Anaphylaxis

Harold KimEmail author and

David Fischer

Allergy, Asthma & Clinical Immunology20117(Suppl 1):S6

DOI: 10.1186/1710-1492-7-S1-S6
Kim and Fischer; licensee BioMed Central Ltd. 2011
Published: 10 November 2011

Abstract
Anaphylaxis is an acute, potentially fatal systemic reaction with varied mechanisms and clinical
presentations. Although prompt recognition and treatment of anaphylaxis are imperative, both
patients and healthcare professionals often fail to recognize and diagnose early signs and
symptoms of the condition. Clinical manifestations vary widely, however, the most common signs
are cutaneous symptoms, including angioedema, urticaria, erythema and pruritus. Immediate
intramuscular administration of epinephrine into the lateral thigh is first-line therapy, even if the
diagnosis is uncertain. The mainstays of long-term management include specialist assessment,
avoidance measures, and the provision of an epinephrine auto-injector and an individualized
anaphylaxis action plan. This article provides an overview of the causes, clinical features, diagnosis
and acute and long-term management of this serious allergic reaction.

Introduction
Anaphylaxis is defined as a serious allergic reaction that is rapid in onset and may cause death
[1, 2]. The prevalence of anaphylaxis is estimated to be as high as 2%, and appears to be rising,
particularly in the younger age group [3, 4, 5].
The more rapidly anaphylaxis develops, the more likely the reaction is to be severe and lifethreatening [4]. Therefore, prompt recognition and management of the condition are imperative.
However, anaphylaxis is often under-recognized and treated inadequately. Diagnosis and
management are challenging since reactions are often immediate and unexpected. Furthermore,
there is no single test to diagnose anaphylaxis in routine clinical practice [3, 6]. This article will
provide an overview of the causes and clinical features of anaphylaxis as well as strategies for the
accurate diagnosis and management of the condition.

Causes
Most episodes of anaphylaxis are triggered through an immunologic mechanism involving
immunoglobulin E (IgE) which leads to mast cell and basophil activation and the subsequent
release of inflammatory mediators such as histamine, leukotrienes, tryptase and prostaglandins.
Although any substance has the potential to cause anaphylaxis, the most common causes of IgEmediated anaphylaxis are: foods, particularly, peanuts, tree nuts, shellfish and fish, cows milk, eggs
and wheat; medications (most commonly penicillin), and natural rubber latex. Exercise, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), opiates, and radiocontrast agents can also cause
anaphylaxis, but anaphylactic reactions to these agents often result from non-IgE-mediated
mechanisms. In other cases, the cause of anaphylactic reactions is unknown (idiopathic
anaphylaxis). In children, anaphylaxis is most often caused by foods, while venom- and drug-

induced anaphylaxis is more common in adults [4, 7, 8, 9]. Table 1 provides a more comprehensive
list of the potential causes of anaphylaxis.
Table 1
Causes of anaphylaxis.
Common:
Foods: most commonly peanuts, tree nuts, egg, seafood and fish, cows milk, wheat
Medications: most commonly antibiotics
Insect stings (bees and wasps)
Natural rubber latex
Skin
Urticaria (hives)
Angioedema (swelling)
Erythema (flushing)
Pruritus (itching)
Less common:

Gastrointestinal:
Nausea
Vomiting
Abdominal pain
Diarrhea

Respiratory:
Exercise
Upper airway:
Semen

Neurologic:

Nasal congestion
Food additives: monosodium glutamate, metabisulfite
Light-headedness
Sneezing
Hormonal changes: menstrual factors

