• Genevieve SantillanesEmail author
  • Julie C. Brown


Anaphylaxis is a potentially fatal allergic reaction that is frequently underdiagnosed and undertreated. Presentations vary but may include signs and symptoms such as urticaria, angioedema, wheezing, stridor, hypotension, abdominal cramping, and persistent vomiting and diarrhea. Early, appropriate treatment is critical. Epinephrine is the only first-line therapy for anaphylaxis and should be administered immediately. Given the risk of a biphasic reaction, patients should generally be observed in a monitored setting for at least 4 h. All patients with anaphylaxis require education in allergen avoidance and a prescription for an epinephrine auto-injector.


Anaphylaxis Allergy Food allergy Urticaria Wheeze Stridor 


  1. 1.
    Campbell RL, Li JT, Nicklas RA, Sadosty AT. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014;113:599–608.CrossRefPubMedGoogle Scholar
  2. 2.
    Clark S, Bock SA, Gaeta TJ, Brenna BE, Cydulka RK, Camargo CA Jr. Multicenter study of emergency department visits for food allergies. J Allergy Clin Immunol. 2004;113:347–52.CrossRefPubMedGoogle Scholar
  3. 3.
    Grabenhenrich LB, Dolle S, Moneret-Vautrin A, et al. Anaphylaxis in children and adolescents: The European Anaphylaxis Registry. J Allergy Clin Immunol. 2016;137:1128–37.e1.CrossRefPubMedGoogle Scholar
  4. 4.
    Nowakgerc R, Farrar JR, Brenner BE, Lewis L, Silverman RA, Emerman C, et al. Customizing anaphylaxis guidelines for emergency medicine. J Emerg Med. 2013;45:299.CrossRefGoogle Scholar
  5. 5.
    Sampson HA, Munoz-Furlong A, Campbell RL, Adkinson NF, Bock SA, et al. Epidemiology of anaphylaxis: findings of the American College of Allergy, asthma and immunology epidemiology of anaphylaxis working group. Ann Allergy Asthma Immunol. 2006;97:596–602.CrossRefGoogle Scholar
  6. 6.
    Lin RY, Anderson AS, Shah SN, Nurruzzaman F. Increasing anaphylaxis hospitalizations in the first 2 decades of life: New York State, 1990–2006. Ann Allergy Asthma Immunol. 2008;101:387–93.CrossRefPubMedGoogle Scholar
  7. 7.
    Lieberman P, Nicklas R, Oppenheimer J, Kemp S, Lang D. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol [AnaphylaxisPracticeParameterAAAAI]. 2010;126:477–80.CrossRefGoogle Scholar
  8. 8.
    Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the United States: summary of the NIAID-sponsored expert panel report. J Allergy Clin Immunol. 2010;126:1105–18.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Wang J, Sicherer SH, Section on Allergy and Immunology. Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics. 2017;139 Epub 2017 Feb 13.
  10. 10.
    Food allergy & anaphylaxis emergency care plan. Available at: Accessed 10 Aug 2014.
  11. 11.
    de Silva IL, Mehr SS, Tey D, Tang ML. Paediatric anaphylaxis: a 5 year retrospective review. Allergy. 2008;63:1071–6.CrossRefPubMedGoogle Scholar
  12. 12.
    De Swert LF, Bullens D, Raes M, Dermaux AM. Anaphylaxis in referred pediatric patients: demographic and clinical features, triggers, and therapeutic approach. Eur J Pediatr. 2008;167:1251–61.CrossRefPubMedGoogle Scholar
  13. 13.
    Rudders SA, Banerji A, Clark S, Camargo CA Jr. Age-related differences in the clinical presentation of food-induced anaphylaxis. J Pediatr. 2011;158:326–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Lee JM, Greenes DS. Biphasic anaphylactic reactions in pediatrics. Pediatrics. 2000;106:762–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Feng C, Teuber S, Gershwin ME. Histamine (scombroid) fish poisoning: a comprehensive review. Clin Rev Allergy Immunol. 2016;50:64–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Nowak RM, Macias CG. Anaphylaxis on the other front line: perspectives from the emergency department. Am J Med. 2014;127:S34–44.CrossRefPubMedGoogle Scholar
  17. 17.
    Lieberman P, Simons FE. Anaphylaxis and cardiovascular disease: therapeutic dilemmas. Clin Exp Allergy. 2015;45:1288–95.CrossRefPubMedGoogle Scholar
  18. 18.
    Wood JP, Traub SJ, Lipinski C. Safety of epinephrine for anaphylaxis in the emergency setting. World J Emerg Med. 2013;4:245–51.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Hochstadter E, Clarke A, De Schryver S, 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.CrossRefPubMedGoogle Scholar
  20. 20.
    Fleming JT, Clark S, Camargo CA Jr, Rudders SA. 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.CrossRefPubMedGoogle Scholar
  21. 21.
    Pumphrey RS. Fatal anaphylaxis in the UK, 1992–2001. Novartis Found Symp. 2004;257:116–28. discussion 128–32, 157–60, 276–85PubMedGoogle Scholar
  22. 22.
    Pumphrey RS, Gowland MH. Further fatal allergic reactions to food in the United Kingdom, 1999-2006. J Allergy Clin Immunol. 2007;119:1018–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Clark S, Bock SA, Gaeta TJ, et al. Multicenter study of emergency department visits for food allergies. J Allergy Clin Immunol. 2004;113:347–52.CrossRefPubMedGoogle Scholar
