Subcutaneous epinephrine in the prehospital setting

To outline current practice regarding the prehospital use of subcutaneous epinephrine, and systematically review the existing literature to determine the level of support for its use in the elderly. Many health care personnel are reluctant to administer subcutaneous epinephrine for potentially life-threatening conditions such as asthma and anaphylaxis in older patients. This sytematic review examined the following focused question: "For older patients not known to have coronary artery disease, does administration of subcutaneous epinephrine carry a significant enough risk of cardiovascular side effects to mandate age as a relative contraindication to self-administration or emergency medical services administration in the prehospital setting?"

The MEDLINE and Health Star databases were searched to identify studies evaluating the use of subcutaneous epinephrine in the treatment of asthma and anaphylaxis. Bibliographies from included studies, known reviews, and textbooks were examined to identify additional studies. The strength of evidence presented in each study was assessed in accordance with the classification system proposed by the American Heart Association's Emergency Cardiovascular Care Committee.

The review of the literature revealed only three case reports (level VII evidence) that record adverse reactions of epinephrine when used for anaphylaxis and allergy, while several level III and V studies found no adverse effects when used for asthma. No controlled trials documenting adverse effects were found.

The authors did not find significant evidence to contraindicate the use of subcutaneous epinephrine in older patients who are not known to have coronary artery disease, who present with either asthma or allergic reactions.