The Ability of First Aid Providers to Recognize Anaphylaxis: A Scoping Review

Early recognition of anaphylaxis is critical to early treatment and often occurs in the first aid setting. However, the ability of first aid providers to recognize anaphylaxis is unknown. We sought to examine the evidence regarding first aid providers’ ability to recognize anaphylaxis. Our scoping review was performed as part of the International Liaison Committee on Resuscitation (ILCOR) continuous evidence evaluation processes to update the 2020 ILCOR Consensus on Science with Treatment Recommendations. We searched Medline, Embase, Cochrane, and the gray literature from 2010 to September 2022. The population included adults and children experiencing anaphylaxis with a description of any specific symptom to a first aid provider. Recognition of anaphylaxis was the primary outcome. Two investigators (DM and PC) reviewed abstracts and extracted and assessed the data. Discrepancies between the reviewers were resolved by discussion and consensus with the ILCOR First Aid Task Force. Out of 957 hits, 17 studies met inclusion criteria: one review and meta-analysis, two experimental studies, and 14 observational studies. We did not identify any studies that directly addressed our PICOST (Population, Intervention, Control, Outcomes, Study Design, and Timeframe) as none were performed in the first aid setting. Articles included individuals who may be first aid providers as patients and parents (n=5), teachers, students or school staff (n=8), caregivers and patients (n= 2) or nannies (n=1). All included studies were conducted in high-income countries. Our scoping review found that signs and symptoms of anaphylaxis were not specific and did not allow for easy identification by the first aid provider. Studies focused on education (n=10) and protocols (n=2) and found that both could have a positive impact on anaphylaxis recognition and management. While we did not identify any clinical studies that directly addressed the ability of first aid providers to identify anaphylaxis, future studies examining education methods and action plans may help improve the identification of anaphylaxis by first aid providers.


Introduction
Anaphylaxis is a serious, potentially life-threatening allergic reaction that can occur rapidly and unexpectedly and requires prompt medical treatment. Estimates suggest that up to 5.1% of the United States (US) population has experienced anaphylaxis [1,2]. Although there is no consensus on the incidence of anaphylaxis on a global scale, there is evidence of a global increase in the prevalence of anaphylaxis cases as well as hospitalizations [3]. Rates of hospitalizations for anaphylaxis in children have increased in many Western countries [4]. This may be due in part to improved recognition of common signs and symptoms [5], which can be variable depending on the cause of the anaphylaxis and the age of the patients [6].
Allergic reactions can advance to anaphylaxis within minutes. Therefore, it is essential for first aid providers to recognize the signs and symptoms of anaphylaxis for individuals to receive treatment in a timely manner. While epinephrine is the first line of treatment [7], a delay in treatment greater than 20 minutes is associated with an increase in fatal and near-fatal reactions [8].
Recognition of anaphylaxis can be difficult due to confounding definitions and diagnostic criteria which impact patient care practices. Furthermore, diagnosis can be challenging due to a wide constellation of symptoms that often mimic related allergic and non-allergic disorders [4]. Poor recognition and inadequate treatment by health professionals can lead to preventable errors and death. Studies show that both physicians [4,9] and prehospital providers have difficulty recognizing anaphylaxis [10,11]. Given the timecritical nature of epinephrine administration in anaphylaxis, it is important to understand the ability of first aid providers to recognize anaphylaxis.
Many signs and symptoms of anaphylaxis are typically described, helping first aid providers to recognize anaphylaxis. The most listed signs and symptoms reported for teaching to first aid providers from various international organizations are anxiety, breathing difficulties, including noisy breathing, wheezing or persistent cough, airway narrowing, swelling of the face and the tongue, difficulty talking and/or hoarse voice, abdominal pain, diarrhea, nausea and vomiting, hives, welts and body redness, signs of shock, including confusion or agitation, pallor and floppiness (young children), loss of consciousness, and cardiac arrest [12][13][14][15].
The most recent International Liaison Committee on Resuscitation (ILCOR) First Aid Consensus on Science with Treatment Recommendations (CoSTR) for this topic was published in 2010 and identified very lowcertainty evidence from eight studies highlighting the limited ability of first aid providers to correctly identify anaphylaxis [16]. As part of the ILCOR First Aid Task Force (FATF), we performed a scoping review to identify studies evaluating or describing the ability of first aid providers to recognize anaphylaxis. The appropriate recognition of anaphylaxis by first aid providers is hoped to subsequently increase the use of epinephrine in this population.

