Evaluation of Prehospital Management in a Canadian Emergency Department Anaphylaxis Cohort

Published:April 26, 2019DOI:


      Studies assessing the use of antihistamines and corticosteroids for the treatment of anaphylaxis have not supported a conclusive effect.


      To assess prehospital management of anaphylaxis by measuring the effect of epinephrine use compared with antihistamines and corticosteroids on negative outcomes of anaphylaxis (intensive care unit/hospital ward admission, multiple doses of epinephrine in the emergency department [ED], and intravenous fluids given in the ED).


      The Cross-Canada Anaphylaxis Registry is a cohort study that enrolls anaphylaxis cases presenting to EDs in 5 Canadian provinces over a 6-year period. Participants were recruited prospectively and retrospectively and were excluded if the case did not meet the definition of anaphylaxis.


      A total of 3498 cases of anaphylaxis, of which 80.3% were children, presented to 9 EDs across Canada. Prehospital treatment with epinephrine was administered in 31% of cases, whereas antihistamines and corticosteroids were used in 46% and 2% of cases, respectively. Admission to the intensive care unit/hospital ward was associated with prehospital treatment with corticosteroids (adjusted odds ratio, 2.84; 95% confidence interval [CI], 1.55, 6.97) while adjusting for severity, treatment with epinephrine and antihistamines, asthma, sex, and age. Prehospital treatment with epinephrine (adjusted odds ratio, 0.23; 95% CI, 0.14, 0.38) and antihistamines (adjusted odds ratio, 0.61; 95% CI, 0.44, 0.85) decreased the likelihood of receiving multiple doses of epinephrine in the ED, while adjusting for severity, treatment with corticosteroids, asthma, sex, and age.


      Prompt epinephrine treatment is crucial. Use of antihistamines in conjunction with epinephrine may reduce the risk of uncontrolled reactions (administration of 2 or more doses of epinephrine in the ED), although our findings do not support the use of corticosteroids.

      Key words

      Abbreviations used:

