Pediatric anaphylaxis management in the prehospital setting

Anaphylaxis is a life-threatening systemic allergic reaction that occurs after contact with an allergy-causing substance. Timely administration of intramuscular epinephrine is the treatment of choice for controlling symptoms and decreasing fatalities. Our purpose was to investigate the prehospital management of anaphylaxis among patients receiving care in an urban tertiary care pediatric emergency department (PED).

We performed a retrospective chart review from May 2008 to January 2010 of patients 18 years or younger who received care in the PED for anaphylaxis. Data were extracted by one investigator and included demographic information, patient symptoms, past medical history, medications administered (including route and provider), and final disposition.

We reviewed 218 cases of anaphylaxis in 202 children. Mean age of patients was 7.4 years; 56% of patients were male. A total of 214 (98%) manifested symptoms in the skin/mucosal system, 68% had respiratory symptoms, 44% had gastrointestinal symptoms, and 2% had hypotension. Sixty-seven percent had a previous history of allergic reaction and 38% had a history of asthma. Seventy-six percent of the patients presented with anaphylaxis to food products, 8% to medications, 1% to stings, and 16% to unknown allergens. Reactions occurred at home or with family members 87% of the time, and at school 12% of the time. Only 36% of the patients who met criteria for anaphylaxis had epinephrine administered by emergency medical services (EMS). Among 26 patients with anaphylactic reactions at school, 69% received epinephrine by the school nurse. Of the 117 patients with known allergies who were with their parents at the time of anaphylactic reaction, 41% received epinephrine. Thirteen patients were seen by a physician prior to coming to the PED; all received epinephrine at the physician's office. In total, epinephrine was given to 41% (89) of the 218 cases prior to coming to the PED.

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.