Dizziness

Topical medications

Confusion

Hoarseness
Cough
Transfusions
Oropharyngeal
Co-morbidities
or laryngeal edema
and concurrent medications may also affect the severity of anaphylactic reactions
and patient response to treatment. For example, patients with asthma and cardiovascular disease
are more likely to experience a poor outcome from anaphylaxis. Concurrent administration of beta Lower airway: dyspnea
blockers can interfere with the patient's ability to respond to epinephrine, the first-line of treatment
Oral:
for anaphylaxis (discussed later). Furthermore, the use of angiotensin-converting enzyme (ACE)
Bronchospasms
inhibitors and angiotensin receptor blockers (ARBs) can impact a patients compensatory
physiologic response to anaphylaxis, leading toItching
more severe reactions [10].
Wheezing

Tingling
or swelling
of theis
lips,
tonguefollowing
or palateexposure to an allergen:
Anaphylaxis is highly likely when any 1 of
the following
3 criteria
fulfilled
Chest tightness
1 Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both
Cardiovascular:
hives, pruritus or flushing, swollen lips-tongue-uvula) and at least 1 of the following:
Hypotension

Other:
a. Respiratory compromise (e.g. dyspnea, wheeze, bronchospasm, stridor, reduced PEF, hypoxemia)

Dizziness

Sense of impending doom

b. Reduced BP or associated symptoms of end-organ dysfunction (e.g. hypotonia [collapse], syncope, incontinenc

Syncope
Tachycardia

Anxietyafter exposure to a likely allergen for that patient (minutes to se

2 or more of the following that occur rapidly
a. Involvement of the skin-mucosal tissue (e.g., generalized hives, itch-flush, swollen lips-tongue-uvula)

Anaphylaxis is highly likely when any 1 of the following 3 criteria is fulfilled following exposure to an allergen:

b. Respiratory compromise (e.g., dyspnea, wheeze, bronchospasm, stridor, reduced PEF, hypoxemia)
c. Reduced BP or associated symptoms (e.g., hypotonia [collapse], syncope, incontinence)
d. Persistent GI symptoms (e.g., painful abdominal cramps, vomiting)
Reduced BP after exposure to a known allergen for that patient (minutes to several hours):
3

a. Infants and children: low systolic BP (age specific) or > 30% decrease in systolic BP *
b. Adults: systolic BP < 90 mmHg or > 30% decrease from that persons baseline

Signs and symptoms

Since anaphylaxis is a generalized reaction, a wide variety of clinical signs and symptoms involving
the skin, gastrointestinal and respiratory tracts, and cardiovascular system can be observed (see
Table 2). The most common clinical manifestations are cutaneous symptoms, including urticaria and
angioedema, erythema (flushing), and pruritus (itching) [11]. Patients also often describe an
impending sense of death (angor animi). Death due to anaphylaxis usually occurs as a result of
respiratory obstruction or cardiovascular collapse, or both. Evidence suggests that there is a direct
correlation between the immediacy of symptom onset and the severity of the episode, with the more
rapid the onset, the more severe the event [12]. It is important to note that the signs and symptoms
of anaphylaxis are unpredictable and may vary from patient to patient and from one reaction to
another. Therefore, the absence of one or more of the common symptoms listed in Table 2does not
rule out anaphylaxis, and should not delay immediate treatment.
Table 2
Signs and symptoms of anaphylaxis [6, 11].
The signs and symptoms of anaphylaxis typically develop within minutes after exposure to the
offending antigen, but may occasionally occur as late as 1 hour post exposure. Symptoms usually
follow a uniphasic course, with resolution of symptoms within hours of treatment. However, up to
20% of reactions follow a biphasic course characterized by an asymptomatic period of 1-8 hours
followed by recurrent symptoms [13].

Diagnosis
The diagnosis of anaphylaxis is based primarily on clinical signs and symptoms, as well as a
detailed description of the acute episode, including antecedent activities and events. Diagnostic
criteria for anaphylaxis were published by a multidisciplinary group of experts in 2005 and 2006,
and are shown in Table 3[1, 2]. A diagnosis of anaphylaxis is highly likely when any one of the
criteria listed in Table 3 is fulfilled. Since the evaluation and diagnosis of anaphylaxis is often
complex, referral to an allergist with training and expertise in the identification and management of
anaphylaxis should be considered.
Table 3
Clinical criteria for diagnosing anaphylaxis [1, 2]
PEF = Peak expiratory flow; BP: blood pressure; GI: gastrointestinal
* Low systolic blood pressure for children is age specific and defined as: < 70 mmHg for age 1
month to 1 year; < 70mmHg + [2 x age] for age 1 to 10 years; < 90mmHg for age 11 to 17 years.

