The CREATE-ECLA Randomized Controlled TrialThe CREATE-ECLA Trial Group Investigators* See also pp 427 and 489.

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Anaphylaxis in the pediatric population is both serious and potentially lethal. The incidence of allergic and anaphylactic reactions has been increasing and the need for life saving intervention with epinephrine must remain an important part of Emergency Medical Services (EMS) provider training. Our aim was to characterize dosing and timing of epinephrine, diphenhydramine, and albuterol in the pediatric patient with anaphylaxis. In this retrospective chart review, we studied prehospital medication administration in pediatric patients ages 1 month up to 14 years old classified as having a severe allergic reaction or anaphylaxis. We compared rates of epinephrine, diphenhydramine, and albuterol given to patients with allergic conditions including anaphylaxis. In addition, we calculated the rate of epinephrine administration in cases of anaphylaxis and determined what percentage of time the epinephrine was given by EMS or prior to their arrival. Of the pediatric patient contacts, 205 were treated for allergic complaints. Of those with allergic complaints, 98 of 205 (48%; 95% CI 41%, 55%) had symptoms consistent with anaphylaxis and indications for epinephrine. Of these 98, 53 (54%, 95% CI 44%, 64%) were given epinephrine by EMS or prior to EMS arrival. Among the patients in anaphylaxis not given epinephrine prior to EMS arrival, 6 (12%; 95% CI 3%, 21%) received epinephrine from EMS, 10 (20%; 95% CI 9%, 30%) received diphenhydramine only, 9 (18%, 95% CI 7%-28%) received only albuterol and 17 (33%, 95% CI 20%-46%) received both albuterol and diphenhydramine. 9 patients in anaphylaxis received no treatment prior to arriving to the emergency department (18%, 95% CI 7%-28%). In pediatric patients who met criteria for anaphylaxis and the use of epinephrine, only 54% received epinephrine and the overwhelming majority received it prior to EMS arrival. EMS personnel may not be treating anaphylaxis appropriately with epinephrine.

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ObjectivesIf a patient wishes to refuse treatment in the prehospital setting, prehospital providers and consulting emergency physicians must establish that the patient possesses the capacity to do so. The objective of this study is to assess agreement among prehospital providers and emergency physicians in performing patient capacity assessments.MethodsThis study involved 139 prehospital providers and 28 emergency medicine physicians. Study participants listened to 30 medical control calls pertaining to patient capacity and were asked to interpret whether the patients in the scenarios had the capacity to refuse treatment. Participants also reported their comfort level using modified Likert scales. Inter‐rater reliability was calculated utilizing Fleiss' and Model B kappa statistics. Fisher's exact tests were used to calculate p‐values comparing the proportion in each cohort that responded “no capacity.” Primary outcomes included inter‐rater reliability in the physician and prehospital provider cohorts.ResultsThe inter‐rater agreement between the physicians was low (Fleiss' kappa = 0.31, standard error [SE] =0.06; model‐based kappa = 0.18, SE = 0.04). Agreement was similarly low for the 135 prehospital providers (Fleiss' kappa = 0.30, SE = 0.06; model‐based kappa = 0.28, SE = 0.04). The difference between the proportion of physicians and prehospital providers who responded “no capacity” was statistically significant in five of 30 scenarios. Median prehospital provider and physician confidence, on a 1 to 4 scale, was 2.00 (Q1–Q3 = 1.00–3.00 for prehospital providers and Q1–Q3 =1.0–2.0 for physicians).ConclusionsThere was poor inter‐rater reliability in capacity determination between and among the prehospital provider and physician cohorts. This suggests that there is need for additional study and standardization of this task.