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Background: Few studies have evaluated adherence to anaphylaxis guidelines in emergency departments (EDs). Objective: The objective of this study was to evaluate adherence to anaphylaxis guidelines in the ED of a tertiary hospital. Methods: Medical records of patients attended in the ED of University Hospital of Salamanca, Spain were reviewed. Those patients fulfilling the anaphylaxis criteria proposed by the NIAID/FAAN were selected. Results: During a 1-year period, we identified 89 patients (74 adults and 15 children). The anaphylactic reaction was moderate in 65% of adults, severe in 34%, and very severe in 1%. In children, all reactions were moderate. Fewer than half of the patients (42%) received adrenaline in the ED; this was administered intramuscularly in only 19% of cases. As for the severity of the reaction, 65% of patients with moderate reactions and 42% with severe reactions were not treated with adrenaline. At discharge from the ED, an adrenaline auto-injector was recommended to only 5.6% of patients. Fifty-two percent of patients received a documented allergy referral (57% adults vs 27% children, P=.047), 29% instructions about avoidance of triggers (31% adults vs 20% children, NS), and 51% written instructions for recognition of anaphylaxis warning signs (41% adults vs 100% children, P