History
The history is the most important tool to establish the cause of anaphylaxis and should take
precedence over diagnostic tests. It should elicit information about clinical manifestations (e.g.,
urticaria, angioedema, flushing, pruritus, airway obstruction, gastrointestinal symptoms, syncope,
and hypotension); agents encountered before the reaction, such as foods, medications or insect
bites/stings, as well as the patients activities preceding the event (e.g., exercise, sexual activity).
The absence of cutaneous symptoms puts the diagnosis in question since the majority of
anaphylactic episodes include cutaneous symptoms; however, their absence does not rule out
anaphylaxis [4].

Additional diagnostic tests

The diagnosis of a specific cause of anaphylaxis may be supported by the results of skin tests
and/or in vitroIgE tests [4]. These tests can determine the presence of specific IgE antibodies to
foods, medications (e.g., penicillin), and stinging insects. However, for the majority of medications,
standardized skin tests and/or in vitro tests are not available. In general, skin testing is more
sensitive than in vitro testing and is the diagnostic procedure of choice for the evaluation of most
IgE-mediated causes of anaphylaxis (if available for the relevant trigger or allergen). If skin testing is
performed, it should be done under the supervision of a physician who is experienced in the
procedure in a setting with appropriate rescue equipment and medication available [4].
The clinical diagnosis of anaphylaxis can sometimes be supported by the documentation of
elevated concentrations of mast cell and basophil mediators such as plasma histamine or serum or
plasma total tryptase. However, it is critical to obtain blood samples for these measurements as
soon as possible after the onset of symptoms since elevations are transient.

Differential diagnosis
Other diagnoses that might present with signs and/or symptoms characteristic of anaphylaxis
should be excluded. The most common conditions that mimic anaphylaxis include: vasodepressor
(vasovagal/neurocardiogenic) reactions (which are characterized by hypotension, pallor,
bradycardia, weakness, nausea and vomiting); acute respiratory decompensation from severe
asthma attacks, foreign body aspiration and pulmonary embolism; vocal cord dysfunction; acute
anxiety (e.g., panic attack or hyperventilation syndrome); myocardial dysfunction, acute poisoning;
hypoglycemia; and seizure disorders [4,14].

Treatment
Acute management
The acute treatment of anaphylaxis begins with rapid assessment of the airway, breathing and
circulation. Epinephrine is the drug of choice for anaphylaxis and should be given immediately to
any patient with a suspected anaphylactic episode. Treatment should be provided even if the
diagnosis is uncertain since there here are no contraindications to the use of epinephrine [6].
The recommended dosing of epinephrine for the acute treatment of anaphylaxis is 0.01 mg/kg up to
a maximum of 0.5 mg administered intramuscularly every 520 min as necessary [6]. Intramuscular
administration into the lateral thigh is recommended as it allows for more rapid absorption and
higher plasma epinephrine levels compared to subcutaneous administration [10]. Glucagon should
also be considered in patients using beta-blockers.

