SHARED (Saguenay Hospitals Anaphylaxis Rule for Early Discharge) - Phase 2 : a Prospective Theoretical Validation
Conditions: Anaphylaxis, Biphasic Anaphylactic Reaction, Rebound Anaphylactic Reaction
Sponsor: Université de Sherbrooke

 
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RESEARCH PROTOCOL  
 
 
 
 
SHARED study 
Saguenay Clinical Decision Rule for Quick Leave  
emergency after a diagnosis of anaphylaxis 
- Protocol phase 2  - 
 
 
Project to be submitted to the Ethics Committee and  
CIUSSS scientist in Saguenay - Lac-St-Jean 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Emergency service 
CIUSSS du Saguenay - Lac-St-Jean  
 
 
Department of Family Medicine and Emergency Medicine 
Faculty of Medicine and Health Sciences  
Université de Sherbrooke 
 
 
 
 
Version of the 25 Feb. 2020 
 

 
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1. 
PROBLEM 
Anaphylaxis is a condition frequently encountered in emergency departments (0.05 to 2% in the 
general population)1, which is defined by a severe allergic reaction that appears quickly and has 
fatal potential. As a result of an anaphylaxis, a serious phenomenon called a "biphasic reaction" can 
occur. This reaction is the reappearance of anaphylactic symptoms several hours after treatment. 
 
The diagnosis  of anaphylaxis is based on the impairment of more than one system (muco-skin, 
cardiovascular, respiratory, digestive) and its definition, the most recognized, is based on the 
NIAID/FAAN2 criteria developed in 2006 (Box 1). Because of its severity, the treatment of anaphylaxis 
requires rapid management, which relies mainly on the administration of epinephrine. Other 
treatments can also be used. Among other things, antihistamics can decrease skin symptoms; 
intravenous hydration contributes to hemodynamic stabilization; and intravenous corticosteroids  
may decrease the likelihood of a biphasic reaction. However, the effectiveness of the latter treatment 
option remains debated in the literature. 
 
The theoretical risk of rebound reaction, or biphasic reaction,  is  classically described up to 72  hours 
after the initial anaphylactic event. The  biphasic reaction is defined as a recurrence or    occurrence 
of new signs or symptoms after the resolution of the initial reaction, without re-exposure to the 
allergen3. The potential occurrence of a biphasic reaction often warrants observation of patients for 
several hours  in s  emergency    departments following  de  the management of the initial anaphylaxis. 
Although the recommendations and guidelines generally propose observation times of four to six 
hours, there is no clear consensus or evidence to guide this conduct. It may even be suggested to 
observe patients up to 24 hours4.5.6. To date, thereare no prognostic factors to identify a more at-risk 
patient who would benefit from such an observation. As thesereactions are a relatively rare 
phenomenon (4 to 5%, but could be as high as 20% according to some sources5  ) and the symptoms 
observed are usually less significant than at the initial presentation7,  itis therefore  possible  that a 
prolonged observation period is not necessary for some patients who do not have high risk factors for 
biphasic reaction.   
 
Box 1: NIAID/FAAN ANAPHYLAXIS CRITERIA 
Presence of one of three following criteria: 
1. 
Sudden onset, with/without exposure to identified allergen, of skin and/or mucousness with 
at least 1 of 2:  
1. 
Respiratory disease (dyspnea, wheezing, stridor, hypoxemia, ...)  
2. 
HypoTA or Sx associated with a dysfunction of the target organs (hypotonia/collapse, syncope, 
incontinence, ...)  
3. 
Probable allergen exposure and sudden onset (minutes at hours) of at least 2 of 4:  
1. 
Skin and/or mucousness (pruritus, rash, hives, etc.)  
2. 
Respiratory disease (dyspnea, wheezing, stridor, hypoxemia, ...)  
3. 
HypoTA or associated Sx (hypotonia/collapse, syncope, incontinence, ...)  
4. 
Persistent GI Sx (abdominal pain, vomiting, ...)  
5. 
Sudden hypotension (minutes to hours) following known allergen exposure  
1. 
Children: 30% systolic decrease  
2. 
Adults: 30% decrease vs. basic personal systolic tension 
 

