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Biphasic Reactions with Anaphylaxis?

“Incidence of Clinically Important Biphasic Reactions in Emergency Department Patients wit Allergic Reactions or Anaphylaxis”

Grunau BE, Li J, Yi TW, et al.

Annals of Emergency Medicine 2014; 63(6): 736-744


Background: Allergic or anaphylactic reactions are fairly common presentations to the ED.  After initial treatment and clinical improvement, a proportion of patients may develop a second “biphasic” reaction, which may actually be more severe than the initial presentation.  Because of this concern, patients are often held for observation for 6 or more hours.  This prolonged ED stay has not been shown to decrease biphasic reactions’ complications, yet incurs significant costs.  The goal of this study was to examine the incidence of clinically important biphasic reactions.

Methods: Chart review performed on data from 2 urban EDs, collected on adult patients presenting during a 5-yer period with “anaphylaxis” or “allergic reaction.”  Primary outcome was the proportion of patients with a clinically important biphasic reaction, secondary outcome was mortality.

Results: Of 428,634 ED visits, 2819 encounters (496 anaphylactic, 2323 allergic reactions) were reviewed.  185 patients had at least 1 subsequent visit for allergic symptoms.  5 clinically important biphasic reactions were identified (0.18%, 95% CI 0.07-0.44%); 2 occurred during the ED visit, and 3 were post-discharge.  2 patients with the biphasic reaction were in the anaphylaxis group (0.40%), and 3 were from the allergic reaction group (0.13%).  There were no fatalities.

Conclusion:  Clinically important biphasic reactions and fatalities were rare in ED patients presenting with allergic or anaphylactic reactions.  This study’s results suggest that it may not be necessary to conduct routine prolonged monitoring of patients whose symptoms have improved after initial treatment.

Ultrasound Signs of Appendicitis




Appendicitis on ultrasound - the first step is to identify the appendix by finding a blind-ending tubular structure arising from the base of the cecum.

The sonographic signs of appendicitis include:

  • dilated appendix > 6mm outer diameter (left image)
  • noncompressible
  • distinct appendiceal wall layers due to edema (left image)
  • target appearance (axial section)
  • appendicolith - an echogenic focus with posterior shadowing
  • periappendiceal fluid collection (right image)
  • echogenic and prominent periappendiceal and pericecal fat
  • surrounding hypervascularity on color Doppler (centre image)


Credit:  http://radiologysigns.tumblr.com/post/29603927330/appendicitis-on-ultrasound

Visual Diagnosis

52F h/o Protein C deficiency with recent PE diagnosis started on anticoagulation 5 days ago presents with the following skin lesions.  Diagnosis?




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Dimer Dimes

Quantitative D-dimer is a common screening tool to rule-out pulmonary embolism in low-risk population but is there more that it can tell us?


Yes, there have been studies linking increasing d-dimers to: 1) likelihood of PE, 2) location of PE, and 3) clot burden.

1. The level of d-dimer has been shown that with increasing d-dimer magnitude, there is an increasing chance of diagnosing pulmonary embolism by computed tomography with correlatory values as follows (as published by Kaush)[1]:

D-Dimer        % with PE

0.58-1.0        3.6%

1.0-2.0           8.0%

2.0-5.0          16.2%

5.0-20           35.3%

>20                 45.5%


2. There have also been some studies showing correlation between d-dimer magnitudes and location of clot, showing the higher the d-dimer, the more likely the PE is proximal/main (median >5.0) pulmonary artery vs. lobar vs. segmental [2].


3. Higher d-dimer values showing higher clot burden as calculated by CT clot burden scoring  for d-dimer values >4.0 (avg clot score 10 vs. 5) [3]. However, clot scoring varies in its predictive value of outcomes and is not a reliable predictor of patient mortality [4,5,6].


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Ebola Screening Guidelines

Thanks to Dr. Sallustio for these guidelines on screening for Ebola infections in the Emergency Department

Ebola Screening Guidlines