Recognition of Anaphylaxis by First Aid Providers (FA): Scoping Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable

Task Force Scoping Review Citation

Carlson JN, Bendall J, Zideman D, Singletary E on behalf of the International Liaison Committee on Resuscitation First Aid Task Force. Recognition of Anaphylaxis by First Aid Providers Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force, 2019 December 28. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

The general topic of anaphylaxis recognition by first aid providers was reviewed 2010 and a Consensus on Science with Treatment Recommendations was published (Markenson 2010 S582) with a recommendation that first aid providers ‘should not be expected to recognize the signs and symptoms of anaphylaxis without repeated episodes of training and encounters with victims of anaphylaxis.’

As the previous search did not specify signs and symptoms that may aid in the recognition of anaphylaxis, we created a new search strategy to identify relevant work. The continuous evidence evaluation process started with a scoping review of recognition of anaphylaxis by first aid providers conducted by the ILCOR First Aid Task Force Scoping Review team. Evidence from published and grey literature was also sought and considered by the First Aid Task Force.

Scoping Review

Webmaster to insert the Scoping Review citation and link to PubMed using this format when/if it is available.

Not Applicable

PICOST

Search Strategies

Published Literature (See Appendix 1, PRISMA diagram)

Search executed on October 22, 2019

Database: EBM Reviews - Cochrane Database of Systematic Reviews <2005 to October 16, 2019>, EBM Reviews - ACP Journal Club <1991 to September 2019>, EBM Reviews - Database of Abstracts of Reviews of Effects <1st Quarter 2016>, EBM Reviews - Cochrane Clinical Answers <August 2019>, EBM Reviews - Cochrane Central Register of Controlled Trials <September 2019>, EBM Reviews - Cochrane Methodology Register <3rd Quarter 2012>, EBM Reviews - Health Technology Assessment <4th Quarter 2016>, EBM Reviews - NHS Economic Evaluation Database <1st Quarter 2016>, Embase <1974 to 2019 October 21>, Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily <1946 to October 21, 2019>

Search strategy for the databases listed above:

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1 ((recogni* or knowledge* or skill* or educat* or information* or train*) adj5 (anaphyla* or epinephrin* or adrenalin* or epi-pen* or epipen*)).tw,kf. (2403)

2 ((underus* or under-us* or underutili* or under-utili*) adj5 (anaphyla* or epinephrin* or adrenalin* or epi-pen* or epipen*)).tw,kf. (280)

3 ((comfort* or discomfort* or dis-comfort* or uncomfortable or confiden* or empower*) adj5 (anaphyla* or epinephrin* or adrenalin* or epi-pen* or epipen*)).tw,kf. (245)

4 (manage* adj2 anaphyla*).tw,kf. (1353)

5 or/1-4 (3656)

6 Patient Education as Topic/ (184100)

7 Self Administration/ (22935)

8 Self-Management/ (46377)

9 (layperson* or lay-person* or laypeople* or lay-people* or nonprofessional* or non-professional*).tw,kf. (15545)

10 (parent or parents or parental or communit* or teacher* or caregiver* or care-giver* or personnel* or school* or child care worker* or childcare worker* or aide*).tw,kf. (2835809)

11 (patient* adj4 (educat* or train* or manage* or instruct* or confiden* or complian* or adheren*)).tw,kf. (771082)

12 self-manage*.tw,kf. (52188)

13 First Aid/ (16804)

14 Emergency Medical Technicians/ (12950)

15 (first aid* or first respon* or EMT or emergency medical technician* or paramedic* or para-medic* or ambulance*).tw,kf. (112286)

16 or/6-15 (3834288)

17 5 and 16 (1321)

18 exp Animals/ not (exp Animals/ and Humans/) (17905487)

19 17 not 18 [ANIMAL-ONLY REMOVED] (786)

20 (comment or editorial or news or newspaper article).pt. (1997021)

21 19 not 20 [OPINION PIECES REMOVED] (778)

22 21 use ppez [MEDLINE RECORDS] (369)