All patients receiving emergency epinephrine must be transported to hospital immediately (ideally
by ambulance) for evaluation and observation. Patients should also be placed in a recumbent
(supine) position with the lower extremities elevated, unless this is precluded by shortness of breath
or vomiting [6, 15, 16].
As mentioned earlier, patients with asthma, particularly those with poorly controlled asthma, are at
increased risk of a fatal reaction. In these patients, anaphylaxis may be mistaken for an asthma
exacerbation and inappropriately treated solely with asthma inhalers. Therefore, if there are ongoing
asthma symptoms in an individual with known anaphylaxis, epinephrine should be given [6].
Oxygen therapy should also be considered in any patient with symptoms of anaphylaxis, particularly
for those with prolonged reactions. Intravenous fluids (crystalloid solutions or colloid volume
expanders) should also be provided since massive fluid shifts can occur rapidly in anaphylaxis due
to increased vascular permeability. Volume replacement is particularly important for patients whose
hypotension persists despite epinephrine injections. Supportive therapy such as inhaled beta 2agonists (for patients experiencing bronchospasm) and antihistamines (for control of cutaneous
symptoms) can also be helpful, but should never replace epinephrine as first-line therapy.
Vasopressors, such as dopamine, can also be considered if epinephrine injections and volume
expansion with intravenous fluids fail to alleviate hypotension. Glucocorticosteroids have a slow
onset of action and, therefore, these agents have not been shown to be effective for the acute
treatment of anaphylaxis. Theoretically, however, they may prevent biphasic or protracted reactions
and, hence, are often given on an empirical basis. To date, there is no conclusive evidence that the
administration of glucocorticosteroids prevents a biphasic response [4].
If intramuscular epinephrine and intravenous fluids fail to improve anaphylactic symptoms,
intravenous infusions of epinephrine may be required; however, these infusions should be given by
a physician who is trained and experienced in its use and has the capacity for continuous blood
pressure and cardiac monitoring. Figure 1 provides a simplified algorithm for the acute management
of anaphylaxis.

Figure 1
Simplified algorithm for the acute management of anaphylaxis. IV: intravenous *Should be
given by a physician trained in the use of IV epinephrine with capacity for continuous blood
pressure and cardiac monitoring
Following acute treatment, patients should be observed for a period of time due to the risk of a
biphasic response or possible recurrence of the reaction as epinephrine wears off. The observation
period should be individualized based on the severity of the initial reaction and access to care.
Experts have recommended observing patients for 4 to 6 hours following an anaphylactic reaction,
with prolonged observation times for patients with severe or refractory symptoms [6].

Long-term management
The mainstays of long-term management for patients who have experienced an anaphylactic
episode include: specialist assessment, a prescription for an epinephrine auto-injector, patient and
caregiver education on avoidance measures, and the provision of an individualized anaphylaxis
action plan.

Specialist assessment
After acute anaphylaxis, patients should be assessed for their future risk of anaphylaxis, ideally by
an allergist. These specialists are experienced in identifying and confirming the cause of
anaphylaxis, educating patients on appropriate avoidance strategies, drafting an anaphylaxis action
plan, and advising whether immunotherapy is appropriate [4, 6].

Prescription for an epinephrine auto-injector

A prescription for an epinephrine auto-injector should be provided to all patients who have
experienced anaphylaxis previously, including those who have had any rapid-onset systemic
allergic reaction (gastrointestinal, respiratory, cardiac); diffuse hives to any food or insect stings;
or any rapid-onset (i.e., minutes to hours) reaction of any severity to the highest risk foods such as
peanut, tree nuts, fish, and shellfish [6].
There are currently two epinephrine auto-injectors available in North America: EpiPen and
Twinject. Both products come in two dosages (0.15 mg and 0.30 mg), which are prescribed
according to weight. The 0.30 mg dosage should be used for those weighing 30 kg or more, and the
0.15 mg dosage for children weighing between 1530 kg. Certain sources recommend switching to
the 0.30 mg dose at 25 kg rather than 30 kg [16]. These devices should be stored properly
(avoiding temperature extremes) and replaced before the expiration date. More information on
these auto-injectors is available at http://www.epipen.ca andhttp://www.twinject.ca.
Upon prescription of an epinephrine auto-injector, healthcare providers must instruct the patient on
how and when to use the device. Instructions on proper use should be reviewed verbally and
accompanied by a DVD and/or written material, and should be reinforced annually.

