Not sure if it's anaphylaxis? Inject epinephrine just in case, experts advise

When in doubt, administer epinephrine. In other words, you don’t need to be 100% certain that a patient is having a severe allergic reaction to administer epinephrine in an emergency setting. That’s the recommendation from a panel of allergists and emergency physicians convened by the American College of Allergy, Asthma and Immunology (ACAAI).

The panel’s conclusions were published in an August 6 article in Annals of Allergy, Asthma and Immunology. The panel determined that anaphylaxis is underdiagnosed, and epinephrine is underused, in emergency departments.

“Our emergency medicine colleagues told us that if patients don’t fit established guidelines for anaphylaxis, there may be a reluctance in the emergency room to treat with epinephrine,” said allergist and chair of the panel Stanley Fineman, MD, MBA, ACAAI past president and adjunct associate professor in the Department of Pediatrics, Allergy Division, at Emory University School of Medicine, Atlanta, GA. “Because epinephrine is the first line of defense in treating anaphylaxis, the panel agreed it should be used—even if a patient’s reaction may not meet all the established criteria. The consequences for not using epinephrine when it’s needed are much more severe than using it when it might not be necessary.”

Intramuscular administration of epinephrine at proper doses is safe and there are no absolute contraindications for its use in treating anaphylaxis, the panel agreed. In fact, delay in administering epinephrine may lead to more severe and treatment resistant anaphylaxis.

Indeed, epinephrine should be given to patients at risk of an anaphylactic reaction if they have had a previous severe reaction or had a known or suspected exposure to their allergic trigger with or without the development of symptoms, the panel concluded.

“We want emergency medical personnel, as well as people who have had or are at risk for having severe allergic reactions, to know there is no substitute for epinephrine as the most important tool for combatting anaphylaxis,” said panelist Paul Dowling, MD,director of the Allergy/Immunology Training Program at Children’s Mercy Hospital, Kansas City, MO. “Antihistamines and corticosteroids should not be given instead of epinephrine because they don’t work fast enough.”

The other crucial message highlighted by the panel is that anyone seen for anaphylaxis in the emergency department needs to be referred to an allergist to schedule a follow up visit to assist with diagnosis confirmation, trigger identification, and continued outpatient management with a goal of preventing anaphylactic reactions in the future.

This research was supported by an educational grant from Mylan Specialty, maker of EpiPen®.