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    AAP's first-ever action plan for epinephrine and anaphylaxis

    The American Academy of Pediatrics (AAP) has published critical guidance for patients at risk for an allergic emergency. Here’s what you need to know.


    A second injection of epinephrine also may be necessary to resolve anaphylaxis. For very severe reactions, 2 or more doses may be required. However, when response to the initial dose of epinephrine is suboptimal, a second injection of epinephrine is preferred over adjunctive treatments. If necessary, the epinephrine dose may be repeated every 5 to 15 minutes.

    Discrepancies in real-world practice related to the treatment of anaphylaxis need to be addressed. Availability of epinephrine to patients with anaphylaxis is alarmingly low (52% never receiving a prescription for EAs despite previous episodes),11 as is the administration of epinephrine by EMS providers for patients with anaphylaxis symptoms (36% to 54%).12,13 This suggests that there is a significant need for more education on anaphylaxis and when to use epinephrine, even among first responders.

    In a review of pediatric emergency department (ED) records for anaphylactic reactions over a 5-year period at a large academic hospital, collective data indicated that a greater percentage of patients were treated with antihistamines and steroids than were treated with epinephrine.14 Also, H1 receptor antagonists and steroids were administered in 92% and 89% of cases, respectively. The potential administration of these adjunctive agents as first-line therapies is concerning given that they are characterized by a therapeutic onset longer than the time to respiratory and/or cardiovascular arrest during anaphylaxis.

    Recommended: New guidelines for early peanut exposure

    Reports by Greenberger15 and Pumphrey16 have demonstrated that death from anaphylaxis can occur quickly. Greenberger noted that approximately 50% of deaths occurred within the first 60 minutes of allergen exposure, while Pumphrey noted that the median time to respiratory or cardiac arrest was 5 minutes for iatrogenic reactions to medications (eg, IV antibiotics/nonsteroidal anti-inflammatory drugs [NSAIDS]), 15 minutes for venom, and 30 minutes for foods. Reported onset of action for antihistamines, and thereby their use, is incompatible with the reported times to cardiac arrest from anaphylaxis. Progression of anaphylactic reactions is unpredictable, even for the most experienced clinician, so caution is warranted if adjunctive agents are used as first-aid treatment; eg, life-threatening respiratory symptoms can occur after skin symptoms have waned.

    Appropriate route of delivery of epinephrine is also an important consideration in practice. A survey of pediatric emergency medicine physicians identified through the American Board of Pediatrics and American Board of Medical Specialties membership databases revealed that although 93.5% correctly identified epinephrine as the treatment of choice for anaphylaxis, only 66.9% reported using the recommended intramuscular route.17 Prompt and appropriate delivery of epinephrine cannot be overemphasized.

    Attributes of current EAs

    Different EA design is a major determinant of successful administration during a reaction. Table 1 shows select attributes of available EAs. Although there are no prospective comparative data with different EAs during actual anaphylactic reactions, there have been studies done to test the “usability” of several EAs.

    NEXT: Barriers of successful treatment of anaphylaxis

    Todd A Mahr, MD
    Dr Mahr is director, Pediatric Allergy, Asthma, and Immunology, Gundersen Health System, La Crosse, Wisconsin, and adjunct clinical ...
    Vivian P Hernandez-Trujillo, MD
    Dr Hernandez-Trujillo is associate clinical professor of Pediatrics, Herbert Wertheim School of Medicine, Florida International ...


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