Anaphylaxis audit in a busy metropolitan Emergency Department: a review of real life management compared to best practice

BACKGROUND: Deficiencies in anaphylaxis management in Emergency Departments is well recognised despite established guidelines for its treatment. OBJECTIVE: To identify deficiencies in the management of anaphylaxis in a busy metropolitan Emergency Department and determine if an education intervention could correct these. METHODS: Paediatric and adult admissions to the Emergency Department of a busy hospital were tracked over a 10-month period with a targeted educational program being instituted at 5 months. The electronic records were retrospectively reviewed looking for cases of anaphylaxis and milder forms of immediate type allergic reactions presenting with a combination of urticaria and nonairway threatening angioedema. Anaphylaxis presentation was graded using the Brown grading system. Use of all medication during resuscitation was documented. Observation period before discharge and referral to specialist unit for follow-up was noted. RESULTS: In the first 5 months, 38 patients fulfilled our criteria. Three had severe anaphylaxis, 13 had moderately severe anaphylaxis and 12 had urticaria and angioedema without anaphylaxis. Anaphylaxis was not always recognised or graded leading to inappropriate management with adrenaline often being withheld. Promethazine, usually given in parenteral form, was frequently administered. Observation time was often inadequate. Referral to an immunologist was not universally followed through. Following the educational intervention 58 patients fulfilled our criteria over the next 5 months. The appropriate use of adrenaline increased by 21% and the use of sedating antihistamines decreased by 16%, while the number of referrals to an immunologist increased by 24%. There was an 11% reduction in the number of patients who were observed for at least 4 hours. CONCLUSION: A number of deficiencies in the management of anaphylaxis presentations have been identified. Targeted educational activities aimed at the Emergency Department hospital staff may improve outcomes.

A case study of apple seed and grape allergy with sensitisation to nonspecific lipid transfer protein

Lipid transfer proteins can be an important cause of allergy given their stability and high degree of protein sequence homology. We describe the case of a child who developed two separate episodes of anaphylaxis after consuming apple seed and grape, with evidence that nonspecific lipid transfer proteins may have been responsible for these reactions. Lipid transfer protein allergy should be considered when anaphylaxis is inconsistent, such as in patients who can tolerate fruit pulp but react to fresh whole fruit juices.