Anaphylaxis in a New York City pediatric emergency department: Triggers, treatments, and outcomes

Abstract

Background Anaphylaxis incidence is increasing. Objective To characterize anaphylaxis in children in an urban pediatric emergency department (PED). Methods Review of PED records for anaphylactic reactions over 5 years. Results We identified 213 anaphylactic reactions in 192 children (97 males); 6 were infants; 20 had multiple reactions; median age 8 years; range 4 mo-18 yr. Sixty-two reactions were coded as anaphylaxis; 151 additional reactions met the Second symposium anaphylaxis criteria. There was no increase in incidence over 5 years. The triggers included: foods, 71%; unknown, 15%; drugs, 9%, and other, 5%. Food was more likely to be a trigger in multiple PED visits, P=.03. Epinephrine was administered in 169 (79%) reactions; in 58 (27%) epinephrine was given before arrival in PED. Patients with Medicaid were less likely to receive epinephrine before arrival in PED, P<.001. Twenty-eight (14.6%) patients were hospitalized; 9 in the intensive care unit. For thirteen (6%) of the reactions, two doses of epinephrine were administered; 69% of patients treated with two doses of epinephrine were hospitalized, compared to 12% of patients treated with a single dose, P<.001. Administration of both epinephrine doses before arrival to PED was associated with a lower rate of hospitalization compared to epinephrine administration in the PED, P=.05. Conclusions Food is the main anaphylaxis trigger in the urban PED, although the ICD-9 code for anaphylaxis is underutilized. Treatment with two doses of epinephrine is associated with a higher risk of hospitalization; epinephrine treatment before arrival to PED is associated with a decreased risk. Children with Medicaid are less likely to receive epinephrine before arrival in PED.

Adherence to Anaphylaxis Guidelines: Real-World Data From the Emergency Department of a Tertiary Hospital

“…However, in our study, H1 antihistamines (88%) and corticosteroids (85.4%) were the most frequently used drugs in the treatment of anaphylaxis in ED. These results are similar to those found in other studies [4][5][6]12,15,18,24].…”

“…In our study adrenaline was administered only to 42% of the population, clearly indicating that there is a deficit in the treatment of this disease, which has also been described in several studies [4][5][6][12][13][14]. Huang et al, which included only patients younger than 18 years, found that 79% of their patients had received epinephrine in the ED [15]. The authors reported that this high percentage could be due to the fact that the Pediatric Emergency Department was affiliated to an Allergy Service and this could have been reflected in the treatment of anaphylaxis.…”

“…In our opinion, an adrenaline auto-injector should be prescribed in EDs at least to patients with a history of previous anaphylactic reactions and to all patients with severe reactions. In other studies, the rates of prescription of adrenaline varied between 8 and 63% [12,15,24,[26][27][28].…”

“…The lack of appropriate codes in the International Classification of Diseases, ICD-9, makes this classification insufficient to identify all anaphylactic reactions, particularly when only codes specifically indicating anaphylaxis are used [30][31]. The combination of several codes and the subsequent evaluation by an allergy specialist provides better results [15,32,33]. Finally, the lack of agreement in the main anaphylaxis guidelines (Galaxia, EAACI, WAO, AAAAI/ACAAI) regarding certain aspects of the management of patients with anaphylaxis, might be an inconvenient for studies that evaluate the adherence of clinicians to their recommendations.…”

Drug‐induced anaphylaxis in the emergency room

“…Although the ratio of patients with anaphylaxis to all patients admitted to the ER was reportedly 0.08%,4 this ratio was likely to have been underestimated due to the difficulty in diagnosing anaphylaxis. In general, foods are the most common cause of anaphylaxis, although there is a wide variation in the ratio of food‐/non‐food‐induced anaphylaxis among studies 4, 6, 7, 8, 9. An important factor affecting the etiology of anaphylaxis is patient age 6, 10, 11, 12.…”