 
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There are no definitive predictors, but  various factors of poor prognosis are recognized. These differ 
slightly between studies, but some seem to return quite systematically in the literature. First, the  
severity of the reaction  appears to increase the risk of biphasic reaction. "Severe" means,  reactions 
that initially required  1 dose of epinephrine,  those requiring a higher dose of epinephrine or an intra-
venous hydration bolus.8 Also, patients with  hypotension, pharyngeal edema or severe respiratory 
distress upon arrival at the  emergency department are among the reactions considered 
"severe"9. Patients with a total duration of  symptoms  greater than  30 minutes also appear to be 
at greater risk10. On the other hand, delayed administration of epinephrine  or  a  late presentation 
to the emergency department would also increase the risk of adverse developments.11 Finally, a  
history of anaphylaxis  and exposure to an unknown allergen would be two additional risk 
factors for biphasic reaction12. 
 
It should be noted that most studies dealing with biphasic reactions exclude patients chronically 
taking 
corticosteroids, 
antihistamines, 
or 
beta-blockers, as well as patients 
on 
immunosuppressants6. It is therefore difficult to apply any conclusions to these populations. 
1. 
RELEVANCE 
In the current context of increasing emergency department traffic  aux and the introduction   
of newgovernment, ministerial and institutional requirementsto limit emergency  room wait times 
and stretcher time, we believe it is essential to question our practices in order to  release 
patients  more quickly  and  safely  by limiting the periods of unreachable observation. Our research 
team, composed mainly of emergency physicians, hypothesizes  that if onlyone's  clinical decision rules 
remainaivalid in the subsequent stages ofour project, it  is  likely that some patients who have 
had an anaphylactic reaction may be released much earlier than the current conduct. A simple, 
generalized and valid clinical decision rule would therefore be an interesting asset for the modern 
practice of emergency medicine.  
 
These rules could also contribute to the satisfaction of patients who would spend less time in the ER. 
Also,  such  ruless  willenprovide clear guidanceto clinicians working in lower-flow settings, where 
the incidence of anaphylaxis is lower and therefore clinical experience is less sharp. Finally,  these  
ruless  will beenrelevants for teaching purposes for the various learners who do internships in our 
emergency departments. 
 
Our group of emergency medicine clinicians has therefore decided to start a research project to 
identify the rules of clinical decision following an anaphylaxis in an emergency context..  This 
project  was developed in collaboration with the  three emergency departments of Saguenay-Lac-
St-Jean (Chicoutimi, Jonquière and Alma). 
1. 
STEPS TAKEN  
A review of the literature (phase 0; Rapid review) and phase 1 of the project (statistical derivation of 
two clinical decision rules) have already been completed. The initial "rapid review" literature review 
was to highlight the main elements that appeared to be predictors of a biphasic reaction. These 
elements led to the development of an initial clinical decision rule that included 7 variables (Table 1).  
 

 
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Table 1: CLINICAL DECISION RULE ORIGINALLY DEVELOPED FROM THE RAPID REVIEW OF THE LITERATURE 
Promote an observation if one of the following is present: 
1. Time before the first dose of 60min 
2. Severe symptoms (hypoTA, respiratory sx, vomiting, intubation, syncope, incontinence) 
3. Time before symptom resolution - 40 min 
4. Anaphylaxis ATCD 
5. Number of doses of EPI IM - 1 
6. Asthma ATCD 
7. No administration of glucocorticoids 
Conflicting data in the literature review, a criterion included as exploratory in the "literature-based" rule 
 
However, for the purpose of publishing our Phase 0 (literature review), the analysis of all articles 
included in the initial literature review (rapid review) was redone by another team member. As a result 
of this comprehensive review of each article, the literature review has moved from the "rapid review" 
to the "systematic review" type and minor changes have had to be made to the rule based on the 
literature review (below). 
 
