emergency medicine

How to Cite

LEFORT, H., Gloaguen, A., Pouessel, G., Cesareo, E., Vaux, J., Valdenaire, G., Ganansia, O., Renolleau, S., Beaudouin, E., & Meininger, C. (2021). MANAGEMENT OF ANAPHYLAXIS IN EMERGENCY MEDICINE. Mediterranean Journal of Emergency Medicine, (25), 4-24. Retrieved from


These formalized expert guidelines were written by the French Society of Emergency Medicine (SFMU), in partnership with the French Allergology Society (SFA) and the French Speaking Group in Pediatric Intensive Care and Emergency (GFRUP). Their goal is to educate emergency physicians to early diagnosis of this potentially fatal reaction of severe hypersensitivity, the specific features associated with age, and risk factors identification. Anaphylaxis diagnosis is clinical and used Sampson’s clinical criteria. The authors offer helps sheets for emergency medical services dispatch and triage criteria for emergency department nurses. As underlined by the international guidelines, the main treatment is early administration of intramuscular epinephrine. If an epinephrine auto-injector is available, the emergency medical services dispatch center on-call physician (112-call) should encourage its immediate use. The second line of treatment is based on the eviction of the triggering factor, the appropriate waiting position, oxygen therapy, and depending on the symptoms, fluid therapy, bronchodilator and epinephrine nebulization. The severity of the prognosis and the unpredictability of developments justify the deployment of a mobile intensive care unit. A minimum six-hour hospital observation is indicated. Tryptase kinetics evaluation contributes to a posteriori diagnosis. At emergency department discharge, the patient must have a prescription of an emergency kit (containing two epinephrine auto-injectors and β2-agonists), written instructions and a detailed written hospital report. A specialized consultation with an allergologist is essential after the emergency department discharge.



Simons FE, Ardusso LR, Bilo MB, Cardona V, Ebisawa M, El-Gamal YM, et al. International consensus on (ICON) anaphylaxis. WAO J 2014; 7:9.

Simons FE, Ardusso LR, Bilò MB, El-Gamal YM, Ledford DK, Ring J, et al; World Allergy Organization. World allergy organization guidelines for the assessment and management of anaphylaxis. World AllergyOrgan J 2011; 4:13-37.

Muraro A, Roberts G, Worm M, Bilo MB, Brockow K, Fernandez Rivas M, et al; On behalf of the EAACI Food Allergy and Anaphylaxis Guidelines Group. Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology. Allergy 2014; 69:1026-45.

Simons FE, Clark S, Camargo CA Jr. Anaphylaxis in the community: Learning from the survivors. J Allergy ClinImmunol 2009; 124:301-6.

Worm M, Moneret-Vautrin A, Scherer K, Lang R, Fernandez-Rivas M, Cardona V, et al. First European data from the network of severe allergic reactions (NORA). Allergy 2014; 69:1397-404.

Larcan A, Moneret-Vautrin A. Prise en charge des urgences allergiques sévères. Bull Acad Natle Méd 2009; 193:2087-92.

Simons FE, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK, et al. 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines. World Allergy Organ J 2015; 8:32.

Braganza SC, Acworth JP, Mckinnon DR, Peake JE, Brown AF. Paediatric emergency department anaphylaxis: different patterns from adults. Arch Dis Child 2006; 91:159-63.

Turner PJ, Gowland MH, Sharma V, Ierodiakonou D, Harper N, Garcez T, 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.

Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000; 30:1144-50.

Bock SA, Munoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy clin Immunol 2001; 107:191-3.

Wood RA, Camargo CA Jr, Lieberman P, Sampson HA, Schwartz LB, Zitt M, et al. Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States. J Allergy Clin Immunol 2014; 133:461-7.

Muraro A, Werfel T, Hoffmann-Sommergruber K, Roberts G, Beyer K, Bindslev-Jensen C, et al; On behalf of the EAACI Food Allergy and Anaphylaxis Guidelines Group. EAACI Food Allergy and Anaphylaxis Guidelines. Diagnosis and management of food allergy. Allergy 2014; 69:1008-25.

Sampson MA, Muñoz-Furlong A, Sicherer SH. Risk-taking and coping strategies of adolescents and young adults with food allergy. J Allergy Clin Immunol 2006; 117:1440-45.

Beaudouin E, Moneret-Vautrin DA. L’anaphylaxie: connaître, reconnaître mais ne pas méconnaître. J Eur Urg Réa 2014; 26:105-7.

Dewachter P, Mouton Faivre C, Emala CW. Anaphylaxis and anesthesia. Anesthesiology 2009; 111:1145-50.

Theoharides TC, Kempuraj D, Tagen M, Conti P, Kalogeromitros D. Differential release of mast cell mediators and the pathogenesis of inflammation., Immunological Reviews 2007; 217:65-78.

Simons FE. Anaphylaxis pathogenesis and treatment. Allergy 2011; 66:s31-4.

