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Epinephrine use and outcomes in anaphylaxis patients transported by emergency medical services
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- Corresponding author. Tel.: +1 507 255 7002; fax: +1 507 255 6592.
Correspondence
- Corresponding author. Tel.: +1 507 255 7002; fax: +1 507 255 6592.
Article Info
Fig
NIAID/FAAN clinical criteria for the diagnosis of anaphylaxis.
Article Outline
- 1. Introduction
- 2. Methods
- 3. Results
- 3.1. Characteristics of EMS-transported patients with allergic reactions and anaphylaxis
- 3.2. EMS epinephrine administration
- 3.3. Outcomes of patients who received EMS-administered IV epinephrine
- 3.4. Outcomes of patients who received EMS-administered subcutaneous epinephrine
- 3.5. Outcomes of patients who did not receive EMS-administered epinephrine
- 3.6. Associations with EMS epinephrine administration
- 4. Discussion
- 5. Conclusion
- References
Highlights
- •
We examine epinephrine use in anaphylaxis by EMS.
- •
We identify predictors of epinephrine administration by EMS.
- •
Low rates of epinephrine administration by EMS were observed.
- •
Advanced Life Support EMS administered epinephrine based on symptom severity.
- •
Low rate of additional epinephrine use was observed in ED after EMS transport.
Abstract
Background
Anaphylaxis is a potentially life-threatening allergic reaction that may require emergency medical system (EMS) transport. Fatal anaphylaxis is associated with delayed epinephrine administration. Patient outcome data to assess appropriateness of EMS epinephrine administration are sparse.
Objectives
The objectives of this study are to (1) determine the frequency of epinephrine administration in EMS-transported patients with allergic complaints, (2) identify predictors of epinephrine administration, and (3) determine frequency of emergency department (ED) epinephrine administration after EMS transport.
Methods
A cohort study was conducted from over 5 years. A total of 59187 EMS transports of an Advanced Life Support (ALS) ambulance service were studied.
Results
One hundred and three patient transports for allergic complaints were analyzed. Fifteen patients received EMS epinephrine, and epinephrine was recommended for 2 additional patients who refused, for a total of 17 (17%) patients for whom epinephrine was administered or recommended. Emergency medical system epinephrine administration or recommendation was associated with venom as a trigger (29% vs 8%; odds ratio [OR], 4.70; 95% confidence interval [CI], 1.28-17.22; P = .013), respiratory symptoms (88% vs 52%; OR, 6.83; 95% CI, 1.47-31.71; P = .006), and fulfillment of anaphylaxis diagnostic criteria (82% vs 49%; OR, 3.50; 95% CI, 0.94-13.2; P = .0498). Four (4%) patients received epinephrine after ED arrival.
Conclusion
Low rates of epinephrine administration were observed. The association of EMS administration of epinephrine with respiratory symptoms, fulfillment of anaphylaxis diagnostic criteria, and low rate of additional epinephrine administration in the ED suggest that ALS EMS administered epinephrine based on symptom severity. Additional studies of EMS anaphylaxis management including ED management and outcomes are needed.
1. Introduction
Anaphylaxis is sudden, potentially life-threatening reaction to a specific trigger. A considerable number of these reactions occur outside a medical setting in the community and require emergency medical transport and care. Prehospital providers are likely to be the first health care professionals to come in contact with these patients.
