Fran Lowry

November 20, 2012

ANAHEIM, California — Paramedics who respond to emergency calls for patients with signs and symptoms of acute allergic reaction and anaphylaxis are failing to give life-saving epinephrine, according to a study presented in an oral session here at the American College of Allergy, Asthma & Immunology 2012 Annual Scientific Meeting.

A retrospective review of prehospital calls made to 911 for emergency medical services (EMS) in Broward County, Florida found that of 52 patients who were experiencing anaphylaxis, only 15% were given epinephrine by the responding paramedics.

"We need to educate paramedics to be more aggressive when treating patients with anaphylaxis and allergic reactions in the prehospital setting," Nabil El Sanadi, MD, chief of emergency medicine at the Broward Health Medical Center in Fort Lauderdale, Florida, told Medscape Medical News.

"We found that only a small percentage of paramedics actually gave epinephrine to these patients.... We need to educate and enforce the use of epinephrine," Dr. El Sanadi said.

He and his team conducted a retrospective chart review of calls from October 2010 to June 2012. Of the more than 40,000 runs made during this period, the researchers were able to identify 92 that were made for patients with allergic reactions or anaphylaxis.

"It was difficult to determine the exact number because many runs were not properly documented," Dr. El Sanadi noted.

Of these patients, 40 were determined to be an experiencing allergic reaction and 52 to be experiencing anaphylaxis. Prior to the arrival of emergency personnel, 18 had self-medicated.

The results were surprising, Dr. El Sanadi said.

Of the 92 patients, only 39 (42%) were given oxygen (although all should have received it), 6 (6.5%) were given intravenous fluids, 12 (13.0%) were given albuterol, and 15 (16.3%) were given methylprednisolone (Solu-Medrol). The majority (68; 73.9%) were given diphenhydramine (Benadryl).

Of the 52 patients with anaphylaxis, 25 (48.1%) were given oxygen, 8 (15.4%) were given epinephrine, 6 (11.5%) were given intravenous fluids, 10 (19.2%) were given albuterol, and 13 (25.0%) were given methylprednisolone. The majority (42; 80.8%) were given diphenhydramine.

"It is apparent from these results that paramedic education in the use of epinephrine for allergic reactions and anaphylaxis needs to be implemented. We have done that since we collected these data," Dr. El Sanadi noted.

Luz S. Fonacier, MD, from Winthrop University Hospital in Mineola, New York, told Medscape Medical News she is not surprised by these findings.

"Even in the emergency room, when we have emergency room physicians there, there is an underutilization of epinephrine. There may need to be legislation to require all ambulances to carry epinephrine. We also need to emphasize the fact that patients with a history of anaphylaxis should carry their own EpiPen because the EMS may not have it," said Dr. Fonacier, who comoderated the session and was not involved in the study.

Jay M. Portnoy, MD, from the University of Missouri and Mercy Children's Hospital, both in Kansas City, pointed out that the paramedics recognized that the patients had anaphylaxis because they administered diphenhydramine.

"This is scary," said Dr. Portnoy, who comoderated the session.

"Epinephrine is the first treatment — not [diphenhydramine], not steroids — because epinephrine works fast and reverses the anaphylactic reaction in about 30 seconds. [Diphenhydramine] doesn't work for...almost an hour. For some reason, people are afraid to use it, perhaps because it is an injection, but they shouldn't be because it is the treatment of choice. Why wouldn't you use the 30 second drug if a patient is having a life-threatening reaction?"

Dr. El Sanadi, Dr. Fonacier, and Dr. Portnoy have disclosed no relevant financial relationships.

American College of Allergy, Asthma & Immunology (ACAAI) 2012 Annual Scientific Meeting: Abstract 58. Presented November 12, 2012.