Epinephrine In Emergency Department Research Articles

11 Is emergency department transfer always required following anaphylaxis and epinephrine use?

Abstract Background Patients known for anaphylaxis are advised to always carry 2 epinephrine auto-injectors (EAI) with them. With epinephrine being the first-line treatment for anaphylaxis, current guidelines recommend prompt EAI administration, followed by observation in the emergency department (ED) for 4 hours. Data supporting transfer to the ED in all cases after epinephrine are sparse. Recent North American allergy guidelines no longer suggest that ED presentation after EAI use is required for all cases of anaphylaxis. Objectives We aimed to describe the need for additional ED treatment in children known for food-triggered anaphylaxis who received at least 1 EAI pre-hospital. Design/Methods Data on children under 18 years with food-induced anaphylaxis who received at least one dose of pre-hospital epinephrine was collected from the Cross-Canada Anaphylaxis REgistry (C-CARE) from seven hospitals. A standardized questionnaire obtained information on symptoms, allergens, comorbidities, and pre-hospital and in-hospital management. Multivariable logistic regression was performed to identify factors associated with ED management, among children who received 1, 2 or 3 or more doses of epinephrine pre-hospital. Results From 2011 to 2023, 1054 children with known food-triggered anaphylaxis and who used one or more EAIs pre-hospital were enrolled in C-CARE. The mean age at reaction was 8.2 (standard deviation [SD] 5.3) years, 648 (60.8%) were male and 82 (7.8%) of reactions were severe (defined as loss of bowel control, cyanosis, respiratory arrest, hypotension and/or circulatory collapse, dysrhythmia, severe bradycardia and/or cardiac arrest, confusion, and loss of consciousness). Primary triggers included peanuts (n=280; 26.6%) followed by tree nuts (n=173; 16.4%). 193 patients (18.3%) had known asthma and 201 received additional dose(s) of epinephrine in the ED, the majority of whom (177, 88.1%) received one dose. Only 2.9% of patients required admission. Among all patients, reactions to egg were less likely to require additional epinephrine (aOR 0.90; 95% CI 0.83, 0.99), and more likely with severe reactions (aOR 1.24; 95% CI 1.14-1.35). Among patients who received only one EAI pre-hospital, severe reactions (adjusted odds ratio [aOR] 1.19; 95% confidence interval [CI] 1.08-1.31) and reactions to tree nuts (aOR 1.12; 95% CI 1.04-1.20) were associated with increased odds of an additional dose of epinephrine in hospital. Conclusion One-fifth of anaphylaxis cases that used EAI require an additional dose of epinephrine in ED. Children with severe reactions and reactions to tree nuts are more likely to require additional doses; these cases should be considered for ED transfer and treatment following pre-hospital EAI use.

Frequency of cardiotoxicity following intramuscular administration of epinephrine in emergency department patients with anaphylaxis.

Epinephrine can be a life-saving treatment for patients with anaphylaxis. Potential cardiovascular side effects of epinephrine may contribute to clinician hesitancy to use it. However, the frequency of cardiotoxicity resulting from epinephrine treatment for anaphylaxis is not well described. We sought to describe the frequency of cardiotoxicity following intramuscular (IM) administration of epinephrine in adult emergency department (ED) patients with anaphylaxis. We conducted a retrospective observational study at a single, quaternary care academic ED in Tennessee. We identified consecutive ED visits with the diagnosis of anaphylaxis from 2017 to 2021 who received at least one intramuscular (IM) dose of epinephrine in the ED. Analysis was primarily descriptive. The primary outcome was cardiotoxicity, the occurrence of any of the following after epinephrine administration: ischemic electrocardiogram changes, systolic blood pressure>200mmHg, or cardiac arrest ≤4h; elevated troponin ≤12h; or percutaneous coronary intervention or depressed ejection fraction ≤72h. Among 338 included patients, 16 (4.7%; 95%CI: 2.8-7.6%) experienced cardiotoxicity. Cardiotoxic events included eight (2.4%) ischemic electrocardiogram changes, six (1.8%) episodes of elevated troponin, five (1.5%) atrial arrhythmias, one (0.3%) ventricular arrythmia, and one (0.3%) depressed ejection fraction. Patients with cardiotoxicity were significantly older, had more comorbidities, and were more likely to have received multiple doses of epinephrine or an epinephrine infusion compared with a single IM dose of epinephrine. Among 338 consecutive adult ED patients who received IM epinephrine for anaphylaxis during a recent 4-year period, cardiotoxic side effects were observed in approximately 5% of patients.

