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Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. Canadian epidemiological data indicate that the rate of children who visited emergency departments between 2006-2014 for anaphylaxis more than doubled. Although fatalities are rare, anaphylaxis must always be considered a medical emergency requiring immediate treatment.

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Clinical guidelines

Clinical Practice Guideline: Anaphylaxis in Schools & Other Settings, 3rd Edition Revised

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Canadian Society of Allergy and Clinical Immunology

This manual has been developed for primarily non-medical people. It consists of an updated Consensus Statement and an Appendices section from the Canadian Society of Allergy and Clinical Immunology. The Consensus Statement provides recommendations for the management of anaphylaxis in the community, which are based on the most current research. The Appendices section provides resources that will help individuals at risk of anaphylaxis, educators, caregivers, and parents understand the basics of anaphylaxis.

Position Statement: CSACI position statement - epinephrine auto-injectors and children < 15 kg

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Halbrich M, Mack DP, Carr S, Watson W, Kim H

This position statement addresses a number of questions regarding epinephrine administration/prescribing suggestions for the infant under 15kg who is at risk for anaphylaxis, including: What are possible consequences of administering a larger than recommended dose of epinephrine? Are there other ways to prescribe the recommended dose of epinephrine? What are the consequences of not administering epinephrine? What does the Canadian Society for Allergy and Clinical Immunology suggest for the infant less than 15kg?

Clinical Practice Guideline: Anaphylaxis--a practice parameter update 2015

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Lieberman P, Nicklas RA, Randolph C, Oppenheimer J, Bernstein D, Bernstein J,...

The objective of this parameter is to update these previous versions and ultimately to improve the care of patients by providing the practicing physician with an evidence-based approach to the diagnosis and management of anaphylactic events.

Clinical Practice Guideline: 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines

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Simons FE, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK, Lockey RF...

The World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis provide a unique global perspective on this increasingly common, potentially life-threatening disease. Recommendations made in the original WAO Anaphylaxis Guidelines remain clinically valid and relevant, and are a widely accessed and frequently cited resource. In this 2015 update of the evidence supporting recommendations in the Guidelines, new information based on anaphylaxis publications from January 2014 through mid- 2015 is summarized.

Clinical Practice Guideline: Emergency department diagnosis and treatment of anaphylaxis: a practice parameter

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Campbell RL, Li JT, Nicklas RA, Sadosty AT, Members of the Joint Task Force P...

The recommendations made in this document about the management of anaphylaxis apply to anaphylaxis that occurs in an ED setting. Some of these recommendations might be different if anaphylaxis occurs in an office setting.

Clinical Practice Guideline: Anaphylaxis: Guidelines from the European Academy of Allergy and Clinical Immunology

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Muraro A, Roberts G, Worm M, Bil MB, Brockow K, Fernndez Rivas M, Santos AF, ...

Anaphylaxis is a clinical emergency, and all healthcare professionals should be familiar with its recognition and acute and ongoing management. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Taskforce on Anaphylaxis. They aim to provide evidence-based recommendations for the recognition, risk factor assessment, and the management of patients who are at risk of, are experiencing, or have experienced anaphylaxis.

Clinical Practice Guideline: World Allergy Organization guidelines for the assessment and management of anaphylaxis

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Simons FE, Ardusso LR, Bil MB, El-Gamal YM, Ledford DK, Ring J, Sanchez-Borge...

The illustrated World Allergy Organization (WAO) Anaphylaxis Guidelines were created in response to absence of global guidelines for anaphylaxis. They incorporate contributions from more than 100 allergy/immunology specialists on 6 continents. Recommendations are based on the best evidence available, supported by references published to the end of December 2010. The Guidelines review patient risk factors for severe or fatal anaphylaxis, co-factors that amplify anaphylaxis, and anaphylaxis in vulnerable patients, including pregnant women, infants, the elderly, and those with cardiovascular disease. They focus on the supreme importance of making a prompt clinical diagnosis and on the basic initial treatment that is urgently needed and should be possible even in a low resource environment.

Systematic reviews

Review: Do Corticosteroids Prevent Biphasic Anaphylaxis?

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Alqurashi W, Ellis AK

This review analyzes the use of corticosteroids for reducing anaphylaxis severity and preventing biphasic anaphylaxis.

Comprehensive Review: Pitfalls in the use of epinephrine for anaphylaxis: patient and provider opportunities for improvement

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Cohen MB, Saunders SS, Wise SK, Nassif S, Platt MP

The purpose of this study was to identify the scope of epinephrine pitfalls and opportunities for improvement in the management of allergy emergencies.

