Pitfalls in Anaphylaxis in The Emergency Department

RATIONALE: The purpose of our study was to evaluate the diagnosis and management of patients who presented with anaphylaxis (ANX) at our university Emergency Department (ED) and to assess how the management correlated with the severity of the case and the training level of the ED staff.

METHODS: This was a single-center, retrospective, descriptive study that involved reviewing the medical records of patients of any age who met established NIAID/FAAN criteria for ANX during a four-year period at our ED.

RESULTS: By reviewing 1341 charts of potential cases, 60 met the criteria for ANX. Only 23% were correctly diagnosed with ANX. Inappropriate coding was noted in 77%, mainly as an “allergic reaction.” For treatment, whereas systemic corticosteroids were administered to 85% and H1-antihistamines to 73% of patients, only 20% received epinephrine. Of the latter, most of the prescribers were either senior-level residents or faculty members. Ten patients required hospital admission and 50 were discharged home. Among those discharged, prescriptions were given for oral corticosteroids in 64%, H₁-antihistamines in 56%, and epinephrine auto-injector in 54%. Allergy evaluation referral was ordered for 8 (16%), but only 4 came for the visit.

CONCLUSIONS: The observed high rate of miscoding ANX and low rates of epinephrine administration, of prescribing epinephrine auto-injectors, and of referral for allergy evaluation, call for more education on these issues in the ED.