Milk-induced anaphylaxis among children presenting to Canadian emergency departments

BackgroundCow's milk is one of the most common and burdensome allergens in pediatrics, and it can induce severe anaphylactic reactions in children. However, data on cow's milk-induced anaphylaxis are sparse. ObjectiveTo describe the epidemiology of pediatric cow's milk-induced anaphylaxis and to determine risk factors for repeat emergency department (ED) epinephrine administration. MethodsBetween April 2011 and May 2023, data were collected on children with anaphylaxis presenting to 10 Canadian EDs. A standardized form documenting symptoms, triggers, treatment, and outcome was used. Multivariate logistic regression was used. ResultsOf 3118 anaphylactic reactions, 319 milk-induced anaphylaxis cases were identified (10%). In the prehospital setting, 54% of patients with milk-induced anaphylaxis received intramuscular epinephrine. In those with milk-induced anaphylaxis, receiving epinephrine before presenting to the ED was associated with a reduced risk of requiring 2 or more epinephrine doses in the ED (adjusted odds ratio, 0.95 [95% CI, 0.90-0.99]). Children younger than 5 years of age were more likely to experience a mild reaction compared with that in older children, who experienced a moderate reaction more often (P < .0001). Compared with other forms of food-induced anaphylaxis, children presenting with milk-induced anaphylaxis were younger; a greater proportion experienced wheezing and vomiting, and less experienced angioedema. ConclusionPrehospital epinephrine in pediatric milk-induced anaphylaxis is underused; however, it may decrease risk of requiring 2 ED epinephrine doses. Milk-induced anaphylaxis in children younger than 5 years of age may be less severe than in older children. Wheezing and vomiting are more prevalent in milk-induced anaphylaxis compared with that of other foods.

Assessment of ED triage of anaphylaxis patients based on the Emergency Severity Index

To describe the emergency department (ED) triage of anaphylaxis patients based on the Emergency Severity Index (ESI), assess the association between ESI triage level and ED epinephrine administration, and determine characteristics associated with lower acuity triage ESI assignment (levels 3 and 4). We conducted a cohort study of adult and pediatric anaphylaxis patients between September 2010 and September 2018 at an academic ED. Patient characteristics and management were compared between Emergency Severity Index (ESI) triage level 1 or 2 versus levels 3 or 4 using logistic regression analysis. We adhered to STROBE reporting guidelines. A total of 1090 patient visits were included. There were 26 (2%), 515 (47%), 489 (45%), and 60 (6%) visits that were assigned an ESI triage level of 1, 2, 3, and 4, respectively. Epinephrine was administered in the ED to 53% of patients triaged ESI level 1 or 2 and to 40% of patients triaged ESI level 3 or 4. Patients who were assigned a lower acuity ESI level of 3 or 4 had a longer median time from ED arrival to epinephrine administration compared to those with a higher acuity ESI level of 1 or 2 (28min compared to 13min, p<.001). A lower acuity ESI level was more likely to be assigned to visits with a chief concern of hives, rash, or pruritus (OR 2.33 [95% CI, 1.20-4.53]) and less likely to be assigned to visits among adults (OR, 0.43 [0.31-0.60]), patients who received epinephrine from emergency medical services (OR 0.56 [0.38-0.82]), presented with posterior pharyngeal or uvular angioedema (OR, 0.56 [0.38-0.82]), hypoxemia (OR, 0.34 [0.18-0.64]), or increased heart (OR 0.83 [0.73-0.95]) or respiratory (OR 0.70 [0.60-0.82]) rates. Patients triaged to lower acuity ESI levels experienced delays in ED epinephrine administration. Adult and pediatric patients with skin-related chief concerns were more likely to be to be assigned lower acuity ESI levels. Further studies are needed to identify interventions that will improve ED anaphylaxis triage.