Although there have been no randomized controlled trials, there is consensus that epinephrine is the treatment of choice for anaphylaxis [1x[1]Kemp, S.F., Lockey, R.F., and Simons, F.E. Epinephrine: the drug of choice for anaphylaxis. A statement of the World Allergy Organization. Allergy. 2008;
63: 1061–1070
CrossRef | PubMed | Scopus (162)See all References][1]. Prehospital management of patients with anaphylaxis has not been well studied. The National Association of EMS Physicians published an article outlining the importance of equipping all ambulances with epinephrine to be used in the management of anaphylaxis [2x[2]Jacobsen, R.C. and Millin, M.G. The use of epinephrine for out-of-hospital treatment of anaphylaxis: resource document for the National Association of EMS Physicians position statement. Prehosp Emerg Care. 2011;
15: 570–576
CrossRef | PubMed | Scopus (6)See all References][2]. All 50 states in the United States allow epinephrine to be carried by emergency vehicles, but only 17 states require that epinephrine be carried by all levels of emergency medical system (EMS) providers [3x[3]Wallace, DV, Vitanza, J, and Wesley, K. Use of epinephrine for the treatment of anaphylaxis by US emergency medical service personnel in the pre-hospital setting. in: American College of Allergy, Asthma, and Immunology 2009 Annual Scientific Meeting: Abstract 13. ; 2009
See all References][3]. Although outcomes after emergency department (ED) arrival have been reported among pediatric patients, to our knowledge, this is the first study to evaluate patient management and outcomes after arrival to the ED among both adult and pediatric patients to assess if EMS providers appropriately administer epinephrine in the treatment of anaphylaxis [4x[4]Tiyyagura, G.K., Arnold, L., Cone, D.C. et al. Pediatric anaphylaxis management in the prehospital setting. Prehosp Emerg Care. 2014;
18: 46–51
CrossRef | PubMed | Scopus (5)See all References][4].
The objectives of this study are: (1) to determine the frequency of epinephrine administration in patients transported by EMS for anaphylaxis or other allergic complaints, (2) to identify predictors of EMS epinephrine administration among these patients, and (3) to determine the outcomes of patients transported to the ED by emergency medical providers with regard to need for additional epinephrine administration and ED disposition.
2. Methods
2.1. Study design
An observational cohort study was conducted from July 2002 to July 2007. The Mayo Clinic Institutional Review Board approved the study protocol.
2.2. Setting
Emergency medical system transports of an Advanced Life Support (ALS) ambulance service providing transport for a population of approximately 130000 over 650 sq mi were studied. Patients were transported to a tertiary care academic ED with 73000 annual patient visits.
2.3. Participants
A total of 59187 EMS transports were analyzed for the study. Cases of allergic reactions and anaphylaxis that were transported to our ED were identified by querying our prehospital database using EMS Data Pro (Inspironix, Inc, Sacramento, CA) with the unique identifiers shown in Table 1Table 1. All cases were reviewed by a physician to determine if the transport was related to an allergic reaction or anaphylaxis. Interfacility transports were excluded because these patients were evaluated by a physician before the transport, and thus, the EMS management would likely have been based on the physician assessment rather than on the EMS provider’s.
| Unique identifiers | |
|---|---|
| Allergic reaction | Animal bite/sting |
| Anaphylaxis | Swollen tongue |
| Bronchospasm | Unresponsive |
| Hypotension | Wheezing |
| Environmental | Dyspnea |
| Rash | Drug reaction |
2.4. Variables
Variables collected included demographics, allergic trigger (based on suspected trigger at time of ED evaluation), signs and symptoms, epinephrine dose and route of administration, complications of epinephrine dose, ED management, and disposition.
2.5. Data source
Data were collected from the electronic medical records and EMS documentation using a standardized data abstraction form that was developed as part of the protocol of the study.
2.6. Statistical methods
Continuous data are presented as median with interquartile range (IQR) based on the skewed distribution of data. Categorical data are presented as percent frequency of occurrence. Univariate logistic regression models were fit to estimate the association between signs and symptoms, fulfillment of National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network (NIAID/FAAN) diagnostic criteria for anaphylaxis, and disposition with EMS epinephrine administration or recommendation (Fig..Fig.) [5x[5]Campbell, R.L., Hagan, J.B., Manivannan, V. et al. Evaluation of national institute of allergy and infectious diseases/food allergy and anaphylaxis network criteria for the diagnosis of anaphylaxis in emergency department patients. J Allergy Clin Immunol. 2012;
129: 748–752
Abstract | Full Text | Full Text PDF | PubMed | Scopus (43)See all References][5]. [6x[6]Sampson, H.A., Munoz-Furlong, A., Campbell, R.L. et al. Second symposium on the definition and management of anaphylaxis: summary report—second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. Ann Emerg Med. 2006;
47: 373–380
Abstract | Full Text | Full Text PDF | PubMed | Scopus (159)See all References][6] Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated for each association. When one of the variables was zero, a 0.5 continuity correction factor was applied (0.5 added to all cells) to be able to calculate ORs. P values (Pearson χ2 or Fisher exact test as appropriate for sample size) represent 2-sided hypothesis testing unless otherwise noted, and P ≤ .05 was considered statistically significant. Statistical analyses were performed using JMP software version 9.0 (SAS Institute Inc, Cary, NC).
