Tiyyagua GK, Arnold L, Conde DC, et al. Pediatric anaphylaxis management in the prehospital setting. Prehosp Emerg Care. Sept. 12, 2013. [Epub ahead of print.]
This study comes from Yale University School of Medicine in New Haven, Conn., where researchers examined who administered epinephrine to children suffering from anaphylaxis. In a two-year period, 218 cases of anaphylaxis were seen in the pediatric ED.
The mean age was 7.4 years and the cases were almost evenly split among males and females. Ninety-eight percent (214) manifested symptoms in the skin and mucosal system, 68% (148) had respiratory symptoms, 44% (96) had GI symptoms and only 2% (4)had hypotension. Seventy-six percent of the patients presented with anaphylaxis to food products. Reactions occurred at home or with family members 87% (190 cases) of the time and at school 12% (26 cases) of the time.
Of the 26 patients with reactions at school, 69% (18) received epinephrine by the school nurse. Of the 117 with reactions at home or with parents, 41% (11) received epinephrine. Of the 13 patients seen by a physician before transfer to the ED, all received epinephrine.
Ninety patients were transported to the Pediatric Emergency Department by EMS. Of these, 49% (44) received epinephrine prior to EMS arrival and 8% (7) didn’t meet the 2006-anaphylaxis criteria. Of the remaining 39 patients, EMS administered epinephrine to only 36% (14).
The authors concluded, “Our evaluation revealed low rates of epinephrine administration by EMS providers and parents/patients. Education about anaphylaxis is imperative to encourage earlier administration of epinephrine.”
Medic Karen Wesley Comments:
I agree with the conclusion citing a need for additional training and education. However, I disagree with several points made in this study.
On the use of patient medication, in my experience it’s common that adolescents—and parents of younger children—with a history of anaphylaxis fail to carry the EpiPen or keep them up to date. Often the policy of EMS providers is to use the medications they stock rather than the patient’s medications because the integrity of a patient’s prescription can’t be verified.
Further, many services, unable to afford EpiPen, carry vials that require dosages to be calculated and drawn up. This lengthens the time to administration.
Not every anaphylaxis patient presents the same. Patients often present with respiratory distress alone, which is common to many childhood illnesses. The study states that a larger percentage of the patients had a history of asthma. With this pertinent information, the procedures of albuterol nebulizers and oxygen would be the protocol followed.
The numbers themselves don’t accurately account for the care scenarios, but if the conclusion initiates increased education to heighten awareness on the importance of epinephrine in the patient outcome, and the understanding that anaphylaxis doesn’t stand alone as a separate life threat, I would say the study has enormous value.
Doc Keith Wesley Comments:
Studies have shown that anaphylaxis, particularly in children, is a serious condition. The press is full of stories of children dying at school when exposed to even the smallest amount of peanut dust or other allergens. As a result, many of the nation’s schools have done a phenomenal job educating teachers and parents to the importance of early identification and treatment of symptomatic children.
For this reason it’s not surprising school nurses administered epinephrine to the majority of children with anaphylaxis, closely followed by parents.
So why did EMS perform so poorly in this study? This study occurred in a paramedic system. The average time from EMS scene arrival to delivery of the patient at the hospital was 30 minutes. One would expect paramedics to recognize anaphylaxis and 30 minutes is certainly long enough to have administered the drug once—if not twice—for severe reactions.
The authors contend that lack of education is to blame. Although this may be a component, I believe the real reason is the protocol these paramedics used.
This system’s protocol calls for IV fluid administration as “first-line” care followed by nebulized bronchodilators (albuterol), oral diphenhydramine (Benadryl) and intramuscular epinephrine. Interestingly, of the 39 patients who hadn’t yet received epinephrine prior to EMS arrival, only 2% (1) had an IV started while 41% (16) received diphenhydramine and 32% (12) received albuterol.
When protocols require providers to perform painful and often less successful procedures on children, it’s natural to gravitate to other options like nebs and meds. This study comes from a group of highly respected physicians who are dedicated to prehospital care. I suspect they were as surprised by the results as I was and have not only changed the way they educate providers to the seriousness of anaphylaxis, but have already edited their protocols to place the EpiPen at the top where it belongs.