Prehospital Treatment and Emergency Department Outcomes in Young Children with Food Allergy

Studies assessing food-induced allergic reactions and prehospital treatments in infants and young children are scarce. To describe differences in clinical characteristics in children aged 0 to 4 years presenting to the emergency department (ED) with food allergy (FA) reactions and investigate the association between prehospital epinephrine use and clinical outcomes. Retrospective cohort study of FA ED visits in Kaiser Permanente Northern California from January 2016 to December 2018. Charts were assessed on whether anaphylaxis criteria were met, and outcomes were reviewed after prehospital and ED treatments. A weighted cohort of 1518 children presenting with FA to the ED was evaluated. Infants presented with respiratory symptoms less often than did children age 1 and ages 2 to 4 years (6.8%, 16.1%, and 23.9%, respectively; P < .01), more frequently following first ingestion of offending food (74.8%, 44.2%, and 18.4%, respectively; P < .001), and with egg as the most common trigger (33.8%, 8.6%, and 5.3%, respectively; P < .001). Children younger than age 2 years had a tendency toward meeting anaphylaxis criteria less frequently than older children (31.3% vs 42.2%; P= .06), with ED epinephrine given in 12.6% overall. Prehospital epinephrine was given in 152 patients and was associated with a higher likelihood of admission for observation (adjusted odds ratio, 2.6; 95% CI, 1.0-6.5) but a lower likelihood of ED epinephrine treatment (adjusted odds ratio, 0.2; 95% CI, 0.1-0.5). Infants treated in the ED for FA reactions presented differently than older children. Most infants presented after first-known ingestion of offending foods. Overall, ED epinephrine use was low necessitating additional education to recognize and treat anaphylaxis in the ED.

Clinical Survey and Predictors of Outcomes of Pediatric Out-of-Hospital Cardiac Arrest Admitted to the Emergency Department

Pediatric out-of-hospital cardiac arrest (OHCA) is a rare event with severe sequelae. Although the survival to hospital-discharge (STHD) rate has improved from 2–6% to 17.6–40.2%, only 1–4% of OHCA survivors have a good neurological outcome. This study investigated the characteristics of case management before and after admittance to the emergency department (ED) associated with outcomes of pediatric OHCA in an ED. This was a retrospective study of data collected from our ED resuscitation room logbooks dating from 2005 to 2016. All records of children under 18 years old with OHCA were reviewed. Outcomes of interest included sustained return of spontaneous circulation (SROSC), STHD, and neurological outcomes. From the 12-year study period, 152 patients were included. Pediatric OHCA commonly affects males (55.3%, n = 84) and infants younger than 1 year of age (47.4%, n = 72) at home (76.3%, n = 116). Most triggers of pediatric OHCA were respiratory in nature (53.2%, n = 81). Sudden infant death syndrome (SIDS) (29.6%, n = 45), unknown medical causes (25%, n = 38), and trauma (10.5%, n = 16) were the main causes of pediatric OHCA. Sixty-two initial cardiac rhythms at the scene were obtained, most of which were asystole and pulseless electrical activity (PEA) (93.5%, n/all: 58/62). Upon ED arrival, cardiopulmonary resuscitation (CPR) was continued for 32.66 ± 20.71 min in the ED and 34.9% (n = 53) gained SROSC. Among them, 13.8% (n = 21) achieved STHD and 4.6% (n = 7) had a favorable neurological outcome. In multivariate analyses, fewer ED epinephrine doses (p < 0.05), witness of OHCA (p = 0.001), and shorter ED CPR duration (p = 0.007) were factors that increased the rate of SROSC at the ED. A longer emergency medical service (EMS) scene interval (p = 0.047) and shorter ED CPR interval (p = 0.047) improved STHD.

