Management of Anaphylaxis Following Pre-Hospital Epinephrine Use in Children with Food-induced Anaphylaxis.

ABSTRACT

BACKGROUND: Previous guidelines recommend prompt epinephrine administration, followed by observation in the emergency department (ED). The need for transfer in all cases of anaphylaxis has recently been challenged. OBJECTIVE: We aimed to evaluate the need for additional ED treatment among children with anaphylaxis who received pre-hospital epinephrine. METHODS: Between 2011-2023, data were collected on symptoms, triggers, comorbidities, and pre-hospital and in-hospital management from children (<18 years) with food-induced anaphylaxis who received at least one dose of pre-hospital epinephrine presenting at 7 pediatric EDs. Multivariable logistic regression assessed factors associated with the usage of two or more pre-hospital EAI, epinephrine use in the ED, and hospital admission. RESULTS: Of 1127 children (mean 8.1 +/-5.3 years; 60.6% male) with food-induced anaphylaxis who used at least one EAI pre-hospital, the most common trigger was peanuts (25.3%). 209 (18.5%) received additional epinephrine in the ED, the majority of whom (88.0%) received one dose. 30 (2.7%) patients were admitted to hospital. Among all patients, severe reactions (cardiovascular instability/ cyanosis/ loss of consciousness) (adjusted odds ratio [aOR] 1.22; 95% confidence interval [CI] 1.12-1.33) and reactions to tree nuts (aOR 1.09; 95% CI 1.03-1.16) were associated with increased odds of in-hospital epinephrine use. Pre-hospital inhaled beta-agonists (aOR 1.08; 95% CI 1.01-1.16) use and severe reactions (aOR 1.13; 95% CI 1.05-1.22) were associated with the use of 2 or more EAI pre-hospital. CONCLUSION: A minority of anaphylaxis cases that used pre-hospital EAIs required additional treatment, supporting that shared decision making about transfer to ED works for the vast majority of patients.