Table 2: CLINICAL DECISION RULE FROM SYSTEMATIC LITERATURE REVIEW 
Promote an observation if one of the following is present: 
1. 
Time before the first dose of 60min 
2. 
Severe symptoms (hypoTA, respiratory sx, vomiting, intubation, syncope, arrhythmias,  
diarrhea))  
3. 
Time before symptom resolution - 40 min 
4. 
Anaphylaxis ATCD 
5. 
Number of doses of EPI IM - 1 
6. 
Unknown allergen 
7. 
No administration of glucocorticoids 
Conflicting data in the systematic literature review, a criterion included as exploratory in the "literature-based" rule 
 
Thus, in terms of the criterion of severe symptoms of the initial anaphylactic reaction, we added 
arrhythmias, the presence of diarrhea and we removed incontinence. The asthma history criterion was 
removed from the rule and we added an unknown allergen. 
 
In Phase 1 of the study, two other clinical decision rules were derived retrospectively. By analyzing the 
characteristics of patients who had an anaphylactic reaction, we were able to derive a rule to identify 
a low-risk group of biphasic reaction (any symptom of allergy) and clinically significant biphasic 
reaction (i.e. meeting the criteria for an anaphylactic reaction). These rules were created with the 
highest possible negative predictive sensitivities and values (VPNs). 
 
The next step is to prospectively verify whether  these rules maintain their sensitivity and negative 
predictive value  with a different sample of patients from the same population pool. The first 
rule assesses the probability of clinically significant biphasic reactions (sensitivity of 90%, 7 variables; 
Table 3) and the second, all biphasic reactions (100%, 7 variable sensitivity; Table 4). 
Areas below the ROC curve were 0.896 and 0.874,respectively. Because the variables selected for each 
decision-making rule come from a regression model, the predicted probability of a biphasic reaction 
comes from the linear combination of selected variables. Depending on the coefficients calculated, 
each variable present in the patient will have a different weight in the decision.  
 
TABLE 3: RETROSPECTIVELY DERIVED CLINICAL DECISION RULE FOR CLINICALLY SIGNIFICANT BIPHASIC 
REACTIONS  

 
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1. 
ATCD allergy to a different agent than the one in question 
2. 
Symptoms of diarrhea 
3. 
ATCD allergy to the same agent as the one in question 
4. 
Number of doses of O.R. in the emergency room 
5. 
Food allergen (other than milk, egg, peanuts, seafood) 
6. 
Number of doses of O.R. before emergency 1 
7. 
ENT symptoms 
 
TABLE 4: RETROSPECTIVELY DERIVED CLINICAL DECISION RULE FOR BIPHASIC REACTIONS (ALL SEVERITIES CONFUSED) 
1. 
Number of doses of O.R. in the emergency room 
2. 
Epi doses data different from standard doses (ped: 0.01mg/kg, adult: 0.3-0.5mg) 
3. 
Symptoms of diarrhea 
4. 
ATCD allergy to a different agent than the one in question 
5. 
Secondary anaphylactic reaction to iodine 
6. 
Secondary anaphylactic reaction to a sting or bite 
7. 
Secondary anaphylactic reaction to an unknown allergen 
 
Note that the first two criteria of the rule for all the combined severity of biphasic reactions  (Table 4) 
were, at the time of diversion, contained in a single criterion: "standard or non-standard doses of IM 
epinephrine." However, because this criterion contained several pieces of information, it was divided 
into two new criteria to simplify and clarify data collection. For the first criterion (number of doses of 
ER in the emergency department),  not receiving repeated intramuscular doses of epinephrine 
decreased the likelihood of having a biphasic reaction. For the second criterion (differentear doses 
from standard doses),  receiving standard intramuscular doses of epinephrine decreased the likelihood 
of having a biphasic reaction compared to receiving non-standard intramuscular doses of epinephrine. 
1. 
GOALS AND ASSUMPTIONS 
The main objective of Phase 2 of our study is to validate prospectively and on a theoretical basis the 
rules of clinical decisions from previous phases of our research project. This will allow us to assess the 
internal validity of the different rules derived in the same three circles (Chicoutimi, Jonquière, Alma). 
In addition, the evaluation of the results will identify the most effective rule. 
 
