Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The Task Force members report no conflicts of interest.
Task Force Synthesis Citation
Daniel Meyran, Pascal Cassan, Michael Nemeth, Eunice M. Singletary, James Raitt, Therese Djärv, Jestin N. Carlson on behalf of the International Liaison Committee on Resuscitation first aid Task Force(s). The Ability of First Aid Providers to Recognize Anaphylaxis
Task Force Synthesis of a Scoping Review [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force
Methodological Preamble and Link to Published Scoping Review
The continuous evidence evaluation process started with a 2010 review and worksheet (FA-303) on the ability of first aid providers to recognize anaphylaxis, conducted by the International First Aid Science Advisory Board (IFASAB). {Markenson 2010 S582} A scoping review on this topic completed by the ILCOR First Aid Task Force in 2019 utilized a new search strategy to identify relevant studies. The 2019 review identified educational approaches aimed at improving knowledge of signs and symptoms of anaphylaxis as part of a strategy for first aid management of anaphylaxis, including administration of epinephrine. A 2020 evidence update on this topic identified a significant volume of new studies and led to a recommendation for an updated scoping review. Evidence from the peer-reviewed and grey literature was identified and considered by members of the ILCOR First Aid Task Force.
Scoping Review
Daniel Meyran, Pascal Cassan, Michael Nemeth, Eunice M. Singletary, James Raitt, Therese Djärv, Jestin N. Carlson on behalf of the International Liaison Committee on Resuscitation First Aid Task Force. The Ability of First Aid Providers to Recognize Anaphylaxis.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Adults and children experiencing anaphylaxis
Intervention: Description of any specific symptoms to the first aid provider
Comparators: Absence of any specific description
Outcomes: Anaphylaxis recognition (critical)
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) and case series or reports are eligible for inclusion. Grey literature, social media publications, non-peer reviewed studies, unpublished studies, conference abstracts and trial protocols are eligible for inclusion. All relevant publications in any language are included as long as there is an English abstract
Timeframe: all years.
Literature search updated on 19 September 2022.
Search Strategies Attachment: FA 7110 Search Strategies
Data tables Attachment: FA 7110 Data tables
Task Force Insights
1. Why this topic was reviewed.
The purpose of this scoping review was to examine the literature since the 2010 ILCOR CoSTR{Markenson 2010 S582-605) to establish whether there was new evidence in published and grey literature regarding first aid providers’ ability to recognize anaphylaxis.
A scoping review on this topic completed by the ILCOR First Aid Task Force in 2019 utilized a new search strategy to identify relevant studies. The 2019 review identified educational approaches aimed at improving knowledge of signs and symptoms of anaphylaxis as part of a strategy for first aid management of anaphylaxis, including administration of epinephrine.
A 2020 evidence update on this topic identified a significant volume of new studies and led to a recommendation for an updated scoping review.
2. Narrative summary of evidence identified
We have not identified any new data in the published and grey literature to suggest that the presence or absence of any specific symptom may improve the accuracy of recognizing anaphylaxis by the first-aid provider.
We have extended our search strategy and selected articles including individuals who may be first aid providers as patients, parents, teachers, school staff, and childminders. We have selected articles which do not directly assess the signs or symptoms of anaphylaxis but rather how to assess and improve the level of participant knowledge, recognition and management of anaphylaxis. Ultimately, these studies aim to increase the number of patients with anaphylaxis who receive epinephrine as a potentially lifesaving first aid intervention.
Two experimental studies and eight observational studies reported an increase of knowledge in recognition of anaphylaxis in a population of patients, parents, school staff or caregivers after an educational intervention as a theoretical and practical course, viewing videos, health app use or coaching with clinicians {Brockow 2015 227-35, Canon 2019 2152656719856324, Dumeier 2018 575-81, Ferran 2020 384-89, Gallagher 2019 319-25, Gonzalez-Mancebo 2019 60-63, Jiang 2019 107-08, Litarowsky 2004 279-84, Polloni 2020 380-87, Soller 2018 693-95).
The use and the effect of an action plan and the dissemination of specific recommendations for patients and in school communities are described in two studies with no demonstrated level of effectiveness{Alqurashi 2020 227-33, Korematsu e14973).
The need for learning and training of the population seems important, and the absence of training in recognition of anaphylaxis is identified as a factor of underuse of epinephrine{Miles 2021 2321-33).
Even if the initial level of knowledge in recognition of anaphylaxis before an educational intervention is low and increased after an educational intervention, five observational studies which assessed the level of knowledge of recognition and management of anaphylaxis in a population of caregivers, nurses, nannies, parents and patients who sometimes have been informed or even trained a few months or a few years ago, stay low. Several studies reported a low initial level of knowledge and recognition of anaphylaxis before an educational intervention and training with improvement immediately following the intervention. Despite this, five observational studies of caregivers, nurses, nannies, parents and patients reported that measurements of knowledge and recognition of anaphylaxis remained low within a few months or years of educational interventions and training. {Efthymiou 2021 2083, Esenboga 3-7, Glassberg 2021 175-79.e3, Greiwe 2015 63-67).
3. Narrative Reporting of the task force discussions
One of the most concerning aspects of anaphylaxis happens to be the general global rise in cases. The rate of anaphylaxis and hospital admissions increased for over 15 years in adults and in children{Simons 2011 13-37). Given the increasing rate of anaphylaxis, it is essential to better understanding challenges and limitations to anaphylaxis recognition and treatment in the first aid setting.