23 ((recogni* or knowledge* or skill* or educat* or information* or train*) adj5 (anaphyla* or epinephrin* or adrenalin* or epi-pen* or epipen*)).tw,kw. (2447)

24 ((underus* or under-us* or underutili* or under-utili*) adj5 (anaphyla* or epinephrin* or adrenalin* or epi-pen* or epipen*)).tw,kw. (280)

25 ((comfort* or discomfort* or dis-comfort* or uncomfortable or confiden* or empower*) adj5 (anaphyla* or epinephrin* or adrenalin* or epi-pen* or epipen*)).tw,kw. (255)

26 (manage* adj2 anaphyla*).tw,kw. (1371)

27 or/23-26 (3714)

28 patient education/ (193460)

29 drug self administration/ (11097)

30 self medication/ (14746)

31 (layperson* or lay-person* or laypeople* or lay-people* or nonprofessional* or non-professional*).tw,kw. (15613)

32 (parent or parents or parental or communit* or teacher* or caregiver* or care-giver* or personnel* or school* or child care worker* or childcare worker* or aide*).tw,kw. (2849331)

33 (patient* adj4 (educat* or train* or manage* or instruct* or confiden* or complian* or adheren*)).tw,kw. (781043)

34 self-manage*.tw,kw. (53227)

35 layperson/ (391)

36 first aid/ (16804)

37 rescue personnel/ (7542)

38 (first aid* or first respon* or EMT or emergency medical technician* or paramedic* or para-medic* or ambulance*).tw,kw. (113869)

39 or/28-38 (3839518)

40 27 and 39 (1337)

41 exp animal experimentation/ or exp animal model/ or exp animal experiment/ or nonhuman/ or exp vertebrate/ (48858186)

42 exp human/ or exp human experimentation/ or exp human experiment/ (38944109)

43 40 not (41 not 42) [ANIMAL STUDIES REMOVED] (1326)

44 (editorial or conference abstract).pt. (4774625)

45 43 not 44 [OPINION PIECES, CONFERENCE ABSTRACTS REMOVED] (917)

46 45 use oemezd [EMBASE RECORDS] (478)

47 ((recogni* or knowledge* or skill* or educat* or information* or train*) adj5 (anaphyla* or epinephrin* or adrenalin* or epi-pen* or epipen*)).tw,kw. (2447)

48 ((underus* or under-us* or underutili* or under-utili*) adj5 (anaphyla* or epinephrin* or adrenalin* or epi-pen* or epipen*)).tw,kw. (280)

49 ((comfort* or discomfort* or dis-comfort* or uncomfortable or confiden* or empower*) adj5 (anaphyla* or epinephrin* or adrenalin* or epi-pen* or epipen*)).tw,kw. (255)

50 (manage* adj2 anaphyla*).tw,kw. (1371)

51 or/47-50 (3714)

52 Patient Education as Topic/ (184100)

53 Self Administration/ (22935)

54 Self-Management/ (46377)

55 (layperson* or lay-person* or laypeople* or lay-people* or nonprofessional* or non-professional*).tw,kw. (15613)

56 (parent or parents or parental or communit* or teacher* or caregiver* or care-giver* or personnel* or school* or child care worker* or childcare worker* or aide*).tw,kw. (2849331)

57 (patient* adj4 (educat* or train* or manage* or instruct* or confiden* or complian* or adheren*)).tw,kw. (781043)

58 self-manage*.tw,kw. (53227)

59 First Aid/ (16804)

60 Emergency Medical Technicians/ (12950)

61 (first aid* or first respon* or EMT or emergency medical technician* or paramedic* or para-medic* or ambulance*).tw,kw. (113869)

62 or/52-61 (3855626)

63 51 and 62 (1348)

64 conference abstract.pt. (3633022)

65 63 not 64 [CONFERENCE ABSTRACTS REMOVED] (942)

66 65 use coch [COCHRANE DATABASE OF SYSTEMATIC REVIEWS] (9)