Question and objectives
We sought to answer the population, interventions, comparators, outcomes, study design, timeframe (PICOST) question: Among adults and children experiencing anaphylaxis in the first aid setting, does the description of any specific signs or symptoms, compared with the absence of any specific description, increase the recognition of anaphylaxis by first aid providers? The objective of this scoping review was to examine the literature subsequent to the 2010 ILCOR CoSTR [16] and to establish whether there was new evidence to warrant a systematic review. This scoping review was performed as part of the ILCOR continuous evidence evaluation process, conducted by the ILCOR FATF Scoping Review team for the 2023 CoSTR.

Inclusion and exclusion criteria
Our population included adults and children experiencing anaphylaxis with a description of any specific symptom provided by the person, family member, or any other witness to a first aid provider and in a prehospital setting. We excluded all studies where data collection occurred in an emergency department or other healthcare facility by the healthcare provider.

Information sources and search strategy
The broad topic of anaphylaxis recognition by first aid providers was reviewed by ILCOR in 2010 [16]. As the initial review lacked identification of specific signs and symptoms that may abet the recognition of anaphylaxis, the ILCOR FATF created a revised search strategy in 2019 to review evidence from both published and gray literature ( Figure 1). Two articles were included in a subsequent scoping review [17].  In 2020, the ILCOR FATF executed a time-limited search in PubMed for an evidence update. No new articles were found to directly answer the research question, but 12 studies were identified on educational interventions to improve the recognition of anaphylaxis.
The current scoping review search strategy seeks new evidence in published and in the gray literature from 2019 to 2022 (Appendices). Articles identified using the current search strategy have been combined with studies identified in the previous searches for a comprehensive scoping review of all published and gray literature identified since 2010.

Published literature
The last published literature search using PubMed, Embase, and Cochrane was conducted on September 19, 2022 and updated on April 1, 2023. We included all human studies with no restriction on the language if there was an English abstract. Randomized controlled trials (RCTs) and non-randomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) were excluded unless subsequently retrieved in the gray literature search.

Gray literature
The last gray literature search of Google.com was conducted on September 30, 2022. We performed a structured search from November 2019 to September 2022. The first 100 hits from each search were reviewed to identify additional relevant material.

Screening and selection of sources
For the published literature search, two independent reviewers (DM and PC) screened the title and abstract of each article. Then, the same reviewers performed a full-text review of potential articles to determine the final articles to be included. We manually reviewed references from all included studies. For the gray literature, one reviewer (DM) performed the initial search and identified potential sources. Two reviewers (DM and PC) then reviewed these sources to identify any additional key sources of information. Discrepancies between the reviewers were resolved by discussion with the ILCOR FATF. We present descriptive summaries of the final included studies.

Results
For the literature search and study selection, the updated search strategy from 2019 to 2020 identified 949 unique titles/abstracts. We added two additional records identified in references from other included articles, six from gray literature, two selected studies from the 2019 rerun search strategy for the 2020 ILCOR FATF CoSTR [18], and 12 selected articles for the 2021 ILCOR evidence update. Based on titles and abstract screening, we excluded 934 studies. Of the 37 full-text articles reviewed, a further 20 were excluded, leaving a total of 17 studies, including two from the gray literature ( Figure 2).
Pre-school teachers.
All types of allergies.   Esenboga.
2020 [24] Observational study.  As we did not identify any studies that directly addressed our research question, we selected articles that indirectly related to our search. We selected 10 studies (Table 4), two experimental studies [20,21], and eight observational studies [23,25,26,28,30,[32][33][34] about the impact of an educational intervention in recognition, management of anaphylaxis and epinephrine auto-injector (EAI) use. Two retrospective studies described the effect of the implementation of an action plan or new protocol on knowledge of anaphylaxis recognition and treatment [22,31]. Four studies assessed knowledge about the recognition and management of anaphylaxis in specific populations [24,27,29,35] and on review identified a lack of knowledge to enable recognition of anaphylaxis as a factor associated with the underuse of EAI [27].