3. Results
Of the 59187 EMS transports analyzed, there were 199 (0.3%) transports for complaints of allergic reaction or anaphylaxis during the study period. Ninety-two interfacility transport cases were excluded. Of the remaining 107 patients, 4 patients were excluded due to missing data. Thus, the final cohort consisted of 103 patients, and among these, 63 (61%) met NIAID/FAAN diagnostic criteria for anaphylaxis.
3.1. Characteristics of EMS-transported patients with allergic reactions and anaphylaxis
Eighteen (17%) patients were less than the age of 18 years, and 67 (65%) were women. Twelve (12%) patients received epinephrine before the arrival of EMS (Table 2Table 2). Medications were the most commonly identified trigger (31%), followed by foods (28%), and insect venom (12%). One hundred patients (97%) presented with mucocutaneous symptoms. Cardiovascular and respiratory symptoms were also common (67% and 58%, respectively), followed by gastrointestinal symptoms (16%) (Table 3Table 3). Six patients were admitted to the intensive care unit (ICU) (Table 4Table 4).There were no deaths in the cohort and no documented biphasic reactions.
| Demographics | n = 103 (%) |
|---|---|
| Age, y (IQR) | 39 (24-59) |
| Less than 18 years | 18 (17) |
| Female | 67 (65) |
| Epinephrine given or recommended | |
| Pre-EMS | 12 (12) |
| EMS | 17 (17) |
| ED | 4 (4) |
| Total | 33 (32) |
| Patient characteristic | Overall (n = 103) | Epi EMS (n = 17) | No-epi EMS (n = 86) | OR (95% CI) | P |
|---|---|---|---|---|---|
| Age <18 y | 18 (17) | 2 (11) | 16 (89) | 0.58 (0.12-2.8) | .730 |
| Age ≥18 y | 85 (83) | 15 (18) | 70 (82) | 1.71 (0.35-8.26) | .730 |
| Female | 67 (65) | 12 (18) | 55 (82) | 1.35 (0.46-4.20) | .275 |
| Trigger | |||||
| Food | 29 (28) | 3 (18) | 26 (30) | 0.49 (0.13-1.87) | .384 |
| Medicine | 32 (31) | 4 (24) | 28 (32) | 0.64 (0.19-2.13) | .462 |
| Venom | 12 (12) | 5 (29) | 7 (8) | 4.70 (1.28-17.22) | .013 |
| Other | 7 (7) | 0 (0) | 7 (8) | 0.30 (0.0-4.58) | .597 |
| Unknown | 23 (22) | 5 (29) | 18 (21) | 1.6 (0.49-5.05) | .525 |
| Mucocutaneous symptoms | 100 (97) | 16 (94) | 84 (97) | 0.38 (0.03-4.46) | .469 |
| Urticaria/flushing | 71 (69) | 10 (59) | 61 (71) | 0.58 (0.20-1.71) | .334 |
| Swelling face/lips | 27 (26) | 4 (24) | 23 (27) | 0.84 (0.25-2.85) | .781 |
| Swelling tongue | 21 (20) | 1 (6) | 20 (23) | 0.21 (0.03-1.65) | .070 |
| Throat tightness | 33 (32) | 8 (47) | 25 (29) | 2.17 (0.75-6.26) | .156 |
| Respiratory symptoms | 60 (58) | 15 (88) | 45 (52) | 6.83 (1.47-31.71) | .006 |
| Dyspnea | 47 (46) | 10 (59) | 37 (43) | 1.89 (0.66-5.44) | .233 |
| Voice change | 7 (7) | 2 (12) | 5 (6) | 2.16 (0.38-12.18) | .407 |
| Wheezes | 12 (12) | 4 (24) | 8 (9) | 3.00 (0.79-11.41) | .125 |
| Tachypnea (RR >24) | 12 (12) | 6 (35) | 6 (7) | 7.27 (1.99-26.56) | .003 |
| Hypoxia (O2 sat ≤92) | 5 (5) | 2 (12) | 3 (3) | 3.69 (0.57-23.98) | .197 |
| Gastrointestinal symptoms | 16 (16) | 2 (12) | 14 (16) | 0.69 (0.14-3.34) | .629 |
| Nausea | 8 (8) | 1 (6) | 7 (8) | 0.71 (0.08-6.14) | .743 |
| Vomiting | 10 (10) | 1 (6) | 9 (10) | 0.53 (0.06-4.52) | .537 |
| Abdominal pain | 3 (3) | 0 (0) | 3 (3) | 0.68 (0.0-12.48) | .294 |
| Diarrhea | 2 (2) | 0 (0) | 2 (2) | 0.97 (0.0-20.48) | .393 |
| Cardiovascular symptoms | 69 (67) | 12 (71) | 57 (66) | 1.22 (0.39-3.80) | .728 |
| Presyncope | 10 (10) | 1 (6) | 9 (10) | 0.53 (0.06-4.52) | .537 |
