Anaphylaxis management in the pediatric emergency department: opportunities for improvement

To determine the rate, immediate treatment, and outpatient management for anaphylaxis in patients receiving care in a pediatric emergency department (ED).

This is a retrospective cross-sectional descriptive study of patients (21 years or younger) who received care for anaphylaxis for a 5-year period in the ED of the Children's Hospital of Alabama in Birmingham, AL, which has an annual census of 55,000. The diagnostic criteria for anaphylaxis were symptoms and/or signs involving 2 or more organ systems (dermatologic, respiratory, gastrointestinal, and cardiovascular), hypotension for age, 1 organ system involvement with admission to the hospital, and/or dermatologic system involvement treated with intramuscular epinephrine.

There were 124 patient visits by 103 patients (4.5 events/10,000 ED patient visits) who met the diagnostic criteria for anaphylaxis. This included 114 (92%) patients who had involvement of two or more organ systems. There were 66 (64%) males and 33 (27%) patient visits that resulted in hospitalization. The most common organ system involvement was dermatologic in 121 (98%), followed by respiratory in 101 (81%), gastrointestinal in 33 (27%), and cardiovascular in 11 (9%). Medical interventions include 69 patients treated with intramuscular epinephrine (56%; either in pre-hospital setting and/or during ED visit), 97 patients treated with corticosteroids (79%), 114 patients treated with H1 and/or H2 antihistamine (93%), 15 patients treated with intravenous fluid bolus (12%), and 37 patients treated with albuterol nebulization (30%). Food was the most common inciting allergen (in 45 or 36% of patients). Among the foods that were listed as causing reactions were peanuts, shellfish, milk, ice cream, fruit, nuts, and fried chicken. Compared with ED care-only patients, the hospitalized patients had a significantly greater rate of cardiovascular system involvement and of receiving more ED interventions. Of 91 ED care-only patients, autoinjection epinephrine was prescribed to 63% and referral to an allergist was recommended to 33%. Patients treated with intramuscular epinephrine had a significantly greater rate of hospitalization and of receiving more ED interventions compared with patients who were not treated with epinephrine. There were no patient deaths.

This study is the first to describe the management of anaphylaxis in a pediatric ED. The results revealed opportunities for improvement. Although our ED treatment and outpatient management of patients with anaphylaxis did not meet the recommended standards of care with regard to administration of intramuscular epinephrine, prescribing autoinjection epinephrine, or referral to an allergist for all patients who had a diagnosis of anaphylaxis, we do report a higher concordance with published recommendations than those reported in previous studies performed in adults.