The hypothesis of this study is that one of the derived rules will, when applied to a cohort of patients 
prospectively, adequately identify (sensitivity maintained) patients at low risk of biphasic reaction 
following an anaphylactic reaction. 
 
If the results of the Phase 2 study are successful, a phase 3 will be put forward. The objective of this 
third phase will be to apply the most effective rule in real time to patients who have undergone an 
anaphylactic reaction in different hospitals of the RIUSSS of the University of  Sherbrooke, i.e. to 
complete the validation of the rule in a different population. 
 
In the event of an inconclusive Phase 2 result for the three rules under study, the investigators propose 
to group the data from Phases 1 and 2 to attempt a final diversion of a new clinical decision rule. If this 
ultimate diversion is quite different from the previously tested rules and is clinically plausible, a new 
validation attempt will be made (details below). 

 
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1. 
METHODOLOGICAL 
Based on the three rules of clinical decision (2 derivatives and one based on the literature review), a 
prospective observational study will be carried out in the emergency departments of Chicoutimi, 
Jonquière and Alma. Data collection for this theoretical validation phase has been underway since 
December 2019, having received the approval of the various local research committees (ethics, 
scientific and convenience). 
 
Inclusion and exclusion criteria 
 
The inclusion criteria will be: all patients of minor or adult age who have had anaphylaxis that meet 
the known diagnostic criteria. In addition, if a patient presents with confirmed exposure to an allergen 
and symptoms that do not yet meet the anaphylaxis criteria, they may be included in the study. This 
will only be possible if the doctor deems that he will inevitably progress to anaphylaxis andtreat him 
in this way. Those who have had a reaction to taking a drug (e.g. IECA), who are known for a hereditary 
pathology (hereditary angioedema),immune or other pathology giving an anaphylactoid reaction will 
be excluded, as in Phase 1 of the study. 
 
Sample size 
 
The required sample size was adjusted for the primary objective based primarily on the study of 
sensitivity and specificity. As a low prevalence of biphasic reactions is expected, a calculation based on 
specificity is useless, therefore to be rejected. Thus, using the statistician involved in the study and 
using a sample size calculation adapted for a confidence interval on a ratio adjusted according to the 
Buderer13formula, it was determined that it was necessary to have 553 patients in total to estimate a 
sensitivity of at least 98% with a confidence level of 95% according to an accuracy of 5% and an 
expected prevalence of 6%. Note that a 10% rate was added to the initial size calculation to manage 
the possibility of missing data. The prevalence of 6% was determined from the prevalence of biphasic 
reactions observed when collecting Phase 1 data from the same study.. 
 
Data collection  
 
In the face of a case of anaphylaxis, the doctor will have to answer a short questionnaire developed 
with the variables present in each of the three rules(questionnaire  available in appendix).  The 
variables were randomly arranged on the questionnaire so that no rules could be recognized or 
inferred. If the doctor deems that a patient who does not yet present the anaphylaxis criteria, but in 
the absence of ahead,willeventually progress to real anaphylaxis, he or she will have to indicate it at 
the appropriate location on the questionnaire. Indeed,  as mentioned above, these patients will be 
included in the study, but we will  independently analyze the results of this sample to determine if 
they are different from the overall results in subgroup analyses. 
 