Education on avoidance measures

Patients and their caregivers should be educated about agents or exposures that may place them at
risk for future reactions, and should be counselled on avoidance measures that may be used to
reduce the risk for such exposures. Avoidance strategies should be individualized, taking into
consideration factors such as relevant triggers, age, activity, occupation, hobbies, residential
conditions, access to medical care, and the patients level of personal anxiety. Individuals who have
had anaphylactic reactions to foods should be instructed to read food labels carefully, watching for
hidden ingredients such as natural flavour or spices that may indicate the presence of allergens
(e.g., peanut, tree nuts, milk, egg, shellfish, fish, sesame, soy and wheat), as well as may contain
warnings [4]. Recent evidence suggests that peanut allergic children can be desensitized to peanut
by feeding them increasing amounts of peanut under close supervision [17]. Similar results have
been noted for egg and milk allergy. Although these results are promising, further confirmatory
studies in this area are needed before routinely recommending desensitization procedures to
patients with these food allergies (for more information, see article on Food Allergy in this
supplement).
Patients with anaphylaxis to medications should be informed about all cross-reacting medications
that should be avoided. Should there be a future essential indication for use of the medication

causing anaphylactic reactions, it may be helpful to educate patients about possible management
options, such as medication pretreatment and use of low osmolarity agents in patients with a history
of reactions to radiographic contrast media, or induction of drug tolerance procedures (also known
as drug desensitization) [4]. Induction of drug tolerance procedures temporarily modify a patients
immunologic or non-immunologic response to a drug through the administration of incremental
doses of the drug. However, drug tolerance is usually maintained only as long as the drug is
administered; therefore, the procedure needs to be repeated in the future if the patient requires the
drug again after finishing a prior therapeutic course (for more information, see article on Drug
Allergy in this supplement).
Patients who have had an anaphylactic reaction to an insect sting should be advised about
avoidance measures to reduce the risk of future stings. Such measures include: being alert when
eating outdoors (as wasps are attracted to food), wearing shoes and long pants when in fields, and
having nests or hives near the patients home removed [14]. Patients who have previously
experienced venom-induced anaphylaxis are often candidates for venom immunotherapy, which is
successful in preventing anaphylaxis in up to 98% of patients (see article on Allergen
Immunotherapy in this supplement).
Subjects at high risk of a reaction to latex include: healthcare workers, children with spina bifida and
genitourinary abnormalities; and workers with occupational exposure to latex. Patients with spina
bifida (regardless of a history of latex allergy) and patients with a positive history of latex allergy
should have all medical-surgical-dental procedures performed in a latex-safe environment. This is
an environment in which no natural rubber latex gloves are used in the room or surgical suite and in
which there are limited latex-based accessories (catheters, adhesives, tourniquets, anesthesia
equipment or devices) which come in contact with the patient [4].
Patients should also obtain and wear medical identification (such as a MedicAlert bracelet/necklace)
that indicates that they have experienced anaphylaxis as well as the responsible agent. Patients
should also be instructed to avoid drugs that might increase their susceptibility and/or complicate
the management of an anaphylactic event, such as beta-blockers, ACE inhibitors, or ARBs [4].

Anaphylaxis action plan

Contact details
Names and contact details for emergencies, including family members, allergist/immunologist and family doc
Contact details for local emergency or ambulance services
Allergens/Triggers
Clear identification of allergens/triggers to be avoided
Include generic and proprietary names of drugs and possible cross-sensitivities, if relevant
How to recognize the signs and symptoms of anaphylaxis
Mouth: itching, swelling of lips/tongue
Throat: itching, tightness, closure, hoarseness

Contact details
Names and contact details for emergencies, including family members, allergist/immunologist and family doc
Contact details for local emergency or ambulance services