| Syncope | 4 (4) | 0 (0) | 4 (5) | 0.52 (0.0-8.86) | .225 |
| Chest pain | 6 (6) | 2 (12) | 4 (5) | 2.73 (0.46-16.28) | .297 |
| Hypotension (SBP ≤90) | 5 (5) | 2 (12) | 3 (3) | 3.69 (0.57-24.0) | .297 |
| Tachycardia (HR >100) | 47 (46) | 9 (53) | 38 (44) | 1.42 (0.50-4.03) | .509 |
| NIAID/FAAN criteria met | 63 (61) | 14 (82) | 49 (57) | 3.50 (0.94-13.2) | .0498 |
| Disposition | |||||
| Home | 75 (73) | 12 (71) | 63 (73) | 0.88 (0.28-2.76) | .774 |
| ED observation unit | 8 (8) | 0 (0) | 8 (9) | 0.26 (0.0-3.91) | .347 |
| General hospital floor | 14 (14) | 2 (12) | 12 (14) | 0.82 (0.17-4.06) | 1.00 |
| ICU | 6 (6) | 3 (18) | 3 (3) | 5.92 (1.08-32.4) | .055 |
Abbreviations: Epi, epinephrine; RR, respiratory rate; O2 sat, oxygen saturation; SBP, systolic blood pressure; HR, heart rate.
| Age | EMS management | Presenting signs/symptoms and ED course |
|---|---|---|
| Sex | ||
| 77, M | No medications administered | Patient presented with sudden onset of shortness of breath, swollen tongue, lips, eyes, and throat, with stridor and wheezing that began shortly after taking a laxative. Patient’s BP was 94/59 mm Hg and had normal oxygen saturations. In the ED, he received nebulized albuterol, IM steroids, and diphenhydramine. Epinephrine was considered, but patient had concomitant CHF exacerbation. Nasopharyngoscopy was performed to rule out laryngeal edema. |
| 75, M | 25 mg of IV diphenhydramine | Patient presented with rash, pruritus, urticaria, tongue, and lip swelling after taking sulfamethoxazole-trimethoprim. Patient had normal saturations, but BP was 102/60 mm Hg (significantly lower than baseline). He received IV steroids, IV diphenhydramine, and H2 antihistamines. |
| 28, M | Endotracheal intubation followed by 0.3 mg of subcutaneous epinephrine and 2 doses of 0.25 mg IM epinephrine | Patient was found at home cyanotic and unresponsive after eating Chinese food. Upon arrival to the ED, he was hemodynamically stable and was found to have urticaria. He received nebulized albuterol via endotracheal tube, IV steroids, and H2 antihistamines. |
| 70, F | 0.3 mg of subcutaneous epinephrine, 50 mg of IV diphenhydramine, nebulized albuterol | Patient experienced weakness, shortness of breath, nausea, and vomiting, which began 20 min after taking levofloxacin for a COPD exacerbation. She was hypotensive (BP, 59/39 mm Hg) with saturations of 88%. Upon arrival in the ED, she was hemodynamically stable and received IV fluids, steroids, and H2 antihistamines. |
| 49, F | 50 mg of IV diphenhydramine | Patient presented with lower lip edema, tongue swelling, and throat tightness that developed shortly after using new toothpaste. She was normotensive and had normal oxygen saturations. In the ED, she received IV steroids and H2 antihistamines. She was found to have mild vocal cord edema on nasopharyngoscopy but symptomatically improved and was admitted to the ICU for close airway observation. |
| 24, F | 0.3 mg of subcutaneous epinephrine, 25 mg of IV diphenhydramine. | Patient presented with shortness of breath, tongue swelling, hives, pruritus, and tightness of throat with an unknown trigger. |
| Her blood pressure was 107/67 mm Hg with normal oxygen saturations. In the ED, she received IV steroids and H2 antihistamines. She was admitted to the ICU for close airway observation. |
Abbreviations: M, male; F, female; BP, blood pressure; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease.