The questionnaire will be available at several key locations, including in the paper-based resuscitation 
rooms in the three emergencies where data collection will take place. The questionnaire  will also be 
systematically placed on the file of patients with suspected anaphylaxis at triage. The doctor will be 
required to complete the questionnaire anonymously, but will be required to provide the patient's file 
number. This will be done after the initial stabilization. After completing the questionnaire, the 
physician will simply be able to continue to care for the patient as he would have done in accord with 
his standard clinical practice. No decision rules will be applied to patients. The answers provided to 

 
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the questionnaire will therefore have no impact on the clinical decisions made by the treating 
physician. The research team will then review each of these files to assess whether or not there was a 
biphasic reaction and whether it was clinically significant (according to the NIAID/FAAN2criteria).  
 
At the next emergency department meetings involved, doctors will be notified of the operation of the 
current study. Recalls will be made as required during the course of the study to ensure the 
involvement of the medical profession. Administrative officers and triage nurses will also be advised 
to add the questionnaire to all potential anaphylaxis files. 
 
Data analysis 
 
Based on the data, all three rules will be theoretically applied to all included patients. This will 
determine which patients would have been dismissed or observed and under what rule. Subsequently, 
the records of these same patients will be retrospectively analyzed to determine the occurrence of 
biphasic reaction after the initial visit. It will be particularly interesting to assess whether the biphasic 
reaction occurred during the emergency observation period. 
 
As we seek to evaluate the effectiveness of diagnostic rules, statistical analyses will focus primarily on 
a study of sensitivity and specificity. In order to be able to properly characterize the different derived 
rules, it will also be relevant to obtain the predicted positive and negative values. Confidence intervals 
will be built around the proportions obtained. The choice of the best derived rule will be based on the 
sensitivity value obtained. Indeed, we seek to maximize this parameter in order to obtain the 
combination of variables that will allow us to use a rule to safely discharge patients with low risk of 
biphasic reaction. In the event that none of the rules maintain a fairly high sensitivity and/or negative 
predictive value, all Phase 1 and Phase 2 data will be jointly analyzed and a re-derivation test of a 
statistically stronger rule will be conducted, again using logistic regression models. 
Considering that the sample size has been revised, the study schedule has also been revised. It is 
therefore more realistic for us to expect a period of at least 2 to 3 years to complete the data collection 
for this phase 2. However, we propose to do an interim analysis of the results at least once a year. 
Data collection is currently planned for 2020 and 2021 with an initial interim analysis in May 2020. The 
team is ready to extend the "recruitment" period as needed to reach the 553 patients needed.  Data 
collection is currently well underway and the goal of recruiting 200 to 250 patients per year 
seemsrealistic. 
1. 
ETHICAL CONSIDERATIONS AND INSTITUTIONAL CONVENIENCE 
No clinical decision rules will actually be applied to patients during this phase of the study. Doctors will 
therefore take care of patients according to their usual practice. In addition, the questionnaire will 
only be completed after the initial stabilization of the patient, and will not result in delay in its 
management. We therefore consider that the risk to patients associated with this study is negligible 
or non-existent.  
To preserve the anonymity of patients, the questionnaires, once completed, will be placed in sealed 
envelopes. They will only be opened when the results are analysed by the doctors involved in the 
study. In addition, when counting the data, patients will be identified by a different random number, 
which will be associated with their file number. The "key file" of correlation between file numbers and 
identifier numbers will be securely retained by members of the search team. 

 
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The involvement of clinical staff will be minimal. The administrative officer will be responsible for 
putting the questionnaire sheet on the record of the user who presents himself with potential 
anaphylaxis when creating it. The officer will also be responsible, upon closing the emergency file, for 
removing the questionnaire sheet from the clinical file, ensuring that it is properly identified and 
keeping it in a secure stream for the study investigators..  
The triage nurse, beyond her usual role of triage and identification of potential anaphylaxis cases, will 
also be responsible for attaching a questionnaire sheet to the file, weather permitting.  
The attending physician, on the other hand, will only have to check, depending on the case, the 
appropriate boxes on the questionnaire sheet once his patient has stabilized. 
1. 
SCHEDULE 
Phase 2 will begin as soon as possible or in December 2019. Other steps will take place in the following 
months, such as:  
October 2019:  
1. 
Writing the Phase 2 protocol 
2. 
Asks the Ethics, Scientific and Institutional Convenience Committee of the Saguenay-Lac-Saint-
Jean CIUSSS for approval. 
November 2019:  
1. 
Introducing the study to emergency departments (department meetings) 
 