Ogawa Y, Grant JA. Mediators of anaphylaxis. Immunol Allergy Clin Am 2007; 27:249-60.

Brown SGA, Stone SF, Fatovich DM, Burrows SA, Holdgate A, CelenzaA et al. Anaphylaxis: Clinical patterns, mediator release, and severity. J Allergy Clin Immunol 2013; 132:114-9.

Jönsson F, Mancardi DA, Kita Y, Karasuyama H, Iannascoli B, Van Rooijen N, et al. Mouse and human neutrophils, induce anaphylaxis. J Clin Invest 2011; 121:1484-96.

Brown SGA. The pathophysiology of shock in anaphylaxis. Immunol Allergy Clin N Am 2007; 27:165-75.

Marone G, Genovese A, Varricchi G, Granata F. Human heart as a shock organ in anaphylaxis. Allergo J Int 2014; 23:60-6.

Kounis NG. Coronary Hypersensitivity Disorder: The Kounis Syndrome. Clinical Therapeutics 2013; 35:563-72.

Moneret-Vautrin DA. Facteurs de risque d’anaphylaxie alimentaire sévère, rôle confirmé de certaines classes de médicaments. Médecine/Sciences 2010; 26:719-23.

Peavy RD, Metcalfe DD. Understanding the mechanisms of anaphylaxis. Curr Opin Allergy Clin Immunol 2008; 8:310-15.

Sampson HA, Muñoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, 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; 117:391-7.

Campbell RL, Hagan JB, Manivannan V, Decker WW, Kanthala AR, Bellolio MF, et al. Evaluation of national institute of allergy and infectious diseases

/ food allergy and anaphylaxis network criteria for the diagnosis of anaphylaxis in emergency department patients. J Allergy Clin Immunol 2012; 129:748-52.

Lieberman P, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM, Bernstein DI, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010; 126:477-80.

Moneret-Vautrin DA, Renaudin JM, Petit N, Mertes PM, Bellou A. Anaphylaxie sévère : prise en charge concertée entre médecins de l’urgence et allergologues. Urgences 2009; 353-61.

Rudders SA, Banerji A, Clark S, Camargo CA Jr. Age-related differences in the clinical presentation of food-induced anaphylaxis. J Pediatr 2011; 158:326-28.

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; 115:217-23.

Haute autorité de santé. Conduite à tenir après le traitement d’urgence d’une suspicion d’anaphylaxie. Messages clés à partir d’une recommandation de bonne pratique clinique élaborée par un organisme public. HAS 2013, Ed. Saint-Denis La Plaine 32 p. (last access 13/05/2016)

Beaudouin E. Anaphylaxie alimentaire induite par l’effort : épidémiologie et aspects cliniques. Rev Fr Allergol 2010; 50:184-7.

Commins SP, James HR, Stevens W, Pochan SL, Land MH, King C, et al. Delayed clinical and ex vivo response to mammalian meat in patients with IgE to galactose-alpha-1, 3-galactose. J Allergy Clin Immunol 2014; 134:108-15.

Bonadonna P, Lombardo C, Zanotti R. Mastocytosis and Allergic Diseases. Investig Allergol Clin Immunol 2014; 24:288-97.

Simons FE. Anaphylaxis in infants: Can recognition and management be improved? J Allergy Clin Immunol 2007; 120:537-40.

Floccard B, Javaud N, Crozon J, Rimmelé T. Emergency management of bradykinin-mediated angioedema. Presse Med 2015; 44:70-7.

Ring J, Messmer K. Incidence and severity of anaphylactoïde reactions to colloid volumes substitutes. Lancet 1997; 1:466-9.

Lee S, Hess EP, Nestler DM, BellamkondaAthmaram VR, Bellolio MF, Decker WW et al. Antihypertensive medication use is associated with increased organ system involvement and hospitalization in emergency department patients with anaphylaxis. J Allergy ClinImmunol 2013; 131:1103-8

Maio RF, Garrison HG, Spaite DW, Desmond JS, Gregor MA, Cayten CG, et al. Emergency medical Services outcomes project I (EMSOP I): prioritizing conditions for outcomes research. Ann Emerg Med 1999; 33:423-32.

SAMU Urgences de France et SFMU. Guide d’aide à la régulation, centre 15.Paris, SFEM éditions 2009 (2ème édition) ; 517p.

Simons FE, Ardusso LR, Dimov V, Ebisawa M, El-Gamal YM, Lockey RF, et al. World Allergy Organization Anaphylaxis Guidelines: 2013 update of the evidence base. Int Arch Allergy Immunol 2013; 162:193-204.

Campbell RL, Li JT, Nicklas RA, Sadosty AT; Members of the Joint Task Force; Practice Parameter Workgroup. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol 2014; 113:599-608.

Reitter M, Petitpain N, Latarche C, Cottin J, Massy N, Demoly P et al. Fatal anaphylaxis with neuromuscular blocking agents : a risk factor and management analysis. Allergy 2014; 69:954-9.

