Critical Alerts

• Allergic rhinitis is not an emergency but commonly presents to ED
• Rule out other causes: Sinusitis, URI, foreign body
• Intranasal corticosteroids are most effective: For persistent symptoms
• Second-generation antihistamines are first-line: Less sedating
• Watch for asthma comorbidity: 40% of allergic rhinitis patients have asthma
• Refer to allergist for severe or refractory cases

Key Features

Emergency Treatments

Overview

Allergic rhinitis is IgE-mediated inflammation of the nasal mucosa in response to inhaled allergens. It is characterized by nasal congestion, rhinorrhea, sneezing, and pruritus. While not a medical emergency, patients may present to the ED seeking symptom relief or when symptoms overlap with other conditions (sinusitis, asthma exacerbation).

Classification

By Timing:

By Severity (ARIA Classification):

Epidemiology

• Prevalence: 10-30% of adults
• Most common allergic condition
• Peak onset: Childhood to young adulthood
• Strong association with asthma, eczema, allergic conjunctivitis

Etiology

Common Allergens:

Risk Factors:

Exclude Other Diagnoses

Other Causes of Nasal Symptoms

Clinical Diagnosis

• Allergic rhinitis is a clinical diagnosis
• Based on history and exam

Testing (Usually Outpatient)

Laboratory

• Not routinely needed in ED

Discharge Criteria

• Symptoms controlled
• Medications prescribed
• Follow-up arranged

Admission Criteria

• Not typically indicated for allergic rhinitis

Referral

Condition Explanation

• "You have allergies that cause inflammation in your nose."
• "The best treatment is a steroid nasal spray, which works over a few days."
• "Avoiding your triggers (pollen, dust, pets) can help."

Home Care

• Use nasal spray daily for best effect
• Take antihistamines as directed
• Avoid known triggers
• Shower and change clothes after outdoor activities (for pollen)
• Use HEPA air filters

Warning Signs to Return

• Symptoms not improving after 1-2 weeks
• Facial pain, fever (sinusitis)
• Wheezing or difficulty breathing
• Any sign of severe allergic reaction

Pregnancy

• Intranasal corticosteroids (budesonide) safe
• Second-gen antihistamines generally safe (cetirizine, loratadine)
• Avoid decongestants (pseudoephedrine) especially in first trimester

Children

• Intranasal steroids safe
• Second-gen antihistamines preferred
• Rule out foreign body in unilateral symptoms

Elderly

• Avoid first-gen antihistamines (sedation, anticholinergic effects)
• Be cautious with decongestants (HTN, BPH)

Performance Indicators

Documentation Requirements

• Symptom pattern (seasonal vs perennial)
• Trigger identification
• Comorbid asthma
• Treatment and follow-up

Diagnostic Pearls

• Itching = Allergy: Pruritus is key feature
• Clear watery rhinorrhea: Vs purulent in sinusitis
• Bilateral and seasonal: Classic pattern
• Allergic shiners and salute: Physical exam clues
• Rule out sinusitis if fever or purulent discharge
• Unilateral symptoms warrant further workup

Treatment Pearls

• Intranasal steroids are most effective: For persistent symptoms
• Second-gen antihistamines are first-line: Less sedating
• Decongestants for short-term only: Rebound congestion
• Combination therapy for moderate-severe
• Allergen avoidance is cornerstone: Prevention
• Leukotriene antagonists useful in asthma comorbidity

Disposition Pearls

• Allergic rhinitis rarely needs admission
• Refer refractory cases to allergist: Immunotherapy
• Screen for and treat comorbid asthma
• Educate on long-term use of intranasal steroids