December 2019 
1. Start of data collection 
January and February 2020:  
2. 
Scholarship application 
3. 
Review and Amendment of the Research Protocol (following the external evaluation requested 
by FRIPS) 
February and March 2020:  
4. 
Submission of the amended protocol to the Ethics, Scientific and Institutional Convenience 
Committee of the CiUSSS of Saguenay-Lac-Saint-Jean for approval 
April 2020:  
5. 
Statistical analysis of results (first interim analysis) 
May 2020:  
6. 
Presentation of the study at the research day of the Department of MF/MU of the University of 
Sherbrooke 

 
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June 2020 to April 2021:  
7. 
Continued data collection 
May 2021:  
8. 
Second interim analysis 
9. 
Presentation of the progress of the study at the research day of the department of MF/MU of 
the University of Sherbrooke 
End of 2021 
10. 
Final Analysis or Request for Extension 
11. 
Consideration of results and possible publication 
12. 
Creating a poster and presenting it in various contexts (to be specified) 
13. 
Planning for Phase 3 of the project 
1. 
POTENTIAL OUTCOMES 
If one of the clinical decision rules is sufficiently  effective during this phase of the study (phase 
2),i.e. maintaining good sensitivity and negative predictive value, it can be applied in real time. If more 
than one rule is effective, the most easily applicable rule will be chosen. This will be done as part of a 
phase 3  study with systematic follow-up for each patient for whom the rule has been applied. 
If Phase 3 proveserait  conclusive,, the rule demonstrates has a strong negative predictive value 
during its actual clinical use and good external validity,andit will be disseminated on a larger  scale. 
Thus, we hope to facilitate the management of anaphylaxis in the emergency room by allowing  the 
early and safe release of many patients who have been treated for an anaphylactic 
reaction,ensuring that the risks of biphasic reactions are minimized.. 
The rule bearing the name of the geographic region from which it originates could help to spread the 
environment of the CIUSSS SLSJ. In addition, having received financial assistance and support from the 
MF/MU department of the University of Sherbrooke, the investigators will ensure that the name of 
the University and the Department they represent is clearly visible in their publication; also helping to 
spread the way of thisinstitution. 
 
 
 
 

