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      World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis

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          Abstract:

          The illustrated World Allergy Organization (WAO) Anaphylaxis Guidelines were created in response to absence of global guidelines for anaphylaxis. Uniquely, before they were developed, lack of worldwide availability of essentials for the diagnosis and treatment of anaphylaxis was documented. They incorporate contributions from more than 100 allergy/immunology specialists on 6 continents. Recommendations are based on the best evidence available, supported by references published to the end of December 2010. The Guidelines review patient risk factors for severe or fatal anaphylaxis, co-factors that amplify anaphylaxis, and anaphylaxis in vulnerable patients, including pregnant women, infants, the elderly, and those with cardiovascular disease. They focus on the supreme importance of making a prompt clinical diagnosis and on the basic initial treatment that is urgently needed and should be possible even in a low resource environment. This involves having a written emergency protocol and rehearsing it regularly; then, as soon as anaphylaxis is diagnosed, promptly and simultaneously calling for help, injecting epinephrine (adrenaline) intramuscularly, and placing the patient on the back or in a position of comfort with the lower extremities elevated. When indicated, additional critically important steps include administering supplemental oxygen and maintaining the airway, establishing intravenous access and giving fluid resuscitation, and initiating cardiopulmonary resuscitation with continuous chest compressions. Vital signs and cardiorespiratory status should be monitored frequently and regularly (preferably, continuously). The Guidelines briefly review management of anaphylaxis refractory to basic initial treatment. They also emphasize preparation of the patient for self-treatment of anaphylaxis recurrences in the community, confirmation of anaphylaxis triggers, and prevention of recurrences through trigger avoidance and immunomodulation. Novel strategies for dissemination and implementation are summarized. A global agenda for anaphylaxis research is proposed.

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          Most cited references126

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          Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

          The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.
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            Delayed anaphylaxis, angioedema, or urticaria after consumption of red meat in patients with IgE antibodies specific for galactose-alpha-1,3-galactose.

            Carbohydrate moieties are frequently encountered in food and can elicit IgE responses, the clinical significance of which has been unclear. Recent work, however, has shown that IgE antibodies to galactose-alpha-1,3-galactose (alpha-gal), a carbohydrate commonly expressed on nonprimate mammalian proteins, are capable of eliciting serious, even fatal, reactions. We sought to determine whether IgE antibodies to alpha-gal are present in sera from patients who report anaphylaxis or urticaria after eating beef, pork, or lamb. Detailed histories were taken from patients presenting to the University of Virginia Allergy Clinic. Skin prick tests (SPTs), intradermal skin tests, and serum IgE antibody analysis were performed for common indoor, outdoor, and food allergens. Twenty-four patients with IgE antibodies to alpha-gal were identified. These patients described a similar history of anaphylaxis or urticaria 3 to 6 hours after the ingestion of meat and reported fewer or no episodes when following an avoidance diet. SPTs to mammalian meat produced wheals of usually less than 4 mm, whereas intradermal or fresh-food SPTs provided larger and more consistent wheal responses. CAP-RAST testing revealed specific IgE antibodies to beef, pork, lamb, cow's milk, cat, and dog but not turkey, chicken, or fish. Absorption experiments indicated that this pattern of sensitivity was explained by an IgE antibody specific for alpha-gal. We report a novel and severe food allergy related to IgE antibodies to the carbohydrate epitope alpha-gal. These patients experience delayed symptoms of anaphylaxis, angioedema, or urticaria associated with eating beef, pork, or lamb.
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              Clinical practice. Hereditary angioedema.

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                Author and article information

                Journal
                World Allergy Organ J
                World Allergy Organ J
                wox
                The World Allergy Organization Journal
                World Allergy Organization Journal
                1939-4551
                23 February 2011
                February 2011
                : 4
                : 2
                : 13-37
                Affiliations
                [1 ]Department of Pediatrics & Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Canada
                [2 ]Cátedra Neumonología, Alergia e Inmunología Facultad de Ciencias Médicas, Universidad Nacional de Rosario, Rosario, Argentina
                [3 ]Allergy Unit, Department of Internal Medicine, University Hospital Ospedali Riuniti, Ancona, Italy
                [4 ]Pediatric Allergy and Immunology Unit, Ain Shams University, Cairo, Egypt
                [5 ]University of South Florida College of Medicine, Tampa, FL
                [6 ]Department of Dermatology and Allergy, Technology Universitat Muenchen, Munich, Germany
                [7 ]Centro Medico Docente La Trinidad, Caracas, Clinica El Avila, Caracas, Venezuela
                [8 ]The Allergy Unit, Verona General Hospital, Verona, Italy
                [9 ]Center for Population Health Sciences, The University of Edinburgh, Edinburgh, United Kingdom
                [10 ]Department of Rheumatology, Allergy & Immunology, Tan Tock Seng Hospital, Singapore.
                Author notes

                This paper was approved by the WAO House of Delegates February 18, 2011.

                This paper is also being published in the Journal of Allergy and Clinical Immunology (JACI) as an electronic publication available online in March 2011. A summary of the article will appear in JACI in the March 2011 issue as: Simons FER, Ardusso LRF, Bilo MB, El-Gamal YM, Ledford DK, Ring J, et al. World Allergy Organization Anaphylaxis Guidelines: Summary. J Allergy Clin Immunol. 2011;127(3):587–93. e1-e20.

                DISCLAIMER: The information contained in the text, figures, and tables of the WAO Anaphylaxis Guidelines is correct at the time of publication; however, recommendations, for example, those for medications and doses, might need to be individualized according to the needs of the patient, and the medications, supplies, equipment, and skilled support available; moreover, recommendations change over time.

                Correspondence to: Prof. F. Estelle R. Simons, Room FE125 820 Sherbrook Street, Winnipeg, Manitoba, Canada, R3A 1R9. Telephone: 204-787-2537. Fax: 204-787-5040. E-mail: lmcniven@ 123456hsc.mb.ca .
                Article
                10.1097/WOX.0b013e318211496c
                3500036
                23268454
                ef14303a-cdc2-4e09-a418-a1ce9bf448e6
                Copyright © 2011 by World Allergy Organization
                History
                Categories
                WAO Position Paper

                Immunology
                anaphylaxis,antihistamines,glucocorticoids,clinical diagnosis,risk factors,epinephrine (adrenaline)

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