EMS, patients need guidance on using epinephrine to treat anaphylaxis

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When a patient is suffering anaphylaxis, what is the best first treatment?

The answer: Use epinephrine first, then get the patient to the emergency department for physicians and other clinicians to treat the sudden, severe allergic reaction that can be life-threatening, according to researchers.

If you were not sure about the answer, you’re not alone. Two new studies found patients and emergency medics were able to recognize signs of anaphylaxis. Treating them is another matter: Patients need more and better education, and some emergency medical service (EMS) protocols around the country do not reflect current research.

“We know early recognition of anaphylaxis and treatment with epinephrine improves outcomes,” said Sasha Alvarado, DO, co-director of Quality and Safety for the Division of Immunology, Allergy and Retrovirology at Baylor College of Medicine in San Antonio, Texas.

The American College of Allergy, Asthma and Immunology announced the results for presentation at its Annual Scientific Meeting scheduled in Boston Oct. 24-28.

EMS updates needed

Anaphylaxis can be life-threatening, so proper treatment is crucial before a patient gets to a hospital. But EMS treatment protocols are incomplete, outdated or both, said Carly Gunderson, DO, lead author of the study, “Discrepancies in Anaphylaxis Protocols Across Emergency Medical Services in the United States – Opportunities for Improvement.”

Researchers examined 30 states with mandatory advanced cardiac life support protocols. Epinephrine was the first line recommendation for anaphylaxis for 29 of them, or 97%. Epinephrine injectors are convenient and effective; those were allowed in 25 states (83%) and provided in 17% (57%), according to the researchers.

Among other findings:

• 15 (50%) included gastrointestinal symptoms in the definition of anaphylaxis.
• 12 (40%) included neurologic manifestations.
• 27 (90%) recommended albuterol if respiratory symptoms were present.
• 22 (73%) recommended intravenous fluids as part of treatment.
• 18 (60%) recommended steroids.

The researchers said it was surprising that many EMS protocols did not consider gastrointestinal or neurologic manifestations. Recommendations on steroids and first-generation antihistamines were outdated.

“Given the frequency of EMS activation for allergic reactions, our communities would benefit from standardized protocols using current evidence-based guidelines for the management of anaphylaxis,” the abstract said.

Patient awareness

Researchers went to an allergy clinic waiting room to survey 96 patients about their knowledge of anaphylaxis and an action plan to treat it, lead author Joni Chow, DO, said in a news release. Chow is Pediatric Resident at Baylor College of Medicine.

“The results demonstrate the need for better education of allergy patients to recognize and treat anaphylaxis appropriately,” Chow said.

Among the respondents in the study, 95% were prescribed epinephrine and 73% said they were comfortable with recognizing anaphylaxis symptoms. But only 14% of respondents said they were very likely to use epinephrine first for anaphylaxis, according to the news release.

The researchers said patients identified barriers to using epinephrine:

• 40.6% - Not sure which symptoms to treat
• 24% - Hesitant to go to the emergency room
• 17.7% - Hesitant to call 911
• 11.5% - Not sure how to use epinephrine auto-injectors
• 5.2% - Feared needles

Among the patients, 85% stated antihistamines do not prevent the need for epinephrine, but antihistamines still would be the first choice of treatment for 23.7% them. If patients had a rash and wheezing after a suspected allergen exposure, 64.5% said they would inject epinephrine and 10.8% said they would drive to the emergency department first, according to the findings.

Patients also suggested the best information to include in patient-centered anaphylaxis action plans:

• 93% - How to manage mild, nonanaphylactic allergic reactions
• 87.6% - Visuals on how to inject epinephrine
• 81% - Visuals of anaphylaxis symptoms

The study is “Understanding of Anaphylaxis Management Among Allergy Patient and Components of a Patient-Centered Anaphylaxis Action Plan.”