Systematic Review: Time of Onset and Predictors of Biphasic Anaphylactic Reactions: A Systematic Review and Meta-analysis

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Lee S, Bellolio MF, Hess EP, Erwin P, Murad MH, Campbell RL

The aim of this study was to evaluate the time of onset and predictors of biphasic anaphylactic reactions.

Review: Anaphylaxis: Unique aspects of clinical diagnosis and management in infants (birth to age 2 years)

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Simons FE, Sampson HA

In this rostrum we aim to increase awareness of anaphylaxis in infancy in order to improve clinical diagnosis, management, and prevention of recurrences.

Review: Risk multipliers for severe food anaphylaxis

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Smith PK, Hourihane JO, Lieberman P

This paper reviews the factors that contribute to the risk of severe anaphylactic events and provides a framework for the ongoing management of patients at risk of severe food allergy.

Systematic Review: H2-antihistamines for the treatment of anaphylaxis with and without shock: a systematic review

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Nurmatov UB, Rhatigan E, Simons FE, Sheikh A

The objective of this systematic review was to assess the benefits and harms of H2-antihistamines in the treatment of anaphylaxis.

Cochrane Systematic Review: Glucocorticoids for the treatment of anaphylaxis

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Choo KJ, Simons FE, Sheikh A

We sought to assess the benefits and harms of glucocorticoid treatment during episodes of anaphylaxis.

Cochrane Systematic Review: Adrenaline auto-injectors for the treatment of anaphylaxis with and without cardiovascular collapse in the community

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Sheikh A, Simons FE, Barbour V, Worth A

The objective of this systematic review was to assess the effectiveness of adrenaline (epinephrine) auto-injectors in relieving respiratory, cardiovascular, and other symptoms during episodes of anaphylaxis that occur in the community.

Cochrane Systematic Review: H1-antihistamines for the treatment of anaphylaxis with and without shock

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Sheikh A, ten Broek VM, Brown SG, Simons FE

The objective of this systematic review was to assess the benefits and harm of H1-antihistamines in the treatment of anaphylaxis.

Key studies

Key Study: Epinephrine Use for Anaphylaxis - A Multi-Incident Analysis

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Institute for Safe Medication Practices Canada

This multi-incident analysis was conducted to identify factors contributing to errors when epinephrine was used for the treatment of anaphylaxis and to suggest strategies to prevent or minimize potential harm when epinephrine is used for this indication.

Key Study: The Risk of Recurrent Anaphylaxis

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O'Keefe A, Clarke A, St Pierre Y, Mill J, Asai Y, Eisman H, La Vieille S, Ali...

factors contributing to errors when epinephrine was

Key Study: Lacerations and Embedded Needles Caused by Epinephrine Autoinjector Use in Children

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Brown JC, Tuuri RE, Akhter S, Guerra LD, Goodman IS, Myers SR, Nozicka C, Man...

used for the treatment of anaphylaxis and to suggest

Key Study: Embedded Needles Caused by Epinephrine Autoinjector Use in Children

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Dreborg S, Wen X, Kim L, Tsai G, Nevis I, Potts R, Chiu J, Dominic A, Kim H

strategies to prevent or minimize potential harm

Key Study: Increasing visits for anaphylaxis and the benefits of early epinephrine administration: A 4-year study at a pediatric emergency department in Montreal, Canada

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Hochstadter E, Clarke A, De Schryver S, LaVieille S, Alizadehfar R, Joseph L,...

when epinephrine is used for this indication.

Key Study: Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis

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Alqurashi W, Stiell I, Chan K, Neto G, Alsadoon A, Wells G

The objective of this study was to investigate the incidence and clinical predictors of biphasic reactions in children presenting to the emergency department (ED) with anaphylaxis.

Key Study: Early treatment of food-induced anaphylaxis with epinephrine is associated with a lower risk of hospitalization

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Fleming JT, Clark S, Camargo CA Jr, Rudders SA

The objective of this study was to identify factors associated with early epinephrine treatment for FIA and to specifically examine the association between early epinephrine treatment and hospitalization.

Key Study: Patients' ability to treat anaphylaxis using adrenaline autoinjectors: a randomized controlled trial

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Umasunthar T, Procktor A, Hodes M, Smith JG, Gore C, Cox HE, Marrs T, Hanna H...

Previous work has shown patients commonly misuse adrenaline autoinjectors (AAI). It is unclear whether this is due to inadequate training, or poor device design. We undertook a prospective randomized controlled trial to evaluate ability to administer adrenaline using different AAI devices.