Study finds EMS anaphylaxis protocols outdated, incomplete

Key takeaways:

• Epinephrine autoinjectors were provided by 57% of emergency medical services.
• 97% of states recommended epinephrine as the first-line treatment for anaphylaxis.

BOSTON — Anaphylaxis protocols in emergency medical services have outdated recommendations and guidelines, according to an abstract presented at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

“One of the authors on our study had been noticing a trend where many of the patients that we were seeing in the office had experienced allergic reactions that sounded consistent with anaphylaxis based on the history, but for whatever reason they did not receive epinephrine when emergency medical services (EMS) were called,” Carly Gunderson, DO, allergy/immunology fellow at Memorial Healthcare System and the study’s lead author, told Healio.

Gunderson explained they investigated the EMS anaphylaxis protocols in their local county.

“We were shocked to see how much was missing in regard to how they identified and managed anaphylaxis,” she said.

The most notable omissions were gastrointestinal manifestations as possible symptoms of anaphylaxis.

“For us as pediatric allergists, gastrointestinal symptoms are extremely common, and often the first sign of an allergic reaction,” Gunderson said. “By not including these symptoms in the diagnostic criteria for anaphylaxis, many reactions may be missed initially with worse outcomes due to delayed recognition and treatment. This finding prompted us to investigate other EMS protocols across the country, with the goal of identifying areas for improvement in both the recognition and management of allergic reactions.”

The study examined the 30 states that had mandatory or model state-wide ACLS protocols. Researchers assessed the allergic reaction and anaphylaxis protocols, particularly, definitions used to identify and treat reactions.

Among the 30 states, 50% (n = 15) had gastrointestinal symptoms in their anaphylaxis definitions, 40% (n = 12) included neurologic manifestations and 47% (n = 14) utilized a two-organ system definition. All of the protocols recommended diphenhydramine and epinephrine for anaphylactic reactions. Albuterol was recommended for respiratory symptoms by 90% (n = 27), intravenous fluids by 73% (n = 22) and steroids by 60% (n = 18). Nearly all (97%; n = 29) recommended epinephrine as the first-line treatment for anaphylaxis. Epinephrine autoinjectors (EAIs) were allowed by 83% of states (n = 25), and 57% (n = 17) provided them.

“We were surprised by how many protocols did not include gastrointestinal or neurologic manifestations in their criteria for diagnosing allergic reactions,” Gunderson said. “Additionally, we were shocked to discover how many protocols did not provide EAIs as well as quite a few that wouldn’t permit EMS providers to even administer a patient’s own EAI.”

Gunderson emphasized they see many patients who experienced anaphylaxis and gastrointestinal symptoms in daily practice, as well as neurologic symptoms such as altered mental status or lethargy are quite common.

“People tend to always think of mucocutaneous symptoms such as hives and angioedema or respiratory symptoms like cough or wheezing as the only symptoms of allergic reactions, when in reality patients often present with many other manifestations as well,” she said.

The problem also presents itself in areas where only EMTs are present on EMS vehicles, as many EMTs are not permitted to draw up and administer intramuscular epinephrine, according to Gunderson.

“As allergists, it is essential that we continue to keep ourselves, our colleagues and our patients aware of current guidelines and recommendations,” Gunderson said. “While this study was focused on areas that emergency medical services in particular can improve upon, we can apply these same lessons to how we treat allergic reactions in all settings, including the office and the emergency room.”

Gunderson hopes this study will urge the standardization of EMS protocols for allergic reactions.

“Food allergies are becoming increasingly prevalent and are a very common reason for EMS activation,” she said. “EMS providers are often the first health care providers to assess patients experiencing anaphylaxis, and it is essential that they are able to identify allergic reactions and treat them appropriately to ensure best outcomes.”

Reference:

• Anaphylaxis treatment remains confusing for patients, caregivers and emergency personnel. https://acaai.org/news/anaphylaxis-treatment-remains-confusing-for-patients-caregivers-and-emergency-personnel/. Published Oct. 24, 2024. Accessed Oct. 24, 2024.

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