3.2. EMS epinephrine administration
Fifteen patients received epinephrine from EMS personnel, and epinephrine was recommended for 2 additional patients who refused the medication, for a total of 17 (17%) patients for whom epinephrine was administered or recommended. Among these 17 patients, only one had self-administered a dose of epinephrine before EMS arrival. Eleven (65%) of 17 patients received subcutaneous epinephrine, which was in accordance with the EMS protocol at the time of the study. Four (24%) of 17 patients received intravenous (IV) epinephrine. None of the patients received additional epinephrine after ED arrival.
3.3. Outcomes of patients who received EMS-administered IV epinephrine
Among the 4 patients who received IV epinephrine, 3 patients received 0.3 mg of epinephrine, and one patient received 0.5 mg of epinephrine. All patients also received IV fluids and diphenhydramine. The details of the patient presentations and ED course are shown in Table 5Table 5.
| Age | EMS management | Presenting signs/symptoms and ED course |
|---|---|---|
| Sex | ||
| 82, F | IV fluids, 50 mg IV diphenhydramine, 2.5 mg nebulized albuterol, 0.5 mg of 1:1000 IV epinephrine | Patient presented with angioedema of the tongue, diffuse urticaria, and dyspnea secondary to a medication reaction. She was normotensive (118/93 mm Hg) but in moderate respiratory distress. Symptoms improved after EMS-administered epinephrine; no complications were documented. She was admitted to the general medical floor for additional monitoring. |
| 68, F | IV fluids, 50 mg of IV diphenhydramine, 0.3 mg of 1:10000 IV epinephrine | Patient’s blood pressure was 82/60 mm Hg. She had tongue and lip swelling, throat tightness, hoarse voice, and diffuse urticaria secondary to a medication reaction. After treatment with EMS IV epinephrine, she developed ventricular bigemeny and received IV lidocaine from EMS providers. She stabilized in the ED without any additional epinephrine and was admitted to cardiology. |
| 18, M | IV fluids, 50 mg IV diphenhydramine, 0.3 mg of 1:10000 IV epinephrine | Patient was stung multiple times on the back as well as on the upper lip by a bee. He reported dyspnea and facial swelling. The blood pressure (157/99 mm Hg) was not documented until after epinephrine administration. Symptoms improved, and he was observed in the ED observation unit for approximately 6 h and dismissed home. |
| 55, M | IV fluids, 50 mg IV diphenhydramine, 0.3 mg of 1:1000 IV epinephrine | Patient was stung by a bee on his leg and developed dyspnea. EMS personnel found him diaphoretic, pale, and bradycardic with a systolic blood pressure of 90 mm Hg, while lying supine on the ground. Patient’s symptoms improved after EMS IV epinephrine, and he was dismissed home directly from the ED after approximately 3 h of observation. |
3.4. Outcomes of patients who received EMS-administered subcutaneous epinephrine
Eleven patients received subcutaneous epinephrine. All patients received 0.3 mg of epinephrine except for a 1-year-old boy who received 0.15 mg of epinephrine and a 36-year-old woman who received 0.1 mg of epinephrine (as directed by the medical control physician).
3.5. Outcomes of patients who did not receive EMS-administered epinephrine
As shown in Table 2Table 2, after ED arrival, 4 (4%) additional patients received epinephrine. None of these patients had received epinephrine before EMS arrival or from EMS providers. All patients received subcutaneous epinephrine in the ED. One patient was admitted to the general medical service, one was admitted to the ED observation unit, and 2 were dismissed home. Dispositions of patients who did not receive EMS epinephrine are shown in Table 3Table 3.