      ACE (Angiotensin-converting enzyme), aOR (Adjusted odds ratio), C-CARE (Cross-Canada Anaphylaxis Registry), CI (Confidence interval), ED (Emergency department), ICU (Intensive care unit), IQR (Interquartile range), IV (Intravenous), NSAID (Nonsteroidal anti-inflammatory drug)
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        • Gold M.S.
        • Sainsbury R.
        First aid anaphylaxis management in children who were prescribed an epinephrine autoinjector device (EpiPen).
        J Allergy Clin Immunol. 2000; 106: 171-176
        • Sampson H.A.
        • Munoz-Furlong A.
        • Campbell R.L.
        • Adkinson Jr., N.F.
        • Bock S.A.
        • Branum A.
        • 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.
        J Allergy Clin Immunol. 2006; 117: 391-397
        • Campbell R.L.
        • Li J.T.
        • Nicklas R.A.
        • Sadosty A.T.
        Emergency department diagnosis and treatment of anaphylaxis: a practice parameter.
        Ann Allergy Asthma Immunol. 2014; 113: 599-608
        • Simons F.E.
        • Ebisawa M.
        • Sanchez-Borges M.
        • Thong B.Y.
        • Worm M.
        • Tanno L.K.
        • et al.
        2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines.
        World Allergy Organ J. 2015; 8: 32
        • Choo K.J.
        • Simons F.E.
        • Sheikh A.
        Glucocorticoids for the treatment of anaphylaxis.
        Evid Based Child Health. 2013; 8: 1276-1294
        • Sheikh A.
        • Ten Broek V.
        • Brown S.G.
        • Simons F.E.
        H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review.
        Allergy. 2007; 62: 830-837
        • Lee A.Y.
        • Enarson P.
        • Clarke A.E.
        • La Vieille S.
        • Eisman H.
        • Chan E.S.
        • et al.
        Anaphylaxis across two Canadian pediatric centers: evaluating management disparities.
        J Asthma Allergy. 2017; 10: 1-7
        • Pumphrey R.S.
        Lessons for management of anaphylaxis from a study of fatal reactions.
        Clin Exp Allergy. 2000; 30: 1144-1150
        • Sampson H.A.
        • Mendelson L.
        • Rosen J.P.
        Fatal and near-fatal anaphylactic reactions to food in children and adolescents.
        N Engl J Med. 1992; 327: 380-384
        • Greenberger P.A.
        • Rotskoff B.D.
        • Lifschultz B.
        Fatal anaphylaxis: postmortem findings and associated comorbid diseases.
        Ann Allergy Asthma Immunol. 2007; 98: 252-257
        • Cheng A.
        Emergency treatment of anaphylaxis in infants and children.
        Paediatr Child Health. 2011; 16: 35-40
        • Hochstadter E.
        • Clarke A.
        • De Schryver S.
        • La Vieille S.
        • Alizadehfar R.
        • Joseph L.
        • et al.
        Increasing visits for anaphylaxis and the benefits of early epinephrine administration: a 4-year study at a pediatric emergency department in Montreal, Canada.
        J Allergy Clin Immunol. 2016; 137: 1888-1890.e4
        • Vetander M.
        • Helander D.
        • Flodstrom C.
        • Ostblom E.
        • Alfven T.
        • Ly D.H.
        • et al.
        Anaphylaxis and reactions to foods in children—a population-based case study of emergency department visits.
        Clin Exp Allergy. 2012; 42: 568-577
        • Muraro A.
        • Roberts G.
        • Clark A.
        • Eigenmann P.A.
        • Halken S.
        • Lack G.
        • et al.
        The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology.
        Allergy. 2007; 62: 857-871
        • Fineman S.M.
        Optimal treatment of anaphylaxis: antihistamines versus epinephrine.
        Postgrad Med. 2014; 126: 73-81
        • Simons F.E.
        First-aid treatment of anaphylaxis to food: focus on epinephrine.
        J Allergy Clin Immunol. 2004; 113: 837-844
        • Alvarez-Perea A.
        • Tanno L.K.
        • Baeza M.L.
        How to manage anaphylaxis in primary care.
        Clin Transl Allergy. 2017; 7: 45
        • Kimchi N.
        • Clarke A.
        • Moisan J.
        • Lachaine C.
        • La Vieille S.
        • Asai Y.
        • et al.
        Anaphylaxis cases presenting to primary care paramedics in Quebec.
        Immun Inflamm Dis. 2015; 3: 406-410
        • Fleming J.T.
        • Clark S.
        • Camargo Jr., C.A.
        • Rudders S.A.
        Early treatment of food-induced anaphylaxis with epinephrine is associated with a lower risk of hospitalization.
        J Allergy Clin Immunol Pract. 2015; 3: 57-62
        • Huang F.
        • Chawla K.
        • Jarvinen K.M.
        • Nowak-Wegrzyn A.
        Anaphylaxis in a New York City pediatric emergency department: triggers, treatments, and outcomes.
        J Allergy Clin Immunol. 2012; 129 (e1-3): 162-168
        • Anchor J.
        • Settipane R.A.
        Appropriate use of epinephrine in anaphylaxis.
        Am J Emerg Med. 2004; 22: 488-490
        • Xu Y.S.
        • Kastner M.
        • Harada L.
        • Xu A.
        • Salter J.
        • Waserman S.
        Anaphylaxis-related deaths in Ontario: a retrospective review of cases from 1986 to 2011.
        Allergy Asthma Clin Immunol. 2014; 10: 38
        • Chung T.
        • Gaudet L.
        • Vandenberghe C.
        • Couperthwaite S.
        • Sookram S.
        • Liss K.
        • et al.
        Pre-hospital management of anaphylaxis in one Canadian Urban Centre.
        Resuscitation. 2014; 85: 1077-1082
        • Kawano T.
        • Scheuermeyer F.X.
        • Gibo K.
        • Stenstrom R.
        • Rowe B.
        • Grafstein E.
        • et al.
        H1-antihistamines reduce progression to anaphylaxis among emergency department patients with allergic reactions.
        Acad Emerg Med. 2017; 24: 733-741
        • Greisner III, W.A.
        Onset of action for the relief of allergic rhinitis symptoms with second-generation antihistamines.
        Allergy Asthma Proc. 2004; 25: 81-83
        • Simons F.E.
        • Ardusso L.R.
        • Bilo M.B.
        • Dimov V.
        • Ebisawa M.
        • El-Gamal Y.M.
        • et al.
        2012 Update: World Allergy Organization Guidelines for the assessment and management of anaphylaxis.
        Curr Opin Allergy Clin Immunol. 2012; 12: 389-399
        • Alqurashi W.
        • Ellis A.K.
        Do corticosteroids prevent biphasic anaphylaxis?.
        J Allergy Clin Immunol Pract. 2017; 5: 1194-1205
        • Liyanage C.K.
        • Galappatthy P.
        • Seneviratne S.L.
        Corticosteroids in management of anaphylaxis; a systematic review of evidence.
        Eur Ann Allergy Clin Immunol. 2017; 49: 196-207
        • Liu D.
        • Ahmet A.
        • Ward L.
        • Krishnamoorthy P.
        • Mandelcorn E.D.
        • Leigh R.
        • et al.
        A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy.
        Allergy Asthma Clin Immunol. 2013; 9: 30
        • Waljee A.K.
        • Rogers M.A.
        • Lin P.
        • Singal A.G.
        • Stein J.D.
        • Marks R.M.
        • et al.
        Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study.
        BMJ. 2017; 357: j1415
        • Lee S.
        • Hess E.P.
        • Nestler D.M.
        • Bellamkonda Athmaram V.R.
        • Bellolio M.F.
        • Decker W.W.
        • et al.
        Antihypertensive medication use is associated with increased organ system involvement and hospitalization in emergency department patients with anaphylaxis.
        J Allergy Clin Immunol. 2013; 131: 1103-1108
        • Nassiri M.
        • Babina M.
        • Dolle S.
        • Edenharter G.
        • Rueff F.
        • Worm M.
        Ramipril and metoprolol intake aggravate human and murine anaphylaxis: evidence for direct mast cell priming.
        J Allergy Clin Immunol. 2015; 135: 491-499
        • Matsuo H.
        • Kaneko S.
        • Tsujino Y.
        • Honda S.
        • Kohno K.
        • Takahashi H.
        • et al.
        Effects of non-steroidal anti-inflammatory drugs (NSAIDs) on serum allergen levels after wheat ingestion.
        J Dermatol Sci. 2009; 53: 241-243
        • O'Keefe A.
        • Clarke A.
        • St Pierre Y.
        • Mill J.
        • Asai Y.
        • Eisman H.
        • et al.
        The risk of recurrent anaphylaxis.
        J Pediatr. 2017; 180: 217-221
        • Jung C.
        • Greco S.
        • Nguyen H.H.
        • Ho J.T.
        • Lewis J.G.
        • Torpy D.J.
        • et al.
        Plasma, salivary and urinary cortisol levels following physiological and stress doses of hydrocortisone in normal volunteers.
        BMC Endocr Disord. 2014; 14: 91