epiERBy Gary Fitzgerald and Brenda Silvia-Torma, MEd 

First come the hives … just a little rash on the cheek. Then a tingly sensation in the mouth … and a cough. Were there nuts in that cookie? Is this an allergic reaction? Anaphylaxis?

You don’t want to take a chance, so you call 911 or go directly to the local hospital emergency room (ER).

What then? “The first line of treatment is always epinephrine,” says Christopher Randolph, MD, an allergist and immunologist at the Center for Allergy, Asthma & Immunology in Waterbury, Conn., and volunteer with The Network’s Anaphylaxis Community Experts (ACE) program.

“Anaphylaxis guidelines recommend treatment with epinephrine as soon as possible,” Dr. Randolph says. “However studies have shown that is not always done in the ER. What I found when working with emergency departments is that there’s a real need to improve awareness of the appropriate treatment of anaphylaxis, which is epinephrine – not antihistamines or corticosteroids, which really have no impact.

“We’ve also found some patients are discharged without an anaphylaxis action plan, a prescription for two epinephrine auto-injectors or a referral to a board-certified allergist. That’s why I joined with other allergists and ER physicians to draw up special guidelines for treating anaphylaxis within the fast-paced atmosphere of the ER.”

Christopher Randolph

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.

The key message is that epinephrine injected into the patient’s thigh is the only appropriate treatment for anaphylaxis. “Epinephrine is the only agent we know of that can stop the progression of anaphylaxis,” Dr. Randolph adds. “It may not help if administration is delayed.”

Once epinephrine is given, other interventions – such as IV fluids, oxygen or treatments for asthma or blood pressure – may be appropriate.

The anaphylaxis guidelines also emphasize education and preparedness. They advise ER physicians to discharge patients with an anaphylaxis action plan and a prescription for two epinephrine auto-injectors. The action plan should spell out the anaphylaxis symptoms to watch for, how to use an epinephrine auto-injector, and when to call for help.

The guidelines also recommend ER physicians refer patients to a board-certified allergist who can identify the cause of the allergic reaction – whether it’s food, insect sting or bite, latex, medication or other substance.

Dr. Randolph hopes the new guidelines will change how ER physicians approach treatment when a person is experiencing anaphylaxis. As an ACE volunteer, he plans to reach out to ER physicians and medical associations to explain and help implement the new guidelines.

“Really, these guidelines are for everyone,” Dr. Randolph adds. “It doesn’t matter if you’re a parent, patient, an ER doctor, allergist, primary care physician, nurse, paramedic or ambulance first responder – when anaphylaxis is diagnosed, give epinephrine immediately.”

It’s recommended that people at risk for anaphylaxis carry two epinephrine auto-injectors everywhere, everyday, in case of emergency. After injection, call 911 and/or go to the ER for further evaluation — sometimes there are delayed, secondary responses with anaphylaxis.

What to Do At the ER

• Communicate with the ER physician or nurse as many details as possible about the incident that may have caused the allergic reaction.

• Provide information if and when an epinephrine auto-injector was administered prior to arrival at the ER. Bring the used epinephrine auto-injector with you. Inform physicians of any medications the patient uses.

• Ask the ER physician or nurse to administer epinephrine, if it hasn’t been administered already.

• Ask the ER physician to provide you with an Anaphylaxis Action Plan, a prescription for two epinephrine auto-injectors and a referral to a board-certified allergist. Bring it with you to the emergency room (if possible) and doctor appointments. Keep a copy in the bag or backpack where you or your child carry two epinephrine auto-injectors.

ACE smallAnaphylaxis Community Experts (ACE) is a national, award-winning education, advocacy and outreach program developed and hosted by Allergy & Asthma Network Mothers of Asthmatics in partnership with the American College of Allergy, Asthma & Immunology, sponsored by Mylan Specialty L.P.

Reviewed by Michael Mellon, MD