  24. 24.
    Russell S, Monroe K, Losek JD. Anaphylaxis management in the pediatric emergency department: opportunities for improvement. Pediatr Emerg Care. 2010;26:71–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Pumphrey RS. Fatal posture in anaphylactic shock. J Allergy Clin Immunol. 2003;112:451–2.CrossRefPubMedGoogle Scholar
  26. 26.
    Simons FE, Ardusso LR, Bilo MB, et al. 2012 update: world allergy organization guidelines for the assessment and management of anaphylaxis. Curr Opin Allergy Clin Immunol. 2012;12:389–99.CrossRefPubMedGoogle Scholar
  27. 27.
    Thomas M, Crawford I. Best evidence topic report. Glucagon infusion in refractory anaphylactic shock in patients on beta-blockers. Emerg Med J. 2005;22:272–3.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Nurmatov UB, Rhatigan E, Simons FE, Sheikh A. H2-antihistamines for the treatment of anaphylaxis with and without shock: a systematic review. Ann Allergy Asthma Immunol. 2014;112:126–31.CrossRefPubMedGoogle Scholar
  29. 29.
    Lin RY, Curry A, Pesola GR, et al. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Ann Emerg Med. 2000;36:462–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Banerji A, Long AA, Camargo CA Jr. Diphenhydramine versus nonsedating antihistamines for acute allergic reactions: a literature review. Allergy Asthma Proc. 2007;28:418–26.CrossRefPubMedGoogle Scholar
  31. 31.
    Lee S, Bellolio MF, Hess EP, Erwin P, Murad MH, Campbell RL. Time of onset and predictors of biphasic anaphylactic reactions: a systematic review and meta-analysis. J Allergy Clin Immunol Pract. 2015;3:408–16.e1–2.CrossRefPubMedGoogle Scholar
  32. 32.
    Alqurashi W, Stiell I, Chan K, Neto G, Alsadoon A, Wells G. Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis. Ann Allergy Asthma Immunol. 2015;115:217–223.e2.CrossRefPubMedGoogle Scholar
  33. 33.
    Choo KJ, Simons FE, Sheikh A. Glucocorticoids for the treatment of anaphylaxis. Cochrane Database Syst Rev. 2012;4:CD007596.Google Scholar
  34. 34.
    Grunau BE, Wiens MO, Rowe BH, et al. Emergency department corticosteroid use for allergy or anaphylaxis is not associated with decreased relapses. Ann Emerg Med. 2015;66:381–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immunol. 2005;115:S483–523.CrossRefGoogle Scholar
  36. 36.
    Dhami S, Panesar SS, Roberts G, et al. Management of anaphylaxis: a systematic review. Allergy. 2014;69:168–75.CrossRefPubMedGoogle Scholar
  37. 37.
    Michelson KA, Monuteaux MC, Neuman MI. Glucocorticoids and hospital length of stay for children with anaphylaxis: a retrospective study. J Pediatr. 2015;167:719–24.e1–3.CrossRefPubMedGoogle Scholar
  38. 38.
    Sicherer SH, FER S, Section on Allergy and Immunology. Epinephrine for first-aid management of anaphylaxis. Pediatrics. 2017;139 Epub 2017 Feb 13
  39. 39.
    In brief: Auvi-Q epinephrine auto-inejctor for infants and toddlers. The Medical Letter on Drugs and Theraputics. Issue 1547. May 21, 2018.Google Scholar
  40. 40.
    Bock SA, Munoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001;107:191–3.CrossRefPubMedGoogle Scholar
  41. 41.
    Brown JC, Tuuri RE, Akhter S, et al. Lacerations and embedded needles caused by epinephrine autoinjector use in children. Ann Emerg Med. 2016;67(3):307–315.e8.CrossRefPubMedGoogle Scholar
  42. 42.
    Liew W, Williamson E, Tang ML. Anaphylaxis fatalities and admissions in Australia. J Allergy Clin Immunol [AnaphylaxisDeathsAustralia]. 2009;123(2):434–42.CrossRefGoogle Scholar
  43. 43.
    Turner PJ, Gowland MH, Sharma V, et al. Increase in anaphylaxis-related hospitalizations but no increase in fatalities: an analysis of United Kingdom national anaphylaxis data, 1992–2012. J Allergy Clin Immunol. 2015;135:956–63.e1.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Ma L, Danoff TM, Borish L. Case fatality and population mortality associated with anaphylaxis in the United States. J Allergy Clin Immunol. 2014;133:1075–83.CrossRefPubMedGoogle Scholar
  45. 45.
    Brown JC, Tuuri RE. Lacerations and embedded needles due to EpiPen use in children. J Allergy Clin Immunol Pract. 2016;4:549–51.CrossRefPubMedGoogle Scholar
  46. 46.
    Cluck D, Odle B, Rikhye S. Therapeutic management of accidental epinephrine injection. J Pharm Technol [AccidentalEpi]. 2013;29:123–9.CrossRefGoogle Scholar
  47. 47.
    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. J Allergy Clin Immunol. 2006;117(2):391–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Emergency MedicineKeck School of Medicine of USCLos AngelesUSA
  2. 2.Division of Pediatric Emergency Medicine, Department of PediatricsUniversity of Washington School of MedicineSeattleUSA

Personalised recommendations