3.6. Associations with EMS epinephrine administration
Patients who received epinephrine from EMS personnel were more likely to have venom as a trigger (29% vs 8%; OR, 4.70; 95% CI, 1.28-17.22; P = .013), respiratory symptoms (88% vs 52%; OR, 6.83; 95% CI, 1.47-31.71; P = .006), and specifically, more likely to have tachypnea (35% vs 7%; OR, 7.27; 95% CI, 1.99-26.56; P = .003) as compared with patients who did not receive epinephrine from EMS personnel. They were also more likely to meet the NIAID/FAAN criteria for the diagnosis of anaphylaxis (82% vs 57%; OR, 3.50; 95% CI, 0.94-13.2; P = .0498) (Table 3Table 3). Although differences were not statistically significant, patients who received EMS-administered epinephrine tended to be more likely to be admitted to the ICU (18% vs 3%; OR, 5.92; 95% CI, 1.08-32.4; P = .055). There were no significant differences with regard to patient age or sex.
4. Discussion
Medical literature regarding prehospital management of anaphylaxis is sparse [[4]x[4]Tiyyagura, G.K., Arnold, L., Cone, D.C. et al. Pediatric anaphylaxis management in the prehospital setting. Prehosp Emerg Care. 2014;
18: 46–51
CrossRef | PubMed | Scopus (5)See all References, [7]x[7]Rea, T.D., Edwards, C., Murray, J.A. et al. Epinephrine use by emergency medical technicians for presumed anaphylaxis. Prehosp Emerg Care. 2004;
8: 405–410
CrossRef | PubMed | Scopus (9)See all References, [8]x[8]Capps, J.A., Sharma, V., and Arkwright, P.D. Prevalence, outcome and pre-hospital management of anaphylaxis by first aiders and paramedical ambulance staff in Manchester, UK. Resuscitation. 2010;
81: 653–657
Abstract | Full Text | Full Text PDF | PubMed | Scopus (21)See all References]. To the best of our knowledge, there have been no previous studies documenting patient outcomes after ED arrival in a population of both pediatric and adult anaphylaxis patients transported by EMS. We present a study of a total of 59187 EMS transports between July 2002 to July 2007 of whom 199 (0.3%) were found to have had an allergic reaction or anaphylaxis. After exclusion of interfacility transports, we analyzed 103 cases transported by EMS providers and report outcomes of these patients after arrival to the ED. Emergency medical system epinephrine administration was more likely in patients with venom as a trigger and with respiratory symptoms, particularly tachypnea. They were more likely to meet NIAID/FAAN criteria and tended to be more likely to be admitted to the ICU. After transport to the ED, only 4 (4%) additional patients received epinephrine.
Our finding that 0.3% of EMS transports were for allergic complaints is comparable with the data presented by a retrospective study of emergency transports for allergic reactions published in 2010 by Capps et al [8x[8]Capps, J.A., Sharma, V., and Arkwright, P.D. Prevalence, outcome and pre-hospital management of anaphylaxis by first aiders and paramedical ambulance staff in Manchester, UK. Resuscitation. 2010;
81: 653–657
Abstract | Full Text | Full Text PDF | PubMed | Scopus (21)See all References][8] in which allergic reactions made up approximately 0.2% of total ambulance workload. In addition, an earlier study showed that 0.4% to 0.9% of EMS transports in a population of 13 million was for allergic reactions [9x[9]Spaite, D.W., Maio, R., Garrison, H.G. et al. Emergency Medical Services Outcomes Project (EMSOP) II: developing the foundation and conceptual models for out-of-hospital outcomes research. Ann Emerg Med. 2001;
37: 657–663
Abstract | Full Text | Full Text PDF | PubMed | Scopus (48)See all References][9].
A recent study in pediatric patients showed that 36% of the patients who met criteria for anaphylaxis received epinephrine from EMS personnel [4x[4]Tiyyagura, G.K., Arnold, L., Cone, D.C. et al. Pediatric anaphylaxis management in the prehospital setting. Prehosp Emerg Care. 2014;
18: 46–51
CrossRef | PubMed | Scopus (5)See all References][4]. This is almost double the rate in our cohort, where overall, only 17% either received or were recommended epinephrine. Furthermore, only 11% of children in our study received subcutaneous EMS epinephrine. However, our findings are similar to findings by Capps et al [8x[8]Capps, J.A., Sharma, V., and Arkwright, P.D. Prevalence, outcome and pre-hospital management of anaphylaxis by first aiders and paramedical ambulance staff in Manchester, UK. Resuscitation. 2010;
81: 653–657
Abstract | Full Text | Full Text PDF | PubMed | Scopus (21)See all References][8] who found that overall, 14% of all patients and 8% of children received epinephrine from EMS personnel. Thus, there appears to be significant variation among EMS systems with regard to the use of epinephrine for the management of anaphylaxis [8x[8]Capps, J.A., Sharma, V., and Arkwright, P.D. Prevalence, outcome and pre-hospital management of anaphylaxis by first aiders and paramedical ambulance staff in Manchester, UK. Resuscitation. 2010;
81: 653–657
Abstract | Full Text | Full Text PDF | PubMed | Scopus (21)See all References][8].