Educational interventions
One RCT [20], one controlled before-and-after study [21], and five observational studies [23,25,28,32,33] assessed the effect of a training session on knowledge of signs and symptoms of anaphylaxis and anaphylaxis management. Three other observational studies assessed the effect of a different form of educational intervention [26,30,34].
In the RCT, Brockow et al. measured the difference in knowledge about anaphylaxis (questionnaire) and the competence level in the management of a simulated anaphylactic reaction in 193 participants (95 caregivers and 98 patients) before and three months after a course with two three-hour schooling modules [20]. In comparison with the control group (CG) that did not follow a training module, the intervention group (IG) was shown to have a significant improvement in knowledge for both caregivers (IG 3.2/13.2 improvements/baseline vs CG 0.7/12.6; P<0.001) and patients (IG 3.9/10.8 vs 1.3/12.6; P<0.001).
In a controlled before and after study, Canon et al. evaluated the role of a 1-hour educational session on food allergies and measured its efficacy for improving knowledge in 375 teachers from six private schools randomly assigned into an intervention group (n = 4 schools) and a control group (n = 2 schools) [21]. The post-test intervention group had a knowledge score 19.58% points higher than the control group (95%CI, 16.62-22.53; P<0.001), with no differences in pretest scores. Pretest knowledge score values were higher in teachers who had a graduate school education (9.5%; 95%CI, 0.45-18.52; p=0.04) and a college education (10.4%; 95%CI, 0.70-20.10; P=0.036) versus those who did not complete college.
Five observational studies with a total of 974 participants assessed knowledge in recognition of signs and symptoms of anaphylaxis and anaphylaxis management before and after a training session without a comparison group [23,25,28,32,33]. In 53 unlicensed high school assistive personnel, knowledge assessment in recognition of signs and symptoms of anaphylaxis and perceived self-efficacy in EAI administration revealed a significant improvement following the intervention (p<0.001) [32]. The same result was found in another study in a population of 53 participants (80% teachers, 20% canteen staff), in which 39.6% recognized anaphylaxis in the pre-training questionnaire and 81% in the post-training questionnaire (p<0.001) [25]. Likewise, the proportion of school staff who believed they knew when to use an EAI increased from 19% to 100% (p<0.001). In another study, Polloni et al. reported a baseline low self-efficacy in anaphylaxis management, especially in recognizing anaphylaxis symptoms and administering proper drugs [33]. All scores concerning self-efficacy in anaphylaxis management of 592 teachers and school caretakers improved after the course with a statistically significant difference in recognition of anaphylaxis symptoms as measured by the School Personnel Self-  [28]. An improvement following an educational intervention was also found by Dumeier et al. in a population of 75 preschool teachers [23]. In this study, the knowledge of clinical signs increased significantly after the training session for three symptoms: anal and urinary incontinence (23% at baseline, 81% directly after the education session; 23% at 4 to 12 weeks after the education session, p<0.025); dip in blood pressure and dizziness (65% at baseline, 91% directly after the education session, 87% at 4 to 12 weeks after the education session, p<0.025) and for nausea and vomiting (59% baseline, 89% directly after the education session, 80% at 4 to 12 weeks after the education session, p<0.025). However, no difference was found for two other symptoms, shortness of breath and wheezing, and for swelling of skin and mucosa, which was known before the training course by 56% (shortness of breath/wheezing) and 73% (swelling of skin/mucosa) of participants. A statistically significant difference was also identified for knowledge of all five symptoms correctly related (9% baseline, 60% directly after the education session, 31% at 4 to 12 weeks after the education session; p<0.025).
Three observational before and after studies with a total of 517 participants assessed the effect of new forms of educational interventions [26,30,34]. The efficacy of a peer-to-peer educational video in increasing food allergy knowledge was assessed in a population of children and adolescents (198 elementary, 156 middle, and 203 high school students) [30]. Knowledge scores of common food allergy (FA) symptoms increased significantly among students after viewing the videos (elementary school: 61.5% at the pre-test vs. 85.9% at the post-test, p<0.001; middle school: 46.3% vs. 70.1%, p<0.001; high school: 66.1% vs. 85.2%, p<0.001) and more than 60% of students reported that they learned something new about FA. The use of a smartphone health app for the management of patients with potentially life-threatening FA was studied by Gallagher et al. [26]. Twenty-two adolescents (13 to 19 years) were asked to solve 12 clinical case quizzes with and without the use of the app. The median (range) correct score out of 12 for the baseline testing was 9 (3)(4)(5)(6)(7)(8)(9)(10)(11).
After the utilization of the app's decision support function, scenario testing median scores increased to 11 (9-12), p<0.001. In the last educational study, Soller et al. assessed the efficacy of children and parents coached by clinicians during an oral food challenge (OFC) [34]. In this study, parents and their children (<18 years old) were invited to administer the EAI under the supervision of a nurse/allergist if anaphylaxis occurred during the OFC and to complete a questionnaire before and after the intervention. A total of 353 OFCs were performed, with 5.6% developing an anaphylactic reaction. Epinephrine was used in 15.0% of the anaphylactic reactions and was administered by the parent (69.8%), child (26.4%), or practitioner (

