Use of epinephrine in anaphylaxis: a retrospective cohort study at a Swiss university emergency department

Abstract

AIMS OF THE STUDY: Anaphylaxis is a medical emergency and requires prompt treatment to prevent life-threatening conditions. Epinephrine, considered as the first-line drug, is often not administered. We aimed first to analyse the use of epinephrine in patients with anaphylaxis in the emergency department of a university hospital and secondly to identify factors that influence the use of epinephrine.
 METHODS: We performed a retrospective analysis of all patients admitted with moderate or severe anaphylaxis to the emergency department between 1 January 2013 and 31 December 2018. Patient characteristics and treatment information were extracted from the electronic medical database of the emergency department.
 RESULTS: A total of 531 (0.2%) patients with moderate or severe anaphylaxis out of 260,485 patients admitted to the emergency department were included. Epinephrine was administered in 252 patients (47.3%). In a multivariate logistic regression, cardiovascular (Odds Ratio [OR] = 2.94, CI 1.96–4.46, p <0.001) and respiratory symptoms (OR = 3.14, CI 1.95–5.14, p<0.001) were associated with increased likelihood of epinephrine administration, in contrast to integumentary symptoms (OR = 0.98, CI 0.54–1.81, p = 0.961) and gastrointestinal symptoms (OR = 0.62, CI 0.39–1.00, p = 0.053).
 CONCLUSIONS: Less than half of the patients with moderate and severe anaphylaxis received epinephrine according to guidelines. In particular, gastrointestinal symptoms seem to be misrecognised as serious symptoms of anaphylaxis. Training of the emergency medical services and emergency department medical staff and further awareness are crucial to increase the administration rate of epinephrine in anaphylaxis.

Anaphylaxis in a Swiss university emergency department: clinical characteristics and supposed triggers

“…One explanation for this could be an increased awareness of allergic reactions, since one third of the patients stated that they already had anaphylactic reactions in the past. On the other hand, emergency medical services and perhaps patients have a clearer therapeutic strategy, especially with the use of epinephrine [23]. However, epidemiologic data on anaphylaxis should be interpreted with caution: First, because anaphylactic events often occur outside hospitals, so the true rate of anaphylaxis may be underestimated after all [8].…”

“…According to international guidelines, gastrointestinal symptoms are eligible for therapy with intramuscular epinephrine for anaphylaxis [34]. In a previous study, we showed that especially patients with skin and gastrointestinal symptoms (anaphylaxis grade II) often do not receive the necessary therapy with epinephrine [23]. Therefore, when anaphylaxis is suspected, gastrointestinal symptoms must be actively sought.…”

“…1 Many patients had more than one known allergy2 Aeroallergens e.g., pollen, house dust mites, animal epithelia, fungal spores3 Swiss Triage System (STS), categories: 1 = treatment immediately by a physician, 2 = treatment within 20 min by a physician, 3 = treatment within 120 min by a physician, 4 = no urgent treatment situation This table was partially published in a previous publication[23] …”