Our finding that patients who received epinephrine from EMS personnel were more likely to meet NIAID/FAAN criteria is similar to findings of a previous study of EMS management of allergic reactions, where paramedics were more likely to administer epinephrine to patients with respiratory and circulatory compromise [8x[8]Capps, J.A., Sharma, V., and Arkwright, P.D. Prevalence, outcome and pre-hospital management of anaphylaxis by first aiders and paramedical ambulance staff in Manchester, UK. Resuscitation. 2010;
81: 653–657
Abstract | Full Text | Full Text PDF | PubMed | Scopus (21)See all References][8]. These results suggest that paramedic epinephrine administration was appropriately based on symptom severity. Likewise, the association between venom as a trigger and EMS-provided epinephrine is consistent with previous findings demonstrating a more rapid onset of arrest in patients who had fatal anaphylaxis secondary to venom (median time to arrest, 15 minutes) as compared with food (30 minutes) [10x[10]Pumphrey, R.S. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000;
30: 1144–1150
CrossRef | PubMed | Scopus (617)See all References][10].
Our data showing that only 4% of patients received epinephrine after ED arrival could be viewed as further evidence that most patients who urgently required epinephrine received it from EMS providers. Alternatively, it could be argued that ED providers are also underrecognizing and undertreating anaphylaxis, as has been suggested in some studies [[11]x[11]Clark, S., Bock, S.A., Gaeta, T.J. et al. Multicenter study of emergency department visits for food allergies. J Allergy Clin Immunol. 2004;
113: 347–352
Abstract | Full Text | Full Text PDF | PubMed | Scopus (172)See all References, [12]x[12]Clark, S. and Camargo, C.A. Jr. Emergency treatment and prevention of insect-sting anaphylaxis. Curr Opin Allergy Clin Immunol. 2006;
6: 279–283
PubMedSee all References]. Of note, 3 of 5 patients in our cohort who had hypotension did not receive EMS epinephrine. Furthermore, our results stand in contrast to findings by Tiyyagura et al [4x[4]Tiyyagura, G.K., Arnold, L., Cone, D.C. et al. Pediatric anaphylaxis management in the prehospital setting. Prehosp Emerg Care. 2014;
18: 46–51
CrossRef | PubMed | Scopus (5)See all References][4] who found that, in a cohort of pediatric patients, nearly all patients who did not receive epinephrine from EMS providers received it after arrival to the ED. Thus, additional studies of EMS anaphylaxis management including outcomes after ED arrival are needed to definitively determine if EMS providers are appropriately administering epinephrine to anaphylaxis patients.
