The Dec. 7, 2016 webinar, Epi First. Epi Fast. Ask Questions Later, featured Dr. Scott Russell, Division Chief and Medical Director of Pediatric Emergency Medicine at the Medical University of South Carolina. Dr. Russell opened with anaphylaxis definitions from several sources before recommending a “gut check” definition for parents, noting that anaphylaxis symptoms can affect almost any organ system and that suspected anaphylaxis should be treated with epinephrine.
Patients and providers each have a wide range of reasons for not using epinephrine. However, epinephrine is uniformly recommended as the first-line treatment for severe, systemic (not localized) allergic reactions. Dr. Russell concluded that not enough providers “practice what they preach.” NIAID guidelines for anaphylaxis management call for:
- IM (intramuscular) epinephrine as treatment of choice
- Educational instruction before patient is sent home
- Prescription for epinephrine auto-injectors (EAI)
- Referral to a specialist.
However, research conducted by reviewing charts of anaphylaxis patients revealed that while 92 percent had been given antihistamine and 78 percent had been given corticosteroids, only 54 percent had been given epinephrine.
In the second half of the presentation, Dr. Russell addressed some of fears and beliefs that stand in the way of patients and providers following NIAID’s best practices.
Epinephrine Auto-injector Could Cause Side Effects: The mild effects of intramuscular epinephrine delivered by an auto-injector – such as pale skin, shaking, anxiety, palpitations, dizziness, and headache – indicate that a therapeutic dose has been delivered and is working. Epinephrine auto-injectors are safe, and side effects are mild. In contrast, intravenous (IV) epinephrine can have serious side effects.
Last Reaction Was Mild: Compared to first reactions, a significantly higher proportion of subsequent reactions are more severe and require epinephrine.
Reaction Unlikely to Be Fatal: Fatal reactions may be rare, but they are also unpredictable. Delayed administration of epinephrine increases the risk of a biphasic reactions and is one of the factors often associated with death from anaphylaxis.
Used Antihistamine Instead: Antihistamines do not act quickly enough (an hour or more versus less than 10 minutes).
Epinephrine Auto-injector Dose Was Too Large: It is very difficult for most individuals to draw up an accurate dose of epinephrine with a syringe and ampule. Since the side effects of IM epinephrine are mild, giving a child a larger-than-ideal dose of epinephrine via an auto-injector is better than not giving epinephrine when it’s needed or relying on a syringe and ampule.
Additional resources on anaphylaxis and epinephrine are available here.