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An acute allergic reaction is a rapid-onset, IgE-mediated hypersensitivity reaction. Although it is most commonly caused by food, insect stings, and medications, there are many additional causes. Symptoms can range from mild urticaria and swelling, to abdominal cramping, to respiratory collapse. Anaphylaxis and anaphylactic shock are the most severe, life-threatening forms of allergic reaction, with fast onset and decompensation, requiring urgent airway monitoring and support. This issue reviews the current evidence on managing allergy and anaphylaxis with epinephrine, and reviews the evidence on corticosteroids, antihistamines, and other adjunctive therapies. Guidelines are reviewed to offer assistance with grading of symptoms, which can help determine treatment and disposition. Biphasic reactions and allergic reactions caused by alpha-gal, scombroid poisoning, and Kounis syndrome are also reviewed.
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Following are the most informative references cited in this paper, as determined by the authors.
1. * Rowe B, Gaeta T. Anaphylaxis, allergies, and angioedema. In: Tintinalli J, Stapczynski J, Ma O, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed: McGraw-Hill; 2016:74-79. (Textbook chapter)
3. * Long B, Gottlieb M. Emergency medicine updates: anaphylaxis. Am J Emerg Med. 2021;49:35-39. (Review) DOI: 10.1016/j.ajem.2021.05.006
6. * Campbell RL, Li JTC, Nicklas RA, et al. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014;113(6):599-608. (Literature search, practice parameter) DOI: 10.1016/j.anai.2014.10.007
8. * Sampson HA, Muñoz-Furlong A, Campbell RL, et al. 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(4):373-380. (Symposium guidelines) DOI: 10.1016/j.jaci.2005.12.1303
10. * Cardona V, Ansotegui IJ, Ebisawa M, et al. World Allergy Organization anaphylaxis guidance 2020. World Allergy Organ J 2020;13(10):100472-100472. (Systematic review, guidelines) DOI: 10.1016/j.waojou.2020.100472
16. * Shaker MS, Wallace DV, Golden DBK, 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;145(4):1082-1123. (Systematic review) DOI: 10.1016/j.jaci.2020.01.017
53. U.S. Food and Drug Administration. Vistaril® (hydroxyzine pamoate) capsules and oral suspension. 2014. Accessed June 10, 2022. (FDA drug package insert)
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Keywords: allergy, anaphylaxis, urticaria, alpha-gal, biphasic, epinephrine, corticosteroids, antihistamines, glucagon, scombroid, Kounis
Price: $59
+4 Credits!
Andrea Zeke, MD; Amita Sudhir, MD
Ronna L. Campbell, MD, PhD; Jennifer Maccagnano, DO, FACEP, FACOEP
July 1, 2022
August 1, 2025
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credits.
CME Objectives
CME Information
Date of Original Release: July 1, 2022. Date of most recent review: June 10, 2022. Termination date: July 1, 2025.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credits, subject to your state and institutional requirements.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: The AAFP has reviewed Emergency Medicine Practice, and deemed it acceptable for AAFP credit. Term of approval is from 07/01/2022 to 06/30/2023. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This session, Management of Allergic Reactions and Anaphylaxis in the Emergency Department, is approved for 4.0 enduring material AAFP Prescribed credits.
AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit hours per issue by the American Osteopathic Association.
Needs Assessment: The need for this educational activity was determined by a practice gap analysis; a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation responses from prior educational activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) identify areas in practice that require modification to be consistent with current evidence in order to improve competence and performance; (2) develop strategies to accurately diagnose and treat both common and critical ED presentations; and (3) demonstrate informed medical decision-making based on the strongest clinical evidence.
Discussion of Investigational Information: As part of the activity, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME activities. All faculty participating in the planning or implementation of a CME activity are expected to disclose to the participants any relevant financial relationships and to assist in mitigating the relationships. In compliance with all ACCME accreditation requirements and policies, all faculty for this CME activity were asked to complete a full financial disclosure statement. The information received is as follows: The authors, Dr. Andrea Zeke and Dr. Amita Sudhir; the peer reviewer, Dr. Jennifer Maccagnano; the Editor-in-Chief, Dr. Andy Jagoda; the Associate Editor-in-Chief, Dr. Kaushal Shah; the Course Director and Planning Decisions Peer Reviewer, Dr. Daniel Egan; and the Research Editors, Dr. Aimee Mishler and Dr. Joseph Toscano, report no relevant financial relationships with ineligible companies. Dr. Ronna L. Campbell, peer reviewer for this educational activity, reported receiving consulting/advising honoraria from Brynn Pharma. This financial relationship has been mitigated through faculty attestation and peer review of planning decisions (Dr. Campbell’s peer review was reviewed).
Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
Earning Credit: (1) Go online to www.ebmedicine.net/CME and click on the title of the test you wish to take. When completed, a CME certificate will be emailed to you.
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Anaphylaxis in Pediatric Patients: Early Recognition and Treatment Are Critical for Best Outcomes