Action plan and protocol
Two observational studies assessed the effect of the implementation of an action plan or new protocols [22,31]. In the first study, 205 participants (31 children and 174 parents of children) were involved in appraising the design and written contents of the Canadian Anaphylaxis Action Plan for Kids [22]. The overall comprehension and knowledge of anaphylaxis management including recognition of anaphylaxis were objectively assessed through four hypothetical scenarios after the implementation of the action plan. Out of a maximum score of 12 for the Comprehension Assessment Questionnaire, the mean knowledge score was 11.3 (SD=1.8; range, 0-12). There was no significant difference between parents versus children, participants with versus without previous anaphylaxis experience, or high versus low literacy level.
However, parental education level was the only factor associated with a statistically significant difference in knowledge scores between study participants; the mean knowledge score for parents with a college education or higher was 11.4±1.7 (SD) compared with the mean knowledge score for parents without college education (10.4±1.2; Mean Difference=1; 95%CI, 0.5-0.6, p<0.001).
In the second study, a fact-finding survey aimed at determining if appropriate responses to anaphylaxis onset were implemented in schools, kindergartens, childcare facilities, and nursery schools in a Japanese town [31]. This survey was conducted four years after the issuance of new guidelines focused on the signs and symptoms of anaphylaxis and their time of onset. Five hundred and ninety-seven institutions responded to the questionnaire, showing the underutilization of EAIs (three uses of EAIs on 48 anaphylactic reactions) secondary to the absence of prescriptions and the insufficiency of training on anaphylaxis management.

Knowledge
Four observational studies assessed knowledge about signs and symptoms of anaphylaxis in a population of patients and parents [24,27], schoolteachers [35], and nannies [29]. In a study conducted in a population of caregivers of pediatric patients with food allergies [27], 164 questionnaires were completed. All but one of the caregivers reported previously receiving education about EAI, and all participants reported at least one past food-related allergic reaction in their child. The most typically reported symptoms at the time of most severe reactions are reported in Table 5. In the second study, 190 patients (1 to 18 years) who were prescribed EAIs were invited with their parents to a face-to-face interview and to complete a survey to evaluate their attitudes and knowledge levels to provide standardized and better education [24]. One-fourth of EAI-prescribed patients experienced anaphylaxis requiring the use of an EAI within the previous five years and 30% of the patients used an EAI. Regarding signs and symptoms, 44 patients who experienced anaphylaxis reported the following signs and symptoms during anaphylaxis: itching, urticaria, angioedema (≈37%), breathing difficulty (≈34%), tightening in the throat or chest (≈18%), dizziness, fatigue, near fainting (≈4%), repeated vomiting (≈2%), resistant severe cough (≈13%).  Glasberg et al. [27] In another study, Efthymiou et al. examined the knowledge and beliefs of schoolteachers about food allergy in 11 primary schools in Cyprus [35]. The personnel had received training relevant to allergies in only two of 11 schools (18.2%). Regarding recognition of the signs and symptoms, eight schools out of 11 that responded to a questionnaire stated that they had identified some of the signs of food allergy. They described seven different signs and symptoms: wheals (4/11), itching (2/11), airway obstruction (2/11), wheezing (2/11), dyspnea (1/11), abdominal pain (2/11), and oedema (1/11), but 3/11 could not recall any symptom. The last study identified gaps in knowledge of a nanny's population [29]. Ninety-nine percent of nannies interviewed (n=153) recognized food allergies as a potentially fatal event. Considering signs of food allergies, 51% were comfortable with recognizing a food allergy emergency, and 49% for treating this allergy emergently. Most nannies (66%) desired additional information about recognizing and treating food allergies.

Factors associated with the underuse of epinephrine auto-injectors
One review and meta-analysis identified in our search strategy investigated potential barriers to epinephrine use [19]. In a narrative review of 23 studies, Miles et al. identified potential barriers to epinephrine used at school. Low availability of epinephrine, insufficient education and training in anaphylaxis recognition and management, and insufficient policies or protocol were the main barriers to epinephrine use in the school setting. For insufficient education and training on anaphylaxis management, studies included in this review report that about half of respondents, composed of school staff (i.e., nurses, teachers, and principals), knew to use epinephrine as first-line treatment to manage anaphylaxis; however, a much lower proportion (5%-35%) knew how or when to use an EAI. Four studies found low self-efficacy in anaphylaxis management among school personnel as well as a lack of training [19].
The same search from September 2022 was rerun on April 4, 2023 to identify any additional studies since our last search and before publishing this scoping review. One RCT was identified which described the effect of a mobile web-based food allergy and anaphylaxis management educational program for the recognition and management of anaphylaxis [36]. The findings of this study will be included in a planned upcoming systematic review of educational interventions for the recognition and care of anaphylaxis.