Skin: itching, hives, eczema, swelling, flushing

Gut: vomiting, diarrhea, abdominal pain
Lung: shortness of breath, cough, wheeze
Heart: hypotension, dizziness, syncope, tachycardia
Neuro (or head): light-headedness
Other: feeling of impending doom, anxiety
Medications prescribed and when they should be used

Epinephrine auto-injectors (first-line); should include detailed instructions (with photographs, if possible) on how to c
the auto-injector device (for daycare, school and/or office staff)
Antihistamines (for cutaneous symptoms)
Inhaled beta2-agonists (for bronchospasm)
Where medication is stored at home, work or school
A comprehensive, individualized anaphylaxis action plan should be prepared which defines roles
and responsibilities and emergency protocols [6]. Important information that should be included in
this plan is shown in Table 4[6, 18]. Examples of such a plan, along with other relevant information
and materials, can be downloaded at Anaphylaxis Canada (http://www.anaphylaxis.ca) or the Food
Allergy and Anaphylaxis Network (http://www.foodallergy.org; a US-based association). Action plans
should be reviewed annually and updated if necessary. A copy of the plan should be made available
to all relevant persons, such as day-care providers, teachers, and employers. Recommendations for
the management of anaphylaxis in schools and other community settings [15] are available through
the Allergy Safe Communities website athttp://www.allergysafecommunities.ca.
Table 4
Components of an anaphylaxis action plan [6, 18]

Conclusions
Anaphylaxis is an acute, potentially fatal systemic reaction with varied mechanisms and clinical
presentations. Prompt recognition and treatment of anaphylaxis are imperative; however, both
patients and healthcare professionals often fail to recognize and diagnose anaphylaxis in its early
stages. Diagnostic criteria which take into account the variable clinical manifestations of
anaphylaxis are now available and can assist healthcare providers in the early recognition of the
condition. Immediate intramuscular administration of epinephrine into the lateral thigh is first-line
therapy for anaphylaxis. Acute management may also involve oxygen therapy, intravenous fluids,
and adjunctive therapies such as antihistamines or inhaled beta 2-agonists. The mainstays of longterm management include specialist assessment, a prescription for an epinephrine auto-injector,

patient and caregiver education on avoidance measures, and the provision of an individualized
anaphylaxis action plan.

Key take-home messages

Anaphylaxis is defined as a serious allergic reaction that is rapid in onset and may cause
death.

Prompt recognition and treatment are critical in anaphylaxis.

The diagnosis is based primarily on clinical signs and symptoms.
The most common clinical manifestations are cutaneous symptoms, including urticaria and
angioedema, erythema, and pruritus.
Referral to an allergist or immunologist should be considered for all persons who have
experienced a previous anaphylactic episode.
Epinephrine is the drug of choice for anaphylaxis and should be given immediately, even if
the diagnosis is uncertain; intramuscular administration into the lateral thigh is recommended.
There are no contraindications to the use of epinephrine.
The mainstays of long-term treatment include: specialist assessment, avoidance measures,
and the provision of an epinephrine auto-injector and an individualized anaphylaxis action plan.

Declarations
Acknowledgements
This article has been published as part of Allergy, Asthma & Clinical Immunology Volume 7
Supplement 1, 2011: Practical guide for allergy and immunology in Canada. The full contents of the
supplement are available online at http://www.aacijournal.com/supplements/7/S1

Competing interests
Dr. Harold Kim is the past president of the Canadian Network for Respiratory Care and co-chief
editor of Allergy, Asthma &Clinical Immunology. He has received consulting fees and honoraria for
continuing education from AstraZeneca, GlaxoSmithKline, Graceway Pharmaceuticals, King
Pharma, Merck Frosst, Novartis, and Nycomed.
Dr. David Fischer is a member of the Board of Directors of the Canadian Society of Allergy &
Clinical Immunology. He has received consulting fees and honoraria for continuing education from
AstraZeneca, GlaxoSmithKline, Graceway Pharmaceuticals, King Pharma, Merck Frosst, Novartis,
Paladin Labs and Nycomed.

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