until symptoms have fully resolved. B Consider obtaining extended clinical observation in a setting capable managing anaphylaxis (to detect a biphasic reaction) in patients with resolved severe anaphylaxis and/or requiring > 1 dose of epinephrine. C As per EAACI 2014 guidelines, monitor patients closely for a duration according to their presentation: respiratory compromise: at least 6-8 hours circulatory instability: 12-24 hours. B Discharge from hospital: As per WMS 2022 guidelines, provide patients before discharge from a medical center with an epinephrine prescription and advise to follow-up for allergy testing and consideration of immunotherapy. B As per EAACI 2014 guidelines: Assess the risk of future reactions and prescribe an epinephrine auto-injector before discharging patients at risk of recurrence. B Provide a discharge advice sheet, including allergen avoidance measures (if possible) and instructions for the use of the epinephrine auto-injector. Offer specialist and food allergy specialist dietitian (in food anaphylaxis) follow-up, and contact information for patient support groups. B Indications for allergist referral: refer all patients with anaphylaxis to an allergist. B 10. Quality improvement Health professional training: consider using simulation training and visual prompts to improve healthcare professionals' recognition and management of anaphylaxis in emergency situations. C School policies: consider implementing school policies reflecting anaphylaxis guidelines. C Austere or disaster conditions: consider disassembling an epinephrine auto-injector after intramuscularly administration to obtain another epinephrine dose when no other source is available in austere or disaster conditions. C Show 2 more References 1. A Muraro, G Roberts, M Worm et al. Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology. Allergy. 2014 Aug;69 8 1026 45. Open https://web.pathway.md/diseases/recZK0DO9cy9R1bWR 6/7 6/23/23, 2:35 AM Anaphylaxis Pathway 2. Flavio G Gaudio, David E Johnson, Kelly DiLorenzo et al. Wilderness Medical Society Clinical Practice Guidelines on Anaphylaxis. Wilderness Environ Med. 2022 Mar;33 1 75 91. Open 3. Antonella Muraro, Margitta Worm, Cherry Alviani et al. EAACI guidelines: Anaphylaxis 2021 update). Allergy. 2022 Feb;77 2 357 377. Open 4. Marcus S Shaker, Dana V Wallace, David B K Golden et al. Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation GRADE analysis. J Allergy Clin Immunol. 2020 Apr;145 4 1082 1123. Open 5. Hugh A Sampson, Seema Aceves, S Allan Bock et al. Food allergy: a practice parameter update-2014. J Allergy Clin Immunol. 2014 Nov;134 5 1016 25.e43. Open 6. Ashish R Panchal, Jason A Bartos, Jos G Caba as et al. Part 3 Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S366 S468. Open 7. Johannes Ring, Kirsten Beyer, Tilo Biedermann et al. Guideline (S2k) on acute therapy and management of anaphylaxis: 2021 update: S2k-Guideline of the German Society for Allergology and Clinical Immunology DGAKI , the Medical Association of German Allergologists AeDA , the Society of Pediatric Allergology and Environmental Medicine GPA , the German Academy of Allergology and Environmental Medicine DAAU , the German Professional Association of Pediatricians BVKJ , the Society for Neonatology and Pediatric Intensive Care GNPI , the German Society of Dermatology DDG , the Austrian Society for Allergology and Immunology GAI , the Swiss Society for Allergy and Immunology SGAI , the German Society of Anaesthesiology and Intensive Care Medicine DGAI , the German Society of Pharmacology DGP , the German Respiratory Society DGP , the patient organization German Allergy and Asthma Association DAAB , the German Working Group of Anaphylaxis Training and Education AGATE . Allergo J Int. 2021;30 1 1 25. 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