Pumphrey RS, Gowlan MH. Further fatal allergic reaction to food in the United Kingdom, 1992-2006. J Allergy Clin Immunol 2007; 119:1018-9.

Bautista E, Simos FE, Simons KJ, Becker AB, Duke K, Tillett M, et al. Epinephrine fails to hasten hemodynamic recovery in fully developed canine anaphylactic shock. Int Arch Allergy Immunol 2002; 128:151-64.

European Resuscitation Council Guidelines for Resuscitation. Section 1 to 11. Resuscitation 2015; 95:1-311.

Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol 2001; 108:871-3.

Wood JP, Traub SJ, Lipinski C. Safety of epinephrine for anaphylaxis in the emergency setting. World J Emerg Med 2013; 4:245-51.

Campbell RL, Bellolio MF, Knutson BD, Bellamkonda VR, Fedko MG, Nestler DM et al. Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine. J Allergy Clin Immunol Pract 2015; 3:76-80.

Mertes PM, Malinovsky JM, Jouffroy L; Working Group of the SFAR and SFA, Aberer W, Terreehorst I, Brockow K, Demoly P; ENDA; EAACI Interest Group on Drug Allergy. Reducing the risk of anaphylaxis during anesthesia: 2011 updated guidelines for clinical practice. J Investig Allergol Clin Immunol 2011; 21:442-53.

Brown SGA, Blackman KE, Stenlake V, Heddle RJ. Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation. Emerg Med J 2004; 21:149-54.

L’her E. Revision of the 3rd Consensus Conference in Intensive Care and Emergency Medicine in 1988: management of acute asthmatic crisis in adults and chidren (excluding infants). Rev Mal Respir 2002; 19:658-65.

Pumphrey RS. Fatal posture in anaphylactic shock. J Allergy Clin Immunol 2003; 112:451-2.

Verrijckt A, Mazer B, Toledano B, Gauvin F. Choc anaphylactique et autres réactions allergiques graves. Urgences et soins intensif spédiatriques. Paris, Masson éditions 2012; 241-8.

Zheng F, Barthel G, Collange O, Montémont G, Thornton SN, Longrois D et al. Methylene blue and epinephrine: a synergetic association for anaphylactic shock treatment. Crit Care Med 2013; 41:195-204.

Sleth JC, Lafforgue E, Cherici O, Nagy P. Anaphylaxis in terminal pregnancy: two case studies and review of the literature. Ann Fr Anesth Reanim 2009; 28:790-4.

Ducros A. Reversiblecerebral vasoconstriction syndrome. Lancet Neurol 2012; 11:906-17.

Winogradow J, Geppert G, Reinhard W, Resch M, Radke PW, Hengstenberg C. Tako-tsubo cardiomyopathy after administration of intravenous epinephrine during an anaphylactic reaction. Int J Cardiol 2011; 147:309-11.

Lieberman P, Simons FE. Anaphylaxis and cardiovascular disease: therapeutic dilemmas. Clin Exp Allergy 2015; 45:1288-95.

Schwartz LB. Diagnostic value of tryptase in anaphylaxis and mastocytosis. Immunol Allergy Clin North Am 2006; 26:451-63.

Valent P, Akin C, Arock M, Brockow K, Butterfield JH, Carter MC, et al. Definitions, criteria and global classifications of mast cell disorders with special reference to mast cell activation syndromes: a consensus proposal. Int Arch Allergy Clin Immunol 2012; 157:215-25.

Vitte J. Human mast cell tryptase in biology and medicine. Mol Immunol 2015; 63:18-24.

De Schryver S, Halbrich M, Clarke A, La Vieille S, Eisman H, Alizadehfar R, et al. Tryptase levels in children presenting with anaphylaxis: Temporal trends and associated factors. J Allergy ClinImmunol 2016; 137:1138-42

Laroche D, Gomis P, Gallimidi E, Malinovsky JM, Mertes PM. Diagnostic value of histamine and tryptase concentrations in severe anaphylaxis with shock or cardiac arrest during anesthesia. Anesthesiology 2014; 121:272-9.

Laroche D, Dubois F, Gérard JL, Lefrançois C, André B, Vergnaud MC, et al. Radioimmunoassay for plasma histamine: a study of false positive and false negative values. Br J Anaesth 1995; 74:430-7.

National Institute for health and Clinical Excellence (NICE) (2014) Anaphylaxis. Assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode. London NICE 2011, reviewed. (last access 13/05/2016)

Zambonino MA, Corzo JL, Muñoz C, Requena G, Ariza A, Mayorga C, et al. Diagnostic evaluation of hypersensitivity reactions to ß-lactam antibiotics in a large population of children. Pediatr Allergy Immunol 2014; 25:80-7.

Akeson N, Worth A, Sheikh A. The psycho-social impact of anaphylaxis on young people and their parents. Clin Exp Allergy 2007; 37:1213-20.