67 65 use cctr [COCHRANE CENTRAL] (67)

68 65 use acp [ACP JOURNAL CLUB] (0)

69 65 use dare [DATABASE OF ABSTRACTS OF REVIEWS OF EFFECTS] (2)

70 65 use clcmr [COCHRANE METHODOLOGY REGISTER DATABASE] (0)

71 65 use clhta [HEALTH TECHNOLOGY ASSESSMENT DATABASE] (0)

72 65 use cleed [NATIONAL HEALTH SERVICE ECONOMIC EVALUATION DATABASE] (0)

73 22 or 46 or 66 or 67 or 68 or 69 or 70 or 71 or 72 [ALL DATABASES] (925)

74 remove duplicates from 73 [TOTAL UNIQUE RECORDS] (565)

75 74 use ppez [MEDLINE UNIQUE RECORDS] (37)

76 74 use oemezd [EMBASE UNIQUE RECORDS] (461)

77 74 use coch [COCHRANE DATABASE OF SYSTEMATIC REVIEWS UNIQUE RECORDS] (9)

78 74 use cctr [CENTRAL UNIQUE RECORDS] (56)

79 74 use acp [ACP JOURNAL CLUB UNIQUE RECORDS] (0)

80 74 use dare [DATABASE OF ABSTRACTS OF REVIEWS OF EFFECTS UNIQUE RECORDS] (2)

81 74 use clcmr [COCHRANE METHODOLOGY REGISTER DATABASE] (0)

82 74 use clhta [HEALTH TECHNOLOGY ASSESSMENT DATABASE] (0)

83 74 use cleed [NATIONAL HEALTH SERVICE ECONOMIC EVALUATION DATABASE] (0)

CINAHL

Grey Literature (See Appendix 2)

Google search terms executed on November 18, 2019

Google search results executed on November 18, 2019

Inclusion and Exclusion criteria

Inclusion: Human studies, all languages, all ages.

Exclusion: Studies not reporting recognition of anaphylaxis

Data tables

Details of two identified studies are included below (see Narrative summary of evidence identified). No separate data tables.

Task Force Insights

1. Why this topic was reviewed.

The 2010 ILCOR Consensus on Science for this topic identified very low certainty evidence from eight studies highlighting the limited ability of first aid providers in correctly identifying anaphylaxis. [Markenson 2010 S582] Since the 2010 review, the ILCOR continuous evidence evaluation process has included regular database searches for additional new studies, without results. The First Aid Task Force sought to conduct a scoping review to search for additional publications in the grey literature that may require revisiting recommendations or lead to a systematic review, with a focus on specific symptoms that may help to better identify anaphylaxis.

2. Narrative summary of evidence identified

We did not identify any studies that directly addressed our PICOST however we did identify data from two studies through our published literature search that suggested the rate of recognition may be improved with educational interventions. None were performed in the first aid setting but did include individuals who may be first aid providers (e.g. school teachers). We did not identify any additional literature addressing the outcome of our PICOST in our grey literature search.

Brockow et al. performed a prospective randomized trial of an educational intervention aimed at improving the recognition of anaphylaxis.[Brockow 2015 227] The authors enrolled 95 ‘caregivers’ and 98 patients with previous episodes of anaphylaxis to receive either two 3-hour modules covering various aspects of anaphylaxis (recognition, management, administration of epinephrine autoinjector, etc.) (n=103) compared to no education (n=90) and compared change in knowledge (20 point multiple choice questionnaire), competence (Objective Structured Clinical Exam; OSCE] and anxiety with anaphylaxis (Hospital Anxiety Depression Scale [HADS]) from baseline to 3-months after the intervention. ‘Knowledge’ and ‘Emergency Management Competence’ was higher in the education group at 3-months (estimated marginal mean; 95% confidence interval [CI]) (2.67; 95% CI 1.58 to 3.77 and 6.01; 95% CI 4.57; 7.45 respectively).

