title: Anaphylaxis diagnosis and treatment at an emergency department in Puerto Rico.
abstract: OBJECTIVE
  Anaphylaxis is a severe, potentially life-threatening systemic allergic reaction. Most cases of anaphylaxis are encountered and managed at Emergency Departments (ED). We aimed to evaluate all cases of anaphylaxis and of acute allergic reactions presenting to the ED of the Veterans Affairs Caribbean Healthcare System (VACHS) to assess each patient's presentation, the possible cause of that individual's allergic reaction or anaphylaxis, and the treatment or treatments that that person received.
  
  
  METHODS
  We conducted a retrospective review of all of the cases seen at the ED from July 2007 through July 2009 in which a diagnosis of either anaphylaxis (ICD-9-CM 995.0) or allergic reaction (ICD-9-CM 995.3) was made. We reviewed the diagnosis of each case using the anaphylaxis guidelines and compared the presentations, causes, treatments, and outcomes of patients with recognized or unrecognized anaphylaxis.
  
  
  RESULTS
  The study included 135 adults. Six patients (4.4%) were diagnosed with anaphylaxis and 129 patients (95.6%) were found to have been suffering from allergic reactions. Among the patients diagnosed with allergic reactions, 25 (23%) met the diagnostic criteria for anaphylaxis but were not recognized as having experienced it. The most common causes for anaphylaxis were food (41.9%), medication (38.7%), and insect bites or stings (12.9%); in 12.9% of the cases, a cause could not be determined. There were no statistically significant differences between groups in terms of demographics, causes, or symptoms. Significant differences were found in patient vital signs upon ED arrival. There was under-treatment, particularly among subjects with unrecognized anaphylaxis. Only 67% of recognized and 4% of unrecognized anaphylaxis were treated with epinephrine (p<0.001). It was more likely for subjects whose anaphylaxis was recognized to be admitted than was the case for patients whose anaphylaxis went unrecognized or who were merely suffering from allergic reactions (p<0.001).
  
  
  CONCLUSIONS
  Anaphylaxis is under-diagnosed and under-treated in ED patients receiving care at the VACHS. There is a need to improve anaphylaxis recognition and treatment in the ED setting and, in addition, to better identify barriers to optimal health care.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Calderón
authors.forename: Javier
authors.initials: J
authors.lastname: Méndez
authors.affiliation: School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico.
authors.forename: Sylvette
authors.initials: S
authors.lastname: Nazario
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D000707:Anaphylaxis / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology; D000818:Animals; D003937:Diagnosis, Differential; D003951:Diagnostic Errors; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D004837:Epinephrine / Q000627:therapeutic use; D005260:Female; D005512:Food Hypersensitivity / Q000150:complications / Q000276:immunology; D006787:Hospitals, Veterans / Q000706:statistics & numerical data; D006801:Humans; D006967:Hypersensitivity / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology / Q000209:etiology; D007299:Insect Bites and Stings / Q000150:complications / Q000276:immunology; D008297:Male; D008875:Middle Aged; D011647:Puerto Rico / Q000453:epidemiology; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D063189:Symptom Assessment
chemical_list: D000305:Adrenal Cortex Hormones; D004837:Epinephrine