Prehospital dexamethasone administration in children with croup: a medical record review.

ObjectivesCroup is one of the most common childhood respiratory illnesses. Early dexamethasone administration in croup can improve patient outcomes. The objective of this study was to assess the clinical impact of prehospital administration of dexamethasone to children with croup.MethodsA medical record review that included children between 6 months and 6 years, who were brought via emergency medical services (EMS) to the emergency department (ED) with a final diagnosis of croup, between January 2010 and December 2012, was conducted. Data were collected regarding prehospital management and ED management, length of stay (LOS), final disposition, and patient demographics.ResultsA total of 188 patients with an ED diagnosis of croup were enrolled, 35.1% (66/188) of whom received a prehospital diagnosis of croup. The mean age of the participants was 32.96±17.18 months and 10.6% (20/188) were given dexamethasone in the prehospital setting by EMS, while 30.3% (57/188) were given epinephrine nebulizations. Out of the 66 patients with a prehospital diagnosis of croup, 10.6% (7/66) were given dexamethasone by EMS. In ED, dexamethasone was administered to 88.3% (166/188) while 29.8% of participants (56/188) received epinephrine nebulizations. There was no significant difference in ED LOS between those who received prehospital dexamethasone (2.6±1.6 hours, n=18) and those who did not (3.3±2.7 hours, n=159) (P=0.514). The number of in-hospital epinephrine doses per patient was significantly influenced by the administration of prehospital dexamethasone (P=0.010).ConclusionsPrehospital administration of dexamethasone results in less ED epinephrine use and may reflect dexamethasone’s positive influence on the severity and short-term persistence of croup symptoms.

Use of epinephrine in emergency department depends on anaphylaxis severity in children

Despite multiple recommendations, intramuscular epinephrine is poorly prescribed in emergency department receiving pediatric anaphylaxis. To evaluate the role of severity symptoms on this use, we included all admissions for a diagnosis linked to possible allergy in the two pediatric emergency departments of our institution between January 2010 and December 2015. Selection and analysis were restricted to children under 18years fulfilling Sampson's criteria for anaphylaxis. We retrospectively ranked these admissions with the Ring and Messmer anaphylaxis severity score and compared the use of epinephrine according to this classification. Among 422,483 admissions, 204 (0.05%) fulfilled the anaphylaxis criteria (170 (83.3%) grade II anaphylaxis, and 34 (16.7%) grade III; mean age 7.9years). Previous allergy, anaphylaxis, and asthma were found in respectively 60.8%, 36.8%, and 35.1%. Food allergy was the main suspected causal trigger. Epinephrine was used in 32.7% (n = 65/199), before admission (11.4% (n = 23/201)) or in the emergency department (22.2% (n = 45/202)). Epinephrine was more frequently prescribed in grade III than in grade II anaphylaxis (84.8% vs 22.3%, p < 0.001; OR = 19.05 [7.05-54.10]). Upon discharge, epinephrine auto-injectors prescription and allergy referral were rare (31.7% and 44.2%).Conclusion: Pediatricians intuitively adapt their epinephrine use to the severity of the anaphylaxis and contribute to epinephrine underuse in pediatric anaphylaxis. What is known: • Intramuscular epinephrine is the recommended treatment for pediatric anaphylaxis. However, most of the European and North-American studies show a low prescription rate of epinephrine in both prehospital and pediatric emergency department management. • Reasons for such a low prescription rate are unknown. What is new: • This study confirms that intramuscular epinephrine is poorly prescribed in pediatric anaphylaxis (about one case among 10 before admission and one among 5 in pediatric emergency departments). • Despite recommendations, pediatricians intuitively adapt their prescription to the clinical severity of anaphylaxis, with a fourfold increase prescription in grade III compared to grade II anaphylaxis. This medical behavior ascertainment may be in part explained by the delay between the ED admission/management and the anaphylactic episode onset.

