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Use of epinephrine in emergency department depends on anaphylaxis severity in children

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Abstract

Despite multiple recommendations, intramuscular epinephrine is poorly prescribed in emergency department receiving pediatric anaphylaxis. To evaluate the role of severity symptoms on this use, we included all admissions for a diagnosis linked to possible allergy in the two pediatric emergency departments of our institution between January 2010 and December 2015. Selection and analysis were restricted to children under 18 years fulfilling Sampson’s criteria for anaphylaxis. We retrospectively ranked these admissions with the Ring and Messmer anaphylaxis severity score and compared the use of epinephrine according to this classification. Among 422,483 admissions, 204 (0.05%) fulfilled the anaphylaxis criteria (170 (83.3%) grade II anaphylaxis, and 34 (16.7%) grade III; mean age 7.9 years). Previous allergy, anaphylaxis, and asthma were found in respectively 60.8%, 36.8%, and 35.1%. Food allergy was the main suspected causal trigger. Epinephrine was used in 32.7% (n = 65/199), before admission (11.4% (n = 23/201)) or in the emergency department (22.2% (n = 45/202)). Epinephrine was more frequently prescribed in grade III than in grade II anaphylaxis (84.8% vs 22.3%, p < 0.001; OR = 19.05 [7.05–54.10]). Upon discharge, epinephrine auto-injectors prescription and allergy referral were rare (31.7% and 44.2%).

Conclusion: Pediatricians intuitively adapt their epinephrine use to the severity of the anaphylaxis and contribute to epinephrine underuse in pediatric anaphylaxis.

What is known:

• Intramuscular epinephrine is the recommended treatment for pediatric anaphylaxis. However, most of the European and North-American studies show a low prescription rate of epinephrine in both prehospital and pediatric emergency department management.

• Reasons for such a low prescription rate are unknown.

What is new:

• This study confirms that intramuscular epinephrine is poorly prescribed in pediatric anaphylaxis (about one case among 10 before admission and one among 5 in pediatric emergency departments).

• Despite recommendations, pediatricians intuitively adapt their prescription to the clinical severity of anaphylaxis, with a fourfold increase prescription in grade III compared to grade II anaphylaxis. This medical behavior ascertainment may be in part explained by the delay between the ED admission/management and the anaphylactic episode onset.

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Author information

Authors and Affiliations

  1. Unité de Pneumo-allergologie Pédiatrique, CHU Timone Enfants, APHM, 264 rue Saint-Pierre, 13385, Marseille Cedex 5, France

    Jean-Christophe Dubus, Marie-Sophie Lê & Ania Carsin

  2. Service d’Urgence Pédiatrique, Hôpital Nord, APHM, Marseille, France

    Jean-Christophe Dubus, Philippe Minodier & Guilhem Noel

  3. IRD, AP-HM, MEPHI, IHU-Méditerranée Infection, Aix Marseille Université, Marseille, France

    Jean-Christophe Dubus & Joana Vitte

  4. Service d’Urgence Pédiatrique, CHU Timone-Enfants, APHM, Marseille, France

    Aurélie Boutin

  5. Observatoire Régional des Urgences PACA, Hyères, France

    Gilles Viudes & Guilhem Noel

Authors
  1. Jean-Christophe Dubus
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  2. Marie-Sophie Lê
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  3. Joana Vitte
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  4. Philippe Minodier
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  5. Aurélie Boutin
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  6. Ania Carsin
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  7. Gilles Viudes
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  8. Guilhem Noel
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Contributions

JCD, MSL, and GN conceived the study and designed the trial. JCD, JV, MSL, PM, AB, AC, and GV supervised data collection. GN provided statistical advice on study design and analyzed the data. JCD, MSL, and JV drafted the manuscript, and all authors contributed substantially to its revision. JCD takes responsibility for the paper as a whole.

Corresponding author

Correspondence to Jean-Christophe Dubus.

Ethics declarations

This study was approved by the Ethics Committee of the French Society of Pediatrics (Société Française de Pédiatrie, No. 2016_018_2) and the National Commission of Informatics and Liberty (Commission Nationale Informatique et Libertés, No. 2016-16).

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Additional information

Communicated by Nicole Ritz

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Dubus, JC., Lê, MS., Vitte, J. et al. Use of epinephrine in emergency department depends on anaphylaxis severity in children. Eur J Pediatr 178, 69–75 (2019). https://doi.org/10.1007/s00431-018-3246-3

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  • DOI: https://doi.org/10.1007/s00431-018-3246-3

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