Administration of IV epinephrine is associated with risk of cardiovascular complications and overdose, making administration challenging for even experienced health care providers [[13]x[13]Kanwar, M., Irvin, C.B., Frank, J.J. et al. Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution. Ann Emerg Med. 2010;
55: 341–344
Abstract | Full Text | Full Text PDF | PubMed | Scopus (42)See all References, [14]x[14]Karch, S.B. Coronary artery spasm induced by intravenous epinephrine overdose. Am J Emerg Med. 1989;
7: 485–488
Abstract | Full Text PDF | PubMed | Scopus (40)See all References, [15]x[15]Klein, J.S., Yunginger, J.W., and Rich, M. Myocardial dysfunction after epinephrine treatment of presumed insect venom allergy in a marathon runner. Ann Allergy Asthma Immunol. 2008;
100: 285–286
Abstract | Full Text | Full Text PDF | PubMedSee all References, [16]x[16]Manivannan, V., Li, J.T., Prasad, A. et al. Apical ballooning syndrome after administration of intravenous epinephrine during an anaphylactic reaction. Mayo Clin Proc. 2009;
84: 845–846
Abstract | Full Text | Full Text PDF | PubMed | Scopus (18)See all References, [17]x[17]Shaver, K.J., Adams, C., and Weiss, S.J. Acute myocardial infarction after administration of low-dose intravenous epinephrine for anaphylaxis. CJEM. 2006;
8: 289–294
PubMedSee all References]. The dosing of EMS-administered IV epinephrine in our study would be inappropriate based on current World Allergy Organization guidelines for the treatment of anaphylaxis, given that patients did not receive intramuscular (IM) epinephrine before IV [18x[18]Simons, F.E., Ardusso, L.R., Bilo, M.B. et al. World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2011;
4: 13–37
CrossRef | PubMed | Scopus (138)See all References][18]. Furthermore, the remaining cases of EMS-administered epinephrine in our study was via the subcutaneous route, which is known to have lesser absorption rates as compared with IM route [[19]x[19]Simons, F.E., Roberts, J.R., Gu, X. et al. Epinephrine absorption in children with a history of anaphylaxis. J Allergy Clin Immunol. 1998;
101: 33–37
Abstract | Full Text | Full Text PDF | PubMed | Scopus (249)See all References, [20]x[20]Simons, F.E., Gu, X., and Simons, K.J. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol. 2001;
108: 871–873
Abstract | Full Text | Full Text PDF | PubMed | Scopus (251)See all References]. However, the dosing provided by the EMS providers was in concordance with the local EMS protocol for severe anaphylaxis at the time of the study. The protocol has since been updated to recommend IM epinephrine as first-line treatment for anaphylaxis and requires EMS providers to obtain physician-provided medical direction before the administration of IV epinephrine for patients not in cardiac arrest.
Although delayed administration of epinephrine has been shown to result in adverse outcomes, currently, there is no consensus regarding availability of epinephrine for use in anaphylaxis among EMS providers [[21]x[21]Bock, S.A., Munoz-Furlong, A., and Sampson, H.A. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol. 2007;
119: 1016–1018
Abstract | Full Text | Full Text PDF | PubMed | Scopus (431)See all References, [22]x[22]Pumphrey, R.S. and Gowland, M.H. Further fatal allergic reactions to food in the United Kingdom, 1999-2006. J Allergy Clin Immunol. 2007;
119: 1018–1019
Abstract | Full Text | Full Text PDF | PubMed | Scopus (265)See all References]. In Minnesota, all ambulances are required to carry epinephrine since 2002. However, not all states require ambulances to be equipped with epinephrine nor are all levels of emergency medical technicians fully authorized to administer the medication during an anaphylactic emergency [23x[23]EMTs and epinephrine. http://www.foodallergy.org/page/emergency-medical-services. ([Accessed 16 Jul, 2012])
See all References][23]. Standardized guidelines for EMS anaphylaxis management should be considered, given the possible life-threatening nature of anaphylaxis and relatively uncommon occurrence among EMS transports. Guidelines would need to take into consideration the various levels of training of EMS providers.
Our study has the limitations of a retrospective study. The ability of the study to identify and include all cases of anaphylaxis in our cohort depended on the unique identifiers used. Although our list of identifiers was fairly exhaustive, some cases of anaphylaxis may not have been included. We defined anaphylaxis based on the NIAID/FAAN diagnostic criteria; however, these criteria are not universally accepted. Our patient population was mainly of White origin, and the results may not be generalizable to other populations. Furthermore, our study only included ALS EMS providers and did not include other levels of EMS providers. Hence, the findings may not apply to EMS systems, which rely heavily on basic life support providers for their care.
5. Conclusion
Although low rates of epinephrine administration were observed, the association of EMS administration of epinephrine with respiratory symptoms, fulfillment of NIAID/FAAN diagnostic criteria for anaphylaxis, and low rate of additional epinephrine administration in the ED suggest that ALS EMS-administered epinephrine was based on symptom severity. Additional studies of EMS anaphylaxis management including management and outcomes after ED arrival are needed. Standardized guidelines for EMS anaphylaxis management should be considered given the life-threatening nature of anaphylaxis, its relatively uncommon occurrence among EMS transports, and various levels of EMS provider training.
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