 
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1. BIBLIOGRAPHIE 
1. 
Campbell, R., Kelso, K., Walls, R., Feldweg, A., (2018). Anaphylaxis : Acute diagnosis, Uptodate. 
Repéré à https://www.uptodate.com/contents/. 
2. 
Sampson HA, Muñoz-Furlong A, Campbell RL et coll. 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.  
3. 
Grunau, B., Wiens, M., Rowe, B., McKay, R., Li, J., Won Yi, T., Stenstrom, R., Schellenberg, R., 
Grafstein, E., Scheuermeyer, F. (2015). Emergency Department Corticosteroid Use for Allergy or 
Anaphylaxis Is Not Associated With Decreased Relapse, Annals of Emergency Medicine, 66(4), 381 
- 389. 
4. 
Cheng, A. Société canadienne de pédiatrie, Comité de soins aigus (2011), Le traitement d’urgence 
de l’anaphylaxie chez les nourrissons et les enfants, Paediatric Child Health, 16 (1), 41-6. 
5. 
Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Yealy, D. M., Meckler, G. D., Cline, D. M., (2016), 
Tintinalli’s Emergendy Medicine, A Comprehensive Study Guide (8e éd). McGraw-Hill Education. 
6. 
Marx, John A. and al. (2014) Rosen’s Emergency Medicine : Concepts and Clinical Practice (8e ed). 
Elsevier Saunders. 
7. 
Lieberman, P., Kelso, J., Feldweg, A. (2018), Biphasic and protracted anaphylaxis, Uptodate. 
Repéré à https://www.uptodate.com/content/. 
8. 
Mehr, S., Liew, W. K., Tang, M. L. K., (2009), Clinical predictors for biphasic reactions in children 
presenting with anaphylaxis, Clinical and Experimental Allergy, 39, 1390 - 1396. 
9. 
Lieberman, P. and al, (2015). Anaphylaxis - a practice parameter update, Annals of Allergy, Asthma 
and Immunology, 115, 341 - 384. 
10. Kim, T., Yoonm ,S. H., Lee, S., Choi, Y. H., Park, C. M., Kang, H., Cho, S., (2018), Biphasic and 
protracted anaphylaxis to iodinated contrast media, European Radiology, 28, 1242 - 1252.   
11. Alqurashi, W., Stiell, I., Chan, K., Neto, G., Alsadoon, A., Wells, G., (2015), Epidemiology and clinical 
predictors of biphasic reactions in children with anaphylaxis, Annals of Allergy, Asthma and 
Immunology, 115, 217 - 223. 
12. Alqurashi, W., Ellis, A., (2017), Do Corticosteroids Prevent Biphasic Anaphylaxis? Journal of Allergy 
and Clinical Immunology, 5(5), 1192 - 1205. 
13. Syed Mustansir Hussain Zaidi et Al., Sample size estimation of diagnostic test studies in health 
sciences, Proc. 14th International Conference on Statistical Sciences, Karachi, Pakistan, March 14-
16, 2016, Vol. 29, pp. 239-246. 
 
 
 

 
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1. 
APPENDIX: QUESTIONNAIRE SHARED - Phase 2 study (validation) 
To be filled for any patient with an anaphylactic reaction AFTER initial management but 
BEFORE discharge 
 
Site of the visit: Chicoutimi Jonquière Alma  
Date : __________________________ 
Time of arrival in the emergency room: 
The time at which this questionnaire is completed: 
The patient meets the criteria 
for an anaphylactic reaction:  
yes no  
If answered no  to the last question: the patient confirms 
exposure to an allergen and I believe that it will inevitably 
evolve towards an anaphylactic reaction.     
 yes no  
 
Time of onset of symptoms:  
Exact time: - ESTIMATEd  time: 
 
Hours of cob doses:  
1is_______, 2,and_______, 3,and  _______, 4,and  _______, 5and_______, 6,and________ 
 
History 
ATCD allergy to an allergen other than the one involved.    yes no  
ATCD of allergy to the allergen involved.    yes no  
ANAphylaxis ATCD.    yes no  
Asthma ATCD.    yes no  
 
Allergen 
Insect bite or bite.    yes no  
Iodine.    yes no  
Unknown allergen.    yes no  
Food allergen other than milk/peanuts/eggs/seafood.    yes no  
 
Symptoms 
Severe symptoms (hypoTA, respiratory sx, vomiting, intubation,syncope, arrhythmias).    yes 
no  
ENT symptoms.    yes no  
Diarrhea.    yes no  
Time before symptom resolution - 40 minutes.    yes no  
 
Treatment 
Time before the first dose of ear - 60 minutes.    yes no  

 
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Number of doses of epi IM - 1.    yes no  
Number of ear doses before emergency room arrival.    yes no  
Number of ear doses in the emergency room.    yes no  
Epi doses data different from standard doses (ped: 0.01mg/kg, adult: 0.3-0.5mg).     yes no  
Administration of glucocorticoids.    yes no  
 
 
Section reserved for investigators 
Rb.      yes no  
RBCS.     oui     non  
Mr. RPOU.     yes no 