MULTIPHASIC ANAPHYLAXIS - AN UNCOMMON EVENT IN THE EMERGENCY DEPARTMENT

Objective: To determine the rate of clinically significant recurrence of symptoms in patients treated for anaphylaxis in the ED. Methods: Re trospective chart review of out-of-hospital, ED, and hospital records over a 4.5-year period (July 1991 to December 1995) at a university ho spital ED with an annual patient volume of 60,000. Subjects were ED an aphylaxis patients with greater than or equal to 2 of the following 3 organ systems involved: cutaneous, respiratory, and cardiovascular. Th e major outcome criterion was recurrence of symptoms after ED release. Recurrences were sought at the primary treatment hospital and at surr ounding hospitals (radius of 75 miles from the primary institution) wi thin a 7-day period from the initial visit. Review of the state death registry also was made to verify the absence of out-of-hospital deaths . Results: The medical records of 1,261 allergic reaction patients wer e reviewed, with 67 (5.3%) cases of anaphylaxis identified. Symptoms a nd signs in patients during the ED phase included: dyspnea, 42 (63%); pruritus, 38 (57%); emesis, 27 (41%); throat/chest tightness, 25 (37%) ; orthostatic complaints, 12 (18%); urticaria, 47 (70%); circulatory s hock, 32 (48%); upper airway angioedema, 7 (33%); strider, 11 (16%); a nd bronchospasm, 20 (30%). Of the 67 patients, 93% had immediate resol ution and remained asymptomatic for a mean time of 4.2 hours in the ED . Protracted reaction occurred in 5 cases (3 using beta-adrenergic blo cking agents). For 19 (28%) patients admitted to hospital, the mean ho spital length of stay was 63 hours. Only 2 (3%) recurrent cases were i dentified, both manifested solely by urticaria. Conclusion: Recurrent anaphylactic reactions were rare, occurring in 3% of cases and without life threat in this patient population. Selective outpatient manageme nt of patients with severe anaphylactic reactions that promptly respon d to therapy with complete, rapid resolution may be reasonable. Furthe r study of this medical emergency is required to develop criteria to g uide the choice of an outpatient disposition.