Anaphylaxis cases presenting to primary care paramedics in Quebec

Abstract

Data on anaphylaxis cases in pre‐hospital settings is limited. As part of the Cross Canada Anaphylaxis Registry (C‐CARE), we assessed anaphylaxis cases managed by paramedics in Outaouais, Quebec. A software program was developed to prospectively record demographic and clinical characteristics as well as management of cases meeting the definition of the anaphylaxis. Univariate and multivariate logistic regressions were compared to assess factors associated with severity of reactions and epinephrine use. Among 33,788 ambulance calls of which 23,486 required transport, 104 anaphylaxis cases were identified (anaphylaxis rate of 0.31% [95%CI, 0.25%, 0.37%] among all ambulance calls and 0.44% [95%CI, 0.36%, 0.54%] among those requiring transport). The median age was 46.8 years and 41.3% were males. The common triggers included food (32.7% [95%CI, 24.0%, 42.7%]), drugs (24.0% [16.4%, 33.6%]), and venom (17.3% [10.8%, 26.2%]). Among all reactions, 37.5% (95%CI, 28.4%, 47.6%) were severe. Epinephrine was not administered in 35.6% (95%CI, 26.6%, 45.6%) of all cases. Males were more likely to have severe reactions (Odds ratio [OR]: 2.50 [95%CI, 1.03, 6.01]). Venom‐induced reactions and severe anaphylaxis were more likely to be managed with epinephrine (OR: 6.9 [95%CI, 1.3, 35.3] and 4.2 [95%CI, 1.5, 12.0], respectively). This is the first prospective study evaluating anaphylaxis managed by paramedics. Anaphylaxis accounts for a substantial proportion of the cases managed by paramedics in Outaouais, Quebec and exceeds prior reports of the proportion of Quebec emergency room visits attributed to anaphylaxis. Although guidelines recommend prompt use of epinephrine for all cases of anaphylaxis, more than a third of cases did not receive epinephrine. It is crucial to develop educational programs targeting paramedics to promote the use of epinephrine in all cases of anaphylaxis regardless of the specific trigger.

How to manage anaphylaxis in primary care

“…There is still much room for improvement with respect to knowledge about epinephrine as the initial treatment of anaphylaxis, intramuscular administration, doses, and prescription of EAIs [7–12 ]. Studies that reviewed healthcare databases in Canada [13, 14 ] and The Netherlands [15 ] reported similar findings. Interdisciplinary communication and education on anaphylaxis are the most frequently proposed solutions.…”

Consensus on DEfinition of Food Allergy SEverity (DEFASE) an integrated mixed methods systematic review

“…Additionally, our SR identified 31 previously published symptom-severity scoring systems referred to food allergic reactions 1 , 4 , 15 , 19 , 20 , 22 , 24 , 26 , 27 , 29 , 30 , 31 , 32 , 33 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 [ Table 1 ]. Twenty-three were primary studies providing new symptom-severity scoring systems to assess food-induced allergic reactions 1 , 4 , 19 , 20 , 22 , 24 , 26 , 27 , 29 , 30 , 31 , 32 , 33 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 58 [ Table 1 , Table 2 ]. Of note, we were able to pool primary data eligible for our SR only from 11 of them.…”

“…Of note, we were able to pool primary data eligible for our SR only from 11 of them. 4 , 19 , 20 , 22 , 24 , 26 , 27 , 29 , 30 , 31 , 32 The remaining 20 studies provided new symptom-severity scores but not eligible primary data for our SR since they: a) included allergic reactions triggered by a different 58 or any allergenic source (ie, not only food); 46 , 47 , 48 , 50 b) or were based on self-reported diagnosis of food allergy; 1 , 42 , 45 , 49 c) or included food allergy diagnosis only based on IgE-sensitization without history of ingestion of the suspected culprit food; 44 d) or referred to oral immunotherapy trials. 43 Eight out of the 31 that included symptom-severity scores were provided by secondary research papers.…”

“…Our SR identified 31 previously published instruments focusing on severity of food allergic reactions 1 , 4 , 15 , 19 , 20 , 22 , 24 , 26 , 27 , 29 , 30 , 31 , 32 , 33 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 [ Table 1 ].…”

CSACI guidelines for the ethical, evidence-based and patient-oriented clinical practice of oral immunotherapy in IgE-mediated food allergy

“…54 In one study, these factors were reported by 73% of patients reporting symptoms (1 case series: • High specific IgE serum levels (3 analyses of clinical practice 30 33 40 ) large skin prick wheal size (1 analysis 30 ), history of anaphylactic reactions (2 analyses 53 54 ) and low tolerated dose of food allergen (1 analysis 32 ) were associated with a higher risk of adverse events in some studies. Other analyses did not find an association between safety outcomes and history of anaphylactic reaction, 94 low tolerated dose of food allergen 53 or skin prick wheal size. 53 ; some have started enrolment from age 29 61 or one.…”