Knowledge Gaps in How to Manage Anaphylaxis, Epinephrine Use, Persist for Patients, Even EMS
ACAAI 2024. Two studies here showed that anaphylaxis protocols for EMS are outdated in many states and that many patients don't know how to use epinephrine.
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The gold-standard first line treatment for a person experiencing anaphylaxis is administration of epinephrine, followed by transport to an emergency department for potential adjunctive treatment.
While this may seem as though it should be common knowledge among health care professionals, new research has found that not only patients but emergency medical professionals as may be poorly prepared to act once they recognize the signs of a severe allergic reaction. Two studies presented at the American College of Allergy, Asthma and Immunology (ACAAI) Annual Scientific Meeting in Boston, Oct 24-28, revealed that some emergency medical service (EMS) protocols around the country do not reflect current research1 and that patients and caregivers need more and better education on the components of an anaphylaxis action plan.2
EMS Guidelines Out-of-Date
The life-threatening nature of an anaphylactic reaction makes treatment essential before a patient is transported to a hospital. But EMS treatment protocols for prehospital treatment of anaphylaxis are incomplete, outdated or both, Carly Gunderson, DO, an allergy/immunology fellow at Memorial Healthcare System, Hollywood, FL, and lead author of Discrepancies in anaphylaxis protocols across emergency medical services in the United States – opportunities for improvement, and colleagues wrote in the study abstract.1 "The discrepancies include variations in the definition of anaphylaxis as well as in treatment,” the team emphasized.
For this study, Gunderson and colleagues examined 30 states with mandatory advanced cardiac life support protocols to identify gaps in recognition of anaphylaxis.1
Out of the 30 protocols, 29 recommended epinephrine as the first-line treatment of anaphylaxis. All 30 state protocols recommended diphenhydramine and epinephrine. Most (90%) recommended use of albuterol if the patient had respiratory symptoms; three-quarters (73%) recommended intravenous fluids, and 60% recommended steroids. Epinephrine autoinjectors were allowed in 25 states (83%) and provided in 17 (57%), according to the researchers.1
Among other findings across the 30 states, just 15 (50%) included gastrointestinal symptoms in the definition of anaphylaxis, and only 40% (12) included neurologic manifestations. A 2-organ identification system was in place at 14 (47%).
The researchers said it was surprising that many EMS protocols did not consider gastrointestinal or neurologic manifestations as signs of potential anaphylaxis. It was also a concern that many still include recommendations for use of steroids and first-generation antihistamines, both of which are now outdated, wrote researchers. Further despite the convenience of epinephrine autoinjectors, not all state protocols permitted their use and just more than half provided the devices.1
“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,” Gunderson et al concluded.1
Patient Education, Awareness
Joni Chow, DO, a pediatric resident, and senior author Sasha Alvarado, DO, codirector of quality and safety for the division of immunology, allergy, and retrovirology, at Baylor College of Medicine developed a survey to assess patient and caregiver understanding of anaphylaxis as well as their knowledge of a patient-centered action plan to treat it and enlisted 96 patients/caregivers in an allergy clinic waiting room to respond to the questions.2
“The results demonstrate the need for better education of allergy patients to recognize and treat anaphylaxis appropriately,” Chow said of findings from her study, Understanding of anaphylaxis management among allergy patients and components of a patient-centered anaphylaxis action plan.2
Nearly all of the the respondents (95%) to Chow's survey were prescribed epinephrine and 73% said they were comfortable with recognizing symptoms of an anaphylactic reaction. Despite those responses, only 14% were able to correctly identify symptoms that would require epinephrine, according to the study abstract.2
The majority of the survey respondents (85%) stated antihistamines do not prevent the need for epinephrine, yet 23.7% of them said antihistamines still would be their first choice of treatment in response to symptoms. for 23.7% them. After a suspected allergen exposure, onset of rash and wheezing would lead nearly two-thirds (64.5%) of the respondents to inject epinephrine; one in 10 (10.8%) said they would drive to the emergency department first, Chow and colleagues reported.2
Among the barriers to using epinephrine identified by the survey:
- 40.6% - Not sure which symptoms to treat
- 24.0% - Hesitant to go to the emergency department
- 17.7% - Hesitant to call 911
- 11.5% - Not sure how to use epinephrine auto-injectors
- 5.2% - Feared needles
Chow et al reported that just one-third (36.5%) of the survey cohort had an anaphylaxis action plan (AAP). Components that respondents rated as very or somewhat important to include in an AAP were:
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
Find additional research presented at ACAAI here.