Appropriateness of epinephrine use in ED patients with anaphylaxis

BackgroundStudies have demonstrated low rates of emergency department (ED) epinephrine administration for anaphylaxis patients, suggestive of ED undertreatment of anaphylaxis. Our study assessed the appropriateness of ED epinephrine administration in anaphylaxis management. MethodsA prospective observational study was conducted involving ED patients presenting with possible allergic reactions. Patients and ED providers completed questionnaires regarding the suspected trigger, signs and symptoms, and prehospital treatment. Two board-certified allergists-immunologists independently reviewed the questionnaires, as well as electronic health records, to determine whether the cases represented anaphylaxis and whether ED epinephrine administration was appropriate. ResultsAmong 174 patients enrolled in the study, 61 (35%) were confirmed to have anaphylaxis. Overall, 47 anaphylaxis patients (77%) received epinephrine either before ED arrival or in the ED. In the latter situation, 24 anaphylaxis patients (39%) received epinephrine and 37 (61%) did not. Of the patients who received ED epinephrine, the allergists-immunologists determined that its administration was appropriate in all cases (95% confidence interval [CI], 83%-100%). Among the 37 patients who did not receive ED epinephrine, the allergists-immunologists determined that nonadministration of epinephrine was appropriate in 36 patients (97%; 95% CI, 84%-100%). The allergists-immunologists determined that overall, ED management was appropriate for 60 (98%) of 61 patients with anaphylaxis (95% CI, 90%-100%). ConclusionsAlthough more than 60% of anaphylaxis patients did not receive epinephrine in the ED, the allergists-immunologists deemed ED management appropriate in 98% of total cases. Previous retrospective studies may underestimate the appropriateness of ED anaphylaxis management, particularly when prehospital epinephrine administration is not reported.

Use of Epinephrine for Cardiac Arrest Prior to Hospital Arrival

To the Editor: Dr Hagihara and colleagues analyzed the use of prehospital epinephrine in patients with out-of-hospital cardiac arrest. We have several concerns about the study. The cohort of patients receiving epinephrine comprised a fraction of the overall population (15 030 of 417 188; 4%) for reasons not addressed by the authors and that could represent selection bias. Given that epinephrine was part of the treatment algorithm, insight into reasons for this would allow for better interpretation of the data. The authors reported the algorithm for epinephrine administration: “ . . . after checking the initial rhythm and using defibrillation when appropriate, along with CPR [cardiopulmonary resuscitation], emergency lifesaving technicians perform tracheal intubation and/or insert an intravenous line with approval from an online emergency physician. Then, after verifying the absence of impulse in the carotid artery, the emergency lifesaving technicians administer epinephrine with the approval of the emergency physician.” This algorithm provides 2 potential causes of bias. First, those with early defibrillation and return of spontaneous circulation (ROSC) would never receive epinephrine but clearly have a survival advantage. Second, the time of administration of epinephrine dictated by this protocol may be too late to allow for adequate survival. For example, airway placement is prioritized above epinephrine with only 1 clinician able to perform both duties, and a telephone call for permission to provide epinephrine would lead to further delay. This concern is supported by an investigation in 1 of the prefectures in Japan, in which the average time to defibrillation was a mean (SD) of 9 (3) minutes, whereas the time to epinephrine was a mean (SD) of 21.3 (6.9) minutes despite the predominate rhythm being nonshockable. Thus, timing and selection bias driven by the protocol may have led to worse outcomes, as opposed to the intrinsic properties of the medication. Theauthorsacknowledgeduncontrolleddifferences inemergency department care as a weakness of the study and tried to account for this by evaluating a subgroup of patients who achieved ROSC in the field. They reported a marked difference in 1-month mortality between the epinephrine (18%) and no epinephrine (46.8%) groups to argue against emergency department epinephrine as a confounder. We are concerned that such a marked difference in 30-day mortality from only 1 mg of epinephrine may reflect an unrecognized intrinsic difference in the patient population rather than an adverse effect of this relatively low total dosage. In addition, the acknowledgment that induced hypothermia was not routinely performed might further explain the lack of 30-day benefit despite increased ROSC.