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Epinephrine guidelines created for treatment of anaphylaxis in ED
Recently released guidelines recommend epinephrine use as a primary treatment for patients experiencing anaphylaxis in the ED.
“The practice parameter on the emergency department diagnosis and treatment of anaphylaxis represents another collaboration between emergency physicians and allergist-immunologists designed to improve anaphylaxis patient care,” Ronna L. Campbell, MD, PhD, a guidelines contributor and assistant professor of emergency medicine, Mayo Clinic, Rochester, Minn., told Healio Allergy/Immunology. “Emergency physicians are on the front lines of anaphylaxis management. Because anaphylaxis is a potentially life-threatening allergic reaction, it is imperative that emergency physicians know what to do and are able to act quickly.”
Ronna L. Campbell
The guidelines include 19 recommendations about managing anaphylaxis in an ED setting. The parameters include:
- basing the diagnosis of anaphylaxis on history and physical examination
- triaging and monitoring patients for anaphylaxis symptoms in preparation for epinephrine administration
- positioning the patient to prevent or counteract potential circulatory collapse
- administering oxygen to any patient exhibiting respiratory or cardiovascular symptoms
- determining risk factors for severe and potentially fatal anaphylaxis
- properly administering epinephrine intramuscularly in the anterolateral thigh, followed by an IV infusion of epinephrine if the patient does not respond to the injection
- preparing for airway management if there is suggestion of airway edema or associated respiratory compromise
- “aggressively administering” large volumes of IV or intraosseous normal saline through large-bore catheters for patients with circulatory collapse from anaphylaxis
- administering glucagon when parenteral epinephrine and fluid resuscitation fail to restore blood pressure
- administering beta-agonist if bronchospasm is present
- considering extracorporeal membrane oxygenation when patients are unresponsive to traditional resuscitative efforts
- discouraging the routine use of antihistamines or corticosteroids instead of epinephrine
- identifying anaphylaxis triggers
- strongly considering observation of patients who have experienced anaphylaxis for at least 4 to 8 hours
- prescribing auto-injectable epinephrine and an action plan for patients who have an anaphylactic reaction
- instructing patients to see an allergist/immunologist in a timely fashion after discharge
“Fortunately, most patients who suffer anaphylaxis are able to be treated and dismissed home directly from the emergency department,” Campbell said. “Therefore, it is also important for the emergency physician to advise patients on the risks of future anaphylactic reactions and how to mitigate these risks.” – by Bruce Thiel
Disclosure: See the practice parameter report for a full list of relevant financial disclosures.
Perspective
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Allergists specialize in the diagnosis and treatment of allergic diseases including anaphylaxis. Since many patients presenting with anaphylaxis initially present at the emergency department, there is a clear value for allergists to collaborate with emergency department physicians in the development of guidelines for the management of anaphylaxis.
One of the main points of discussion during our recent roundtable discussion (at the American College of Allergy, Asthma and Immunology Annual Scientific Meeting) included the role of the emergency physician to identify and promptly treat the patient suffering with the symptoms of anaphylaxis and to direct the patient to the allergist for determination of trigger factors and for advice on future management. One of the main roles of the allergist for these patients is to identify allergens that trigger anaphylaxis. The allergist also helps advise the patient on methods to reduce the risk for anaphylaxis including avoidance of triggers and need to have self-injectable epinephrine readily available.
We are fortunate to have had this opportunity to collaborate with our emergency department colleagues; the end result will be improved management for all patients with anaphylaxis.