Litarowsky et al. performed a prospective trial evaluating the impact of an educational intervention aimed at improving the recognition of anaphylaxis. [Litarowsky 2004 279] The authors enrolled 53 adults employed at a high school in the United States. The educational intervention included a slideshow presentation on various aspect of anaphylaxis (recognition, management, administration of epinephrine autoinjector, etc.), a video on how to use an epinephrine autoinjector, and open discussion time with students with a history of anaphylaxis. Participants were provided copies of the presentation as well as a copy of the school districts care plan for anaphylaxis management. Participants were given a 10-question pre and post-test to evaluate knowledge with anaphylaxis recognition. Overall mean knowledge scores (Standard Deviation) improved with the intervention (pre-education 5.28 (1.769) compared to post-education 8.91 (1.484) p<0.001).

Our grey literature search did not identify any additional sources of information that addressed the outcomes of our PICOST.

3. Narrative Reporting of the task force discussions

We discussed many issues relating to evaluation of this PICOST. Our primary outcome was anaphylaxis recognition. We did not examine other outcomes dependent on the ability to identify anaphylaxis such as the time to epinephrine administration. The previous version of this PICOST identified low rates of correct identification of anaphylaxis, including in healthcare providers. We did not identify any data to suggest that the presence or absence of any specific symptom may improve the accuracy of recognizing anaphylaxis in the first aid setting. The previous review has found low rates of appropriate identification of anaphylaxis even among health-care providers. [Markenson 2010 S582] Our task force believes there is difficulty with first aid recognition of most healthcare conditions (anaphylaxis, cerebrovascular accident, etc.) and this issue requires additional evaluation to better understand how to assist first aid providers in identifying a range of conditions. Two different educational interventions were identified that improved the knowledge around anaphylaxis recognition and care although their use was not tested in a real-life scenario. How these findings translate into practice is unknown. The studies highlight the key role that education can plan in anaphylaxis recognition. While outside the scope of this review, education around anaphylaxis recognition, management and epinephrine administration may benefit from a dedicated scoping or systematic review in the future.

We also discussed that patients may report a history of anaphylaxis and that they believe they are having an allergic reaction to first aid providers. This may be a key element in helping first aid providers recognize anaphylaxis.

The 2010 ILCOR Treatment Recommendation for this PICOST states:

“First aid providers should not be expected to recognize the signs and symptoms of anaphylaxis without repeated episodes of training and encounters with victims of anaphylaxis.”[Markenson 2010 S582]

Given these discussion points, combined with the limited additional information identified in this review, the task force did not feel there was sufficient information to warrant reconsideration of the existing ILCOR treatment recommendations or to pursue a systematic review.

Knowledge Gaps

This scoping review highlights significant gaps in the research evidence.

• It is unclear if the presence or absence of specific symptom help first aid providers recognize anaphylaxis
• Educational interventions improve knowledge around anaphylaxis recognition and management; however, research is needed to evaluate how these results translate to the first aid setting
• How the self-reported elements history and symptoms improve recognition for first aid providers is unknown.

Attachments

PRISMA: Appendix-1-PRISMA diagram anaphylaxis recognition

Grey Literature: Appendix-2 Grey Websites Anaphylaxis Recognition

References

Brockow K, Schallmayer S, Beyer K, et al. Effects of a structured educational intervention on knowledge and emergency management in patients at risk for anaphylaxis. Allergy. Feb 2015;70(2):227-235.

Litarowsky JA, Murphy SO, Canham DL. Evaluation of an anaphylaxis training program for unlicensed assistive personnel. The Journal of school nursing: the official publication of the National Association of School Nurses. Oct 2004;20(5):279-284.

Markenson D, Ferguson JD, Chameides L, Cassan P, Chung K-L, Epstein JL, Gonzales L, Hazinski MF, Herrington RA, Pellegrino JL, Ratcliff N, Singer AJ, on behalf of the First Aid Chapter Collaborators. Part 13: first aid: 2010 American Heart Association and American Red Cross International Consensus on First Aid Science With Treatment Recommendations. Circulation. 2010;122(suppl 2):S582–S605.