Why this topic was reviewed
The purpose of this scoping review was to examine the literature since the 2010 ILCOR CoSTR [16] to establish whether there was new evidence in published and gray literature regarding first aid providers' ability to recognize anaphylaxis.

Summary of our findings
We have not identified any new data in the published and gray 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 eligibility criteria and selected articles to include individuals who may be first aid providers as patients, parents, teachers, school staff, and nannies or babysitters. We have selected articles that do not directly assess the signs or symptoms of anaphylaxis but rather how to assess and improve the level of knowledge of participants in the recognition and management of anaphylaxis with the aim that more patients with anaphylaxis can receive epinephrine. Two experimental studies and eight observational studies show an increase of knowledge in the 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 [20,21,23,25,26,28,30,[32][33][34]. 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 [22,31]. The need for learning and training of the population seems indeed important and the absence of training in recognition of anaphylaxis is identified as a factor of underuse of epinephrine [19]. Even if the initial level of knowledge in recognition of anaphylaxis before an educational intervention is low and increased after an educational intervention, the level of knowledge, recognition, and management of anaphylaxis remains low a few months or a year later [24,27,29,35].

Implications of our work
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 provided for patients or for some settings deserve further studies to show their effectiveness in the short and long term. The content and form of the action plan or protocols should also be analyzed as they could affect its efficiency.

Compare and contrast with previous literature
Previous literature has identified different factors contributing to the underuse of epinephrine in anaphylaxis [6,37]. Recognition of anaphylaxis is one of these identified factors which facilitates the administration of epinephrine when it is available even though the evidence is limited. Recognition of anaphylaxis is not alone. The high cost of epinephrine, lack of epinephrine availability among patients or in some settings such as schools, lack of epinephrine use even when available, and incorrect technique to administrate EAIs are also identified as barriers to the use of epinephrine by patients and first aid providers when they need it.
How do we advance the science, where do we go from here?
The results of this scoping review led to two considerations. First, the previous treatment recommendation of the 2010 ILCOR CoSTR continues to be supported by 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" [16]. Second, it appears that there is sufficient evidence to consider for a future systematic review to compare educational approaches to teaching and training lay providers to improve their ability to recognize signs and symptoms and to manage care for a person with anaphylaxis.

Limitations
Our scoping review has several limitations. Our only outcome in the research question is anaphylaxis recognition. No other outcomes are examined but we have not found any articles with other outcomes for this topic, including clinical outcomes. All articles selected were conducted in high-income countries and the results of our research cannot be extrapolated to low-or middle-income countries. The definition of anaphylaxis varied between studies. Skin involvement was not always included in the diagnostic criteria and some studies did not include the definition of anaphylaxis. The included studies assessed the effect of an educational intervention using a survey, or a test completed before and immediately after the intervention. None of the studies show their effectiveness using a real-life scenario or demonstrate clinical outcomes to show persistent improvements that may be associated with the educational intervention. Most studies report results for signs and symptoms of anaphylaxis and do not indicate if they include the medical history of patients in the set of elements for the recognition of anaphylaxis. We were, therefore, unable to examine the importance of patients' medical history as a criterion for the recognition of anaphylaxis independently.

Conclusions
One of the most concerning aspects of anaphylaxis is the general global rise in the number of cases. Epinephrine remains the potentially life-saving gold standard treatment for a person with anaphylaxis. The inability of a first aid provider to recognize anaphylaxis is an identified major barrier to the use of epinephrine auto-injectors. 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 provided for patients or for some settings deserve further study to show their effectiveness in the short and long term. Future studies should examine how educational interventions, local policies, and specific action plans can improve the recognition and management of anaphylaxis by first aid providers. Studies are also needed to evaluate clinical outcomes following educational interventions to improve the recognition and management of anaphylaxis.
While this scoping review did not identify studies that directly address the ability of first aid providers to identify anaphylaxis, most of the included studies focus on the education of lay responders in the recognition and management of anaphylaxis, with outcome measures of knowledge and confidence to use an EAI. A future systematic review is planned to compare educational modalities on outcomes of recognition and management of anaphylaxis.

Medline® with PubMed 2022 search strategies
Results from Medline® with PubMed search strategy from October 22, 2019 to September, 19, 2022 for the 2022 ILCOR First Aid Task Force scoping review on the ability of first aid providers to recognize anaphylaxis are presented in Table 6.    Additional Information

Disclosures
Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.