Management of anaphylaxis in emergency departments

[LinksEtc]

"Evaluating the management of anaphylaxis in US emergency departments: Guidelines vs. practice"
http://www.wjem.org/upload/admin/201306/eecde85a33572698f56aa076af85727e.pdf

This is the first cross-sectional survey to provide "real-world" data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis, treatment, and follow-up of patients with anaphylaxis. The primary gaps are low (or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine.

[lakeswimr]

Are ERs getting better educated?  FAAN published articles on this years ago and took on the goal of educating ERs around the country.  The NIH guildelines talk about this.  Is the situation improving at all?  in the last day read of two people who had ana and didn't get treated properly in the ER.  It would be nice if things were improving.  I have no idea if they are or not.

[CMdeux]

I think it's spotty, Lakeswimr, based on the diversity of experiences of members here-- some of them in larger cities, even, where one would assume that a better, more current standard of care would be common... not always, though.

I think that it's hospital by hospital, truthfully.  I wish that the progress were more even-- and rapid.

[lakeswimr]

I would think there is some kind of systematic way to go about this that would be more effective than what has been done but I could be very wrong.  I am *guessing* that when FAAN had their campaign much of what they sent out to ERs simply got tossed and not even read because of various reasons including that it was from FAAN and not a strictly medical organization.  Maybe material coming from FAAN didn't have much weight to doctors.  I think that now that there are NIH guidelines FARE or some other organization could try to get those guidelines to more doctors somehow.  I don't know.  I am thinking of articles in journals that ER doctors and staff read, med school training on FAs, other journals for pediatricians and other doctors.  But I know very little about all that.  I know my son's ped stays current by going to conferences and reading journals so that's where I think the info should go in order to reach at least the doctors who stay current on things.  For all I know the things FAAN did helped a ton  so i'm not trying to criticize their past efforts but I just wish things were better.  I'm astounded that I can know more about how to treat ana than many ER staff including doctors.  That shouldn't be.

[lakeswimr]

I would say that about half or more of the FA reaction ER stories talk about people who get everything but the epi for clearly epi moments, people who get released after 2 hours instead of the recommended 4+.  It has been an identified problem for over a decade.  If there were at least improvement that would make it better.  I'm not sure there has been.  What do I know but apparently it is at least still a big problem. 

[LinksEtc]

http://www.aanma.org/2014/03/epi-in-the-er/

Dr. Randolph is a member of the Joint Task Force on Practice Parameters, a team of physicians appointed by the American College of Allergy, Asthma & Immunology (ACAAI) and the American Academy of Allergy, Asthma & Immunology (AAAAI) to craft the new ER treatment guidelines. He expects the guidelines will be published in a medical journal this year.

[LinksEtc]

"Safety of epinephrine for anaphylaxis in the emergency setting"
http://www.wjem.org/upload/admin/201311/d095a4afd3dc3f7fc3baa8d33a54d10b.pdf

CONCLUSION: Epinephrine by intramuscular injection is a safe therapy for anaphylaxis but training may still be necessary in emergency care settings to minimize drug dosing and administration errors and to allay concerns about its safety.

[LinksEtc]

J Allergy Clin Immunol Pract. 2014 May-Jun;2(3):294-299.e1. doi: 10.1016/j.jaip.2013.11.009. Epub 2014 Feb 16.

"A multifaceted intervention for patients with anaphylaxis increases epinephrine use in adult emergency department."

Significantly higher proportions of patients with anaphylaxis received epinephrine and were admitted to the ED observation unit after introduction of epinephrine autoinjectors and order set implementation. Slightly more than half of the biphasic reactions occurred within the recommended observation time of 4 to 6 hours. Analysis of these data suggests that the multifaceted approach to changing anaphylaxis management described here improved guideline adherence.

Tweeted by @IgECPD

[LinksEtc]

Tweeted by @AmResProj

"Physicians are noncompliant, too"
http://www.americanresidentproject.com/blog/physicians-are-noncompliant-too

Despite the fact that many guidelines are created after systematic reviews and meta-analyses – processes we would never have time to go through ourselves – we, like our own patients, are often noncompliant.

[LinksEtc]

Took the "US" out of the 1st post title. 


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Tweeted by @AllergyEducator

"Rate, triggers, severity and management of anaphylaxis in adults treated in a canadian emergency department."
http://www.ncbi.nlm.nih.gov/pubmed/25170673

Epinephrine was not administered in almost half of moderate-to-severe cases, and similar numbers of individuals with moderate-to-severe reactions were not prescribed an epinephrine autoinjector.

There is non-adherence to guidelines recommending epinephrine use for all cases of anaphylaxis. We postulate that this may be related to concerns regarding the side effects of epinephrine in adults.

[LinksEtc]

FARE survey about EMS/ER experiences related to FA reactions

[LinksEtc]

Tweeted by @kfatweets

"Emergency Rooms Often Skip The Epinephrine For Severe Allergies"
http://www.npr.org/blogs/health/2014/12/02/367995894/emergency-rooms-often-skip-the-epinephrine-for-severe-allergies?utm_campaign=storyshare&utm_source=twitter.com&utm_medium=social

That's why a joint task force of allergists published guidelines on Tuesday in the Annals of Allergy, Asthma and Immunology, reinforcing that emergency rooms should be using epinephrine "first and fast" to treat a severe allergic reaction.

[LinksEtc]

"If You Are Having a Severe Allergic Reaction, You Need Epinephrine First and Fast"
http://acaai.org/news/IfYouAreHavingaSevereAllergicReaction

At our recent Annual Scientific Meeting, we convened an anaphylaxis roundtable discussion between emergency room physicians and allergists.

[LinksEtc]

Tweeted by @kfatweets

"Emergency Rooms Often Skip The Epinephrine For Severe Allergies"
http://www.npr.org/blogs/health/2014/12/02/367995894/emergency-rooms-often-skip-the-epinephrine-for-severe-allergies?utm_campaign=storyshare&utm_source=twitter.com&utm_medium=social

That's why a joint task force of allergists published guidelines on Tuesday in the Annals of Allergy, Asthma and Immunology, reinforcing that emergency rooms should be using epinephrine "first and fast" to treat a severe allergic reaction.

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Tweeted by @ahier

"ER doctors explain how to decode dangerously inaccurate health reports"
http://qz.com/317985/er-doctors-explain-how-to-decode-dangerously-inaccurate-health-reports/

There are many reasons the article missed the mark about anaphylaxis and its treatment.

Recent evidence from American emergency departments suggests that emergency physicians use epinephrine appropriately in 98% of cases.

Hmmm ... I'm thinking that this response might need a response.


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"Appropriateness of Epinephrine Use in Emergency Department Anaphylaxis Patients"
http://www.annemergmed.com/article/S0196-0644(14)00939-1/pdf


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Alas, I did my small mom part ... but this, I think, will have to be worked out between the allergists & ER docs.

[LinksEtc]

Injectable Epinephrine: An Epidemic of Misuse