Epinephrine is a potentially life-saving intervention for anaphylaxis. The ability of a first aid provider to recognize anaphylaxis is a critical step prior to administering epinephrine.
The studies identified in this scoping review are encouraging, with several surveys reporting improvement in the ability to recognize anaphylaxis immediately following individual or community level educational engagements.
New local policies and implementation of action plans or protocols about recognition and management of anaphylaxis deserve future studies to show their short and long-term effectiveness. The content and form of the action plan or protocols should also be analyzed as they could affect its efficiency.
Previous literature has identified different factors associated with underuse of epinephrine in anaphylaxis{Pflipsen 355-62, Prince 2018 143-51). Recognition of anaphylaxis is one of the identified factors which can decrease temporal delay in the administration of epinephrine when it is available, although evidence for this is limited. Recognition of anaphylaxis is not the only barrier to the first aid use of epinephrine autoinjectors. The high cost of epinephrine, lack of epinephrine availability among patients or in some settings such as schools, the lack of epinephrine use even when available and incorrect AEI administration technique are also barriers contributing to the underuse of epinephrine when it is needed.
The FATF acknowledges that the current scoping review and research question, as worded (the description of any specific symptoms to the first aid provider, compared with the absence of any specific description), does not provide evidence related to the education of recognition. As such the task force suggests that this research question be reworded to focus on educational strategies to improve recognition of anaphylaxis and considered for a future review.
The previous treatment recommendation of the 2010 ILCOR CoSTR continues to be supported with the limited evidence identified: “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”.
Knowledge Gaps
What educational or training techniques can improve the ability of first aid providers to recognize and care for a person with anaphylaxis?
Does the first aid administration of epinephrine to a person with suspected anaphylaxis decrease hospitalization and mortality rates?
References
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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. 2015;70:227-35.
Canon N, Gharfeh M, Guffey D, et al. Role of Food Allergy Education: Measuring Teacher Knowledge, Attitudes, and Beliefs. Allergy Rhinology. 2019;10:2152656719856324.
Dumeier HK, Richter LA, Neininger MP, et al. Knowledge of allergies and performance in epinephrine auto-injector use: a controlled intervention in preschool teachers. Eur J Pediatr. 2018;177:575-81.
Efthymiou D, Panayi P, Feketea G, et al. Alliance with the School Personnel Is Crucial for the Management of Food Allergy and Anaphylaxis in School Children. Foods. 2021;10:2083.
Esenboga S, Kahveci M, Cetinkaya PG, et al. Physicians prescribe adrenaline autoinjectors, do parents use them when needed? Allergol Immunopath. 48:3-7.
Ferran LR, Tornero NG, Álvarez NC, et al. Anaphylaxis at school. Are we prepared? Could we improve? Allergol Immunopath. 2020;48:384-89.
Gallagher JL, Rivera RD, Shepard KV, et al. Life-Threatening Allergies: Using a Patient-Engaged Approach. Telemed E-health. 2019;25:319-25.
Glassberg B, Nowak-Wegrzyn A, Wang J. Factors contributing to underuse of epinephrine autoinjectors in pediatric patients with food allergy. Ann Allergy Asthma Immunol. 2021;126:175-79.e3.
Gonzalez-Mancebo E, Gandolfo-Cano MM, Trujillo-Trujillo MJ, et al. Analysis of the effectiveness of training school personnel in the management of food allergy and anaphylaxis. Allergol Immunopath. 2019;47:60-63.
Greiwe JC, Pazheri F, Schroer B. Nannies' Knowledge, Attitude, and Management of Food Allergies of Children: An Online Survey. The Journal of Allergy and Clinical Immunology: In Practice. 2015;3:63-67.
Jiang J, Gallagher J, Szkodon J, et al. The Development and Evaluation of Peer Food Allergy Education Videos for School- Age Youth. Ann Allergy Asthma Immunol. 2019;123:107-08.
Korematsu S, Kaku M, Kitada S, et al. Anaphylaxis and onsite treatment in schools, kindergartens, and nurseries. Pediatr Int. 64:e14973.
Litarowsky JA, Murphy SO, Canham DL. Evaluation of an Anaphylaxis Training Program for Unlicensed Assistive Personnel. The Journal of School Nursing. 2004;20:279-84.
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Miles LM, Ratnarajah K, Gabrielli S, et al. Community Use of Epinephrine for the Treatment of Anaphylaxis: A Review and Meta-Analysis. The Journal of Allergy and Clinical Immunology: In Practice. 2021;9:2321-33.
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Polloni L, Baldi I, Lazzarotto F, et al. Multidisciplinary education improves school personnel’s self‐efficacy in managing food allergy and anaphylaxis. Pediatr Allergy Immu. 2020;31:380-87.
Prince BT, Mikhail I, Stukus DR. Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities. J Asthma Allergy. 2018;11:143-51.
Simons FE, Ardusso LR, Bilo MB, et al. World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2011;4:13-37.
Soller L, Teoh T, Baerg I, et al. Extended analysis of parent and child confidence in recognizing anaphylaxis and using the epinephrine autoinjector during oral food challenges. The Journal of Allergy and Clinical Immunology: In Practice. 2018;7:693-95.