Annotated Bibliography

This biblography includes references related to preparedness of patients and caregivers to manage anaphylaxis.

Anaphylaxis in the pre-hospital setting.

Kane KE, Cone DC. Anaphylaxis in the pre-hospital setting. J Emerg Med. 2004 Nov;27(4):371-7.

Many Emergency Medical Services (EMS) systems have adopted epinephrine auto-injector (EAI) use by Basic Life Support (BLS) personnel, and several states now require that BLS personnel be trained and authorized to use EAIs. … Although limited by the lack of data from many states, roughly 0.5% of EMS runs are for allergy/anaphylaxis complaints, with epinephrine administered in roughly one-tenth of these. State death rates from anaphylaxis vary considerably, with rates from 0% to 0.94% reported.

Factors determining the ability of parents to effectively administer intramuscular adrenaline to food allergic children.

Arkwright PD, Farragher AJ.  Factors determining the ability of parents to effectively administer intramuscular adrenaline to food allergic children.  Pediatr Allergy Immunol. 2006 May;17(3):227-9.

… The aim of this study was to determine which factors are most strongly associated with the effective use of these devices. 122 children with food allergies who had previously been prescribed EpiPens and were attending a single specialist pediatric allergy center in the UK. were studied prospectively. 69% of parents were unable to use the EpiPen, did not have it available, or did not know when it should be administered. A prior practical demonstration was associated with a 4-5 fold greater chance that parents would be able to use the device (p < 0.005). Prior consultation with an allergy specialist rather than a general physician, and parents who independently sought additional information from the national self-help allergy organization were also four to six times more likely to be competent with these devices (p < 0.005)…

Self-injectable epinephrine for first-aid management of anaphylaxis.

Sicherer SH, Simons FE.  Self-injectable epinephrine for first-aid management of anaphylaxis. Pediatrics. 2007 Mar;119(3):638-46.

… This clinical report focuses on practical issues concerning the administration of self-injectable epinephrine for first-aid treatment of anaphylaxis in the community… This report also describes several quandaries in regard to management, including the selection of dose, indications for prescribing an autoinjector, and decisions regarding when to inject epinephrine. Effective care for individuals at risk of anaphylaxis requires a comprehensive management approach involving families, allergic children, schools, camps, and other youth organizations. Risk reduction entails confirmation of the trigger, discussion of avoidance of the relevant allergen, a written individualized emergency anaphylaxis action plan, and education of supervising adults with regard to recognition and treatment of anaphylaxis.

Doctor - how do I use my EpiPen?

Mehr S, Robinson M, Tang M.  Doctor--how do I use my EpiPen?  Pediatr Allergy Immunol. 2007 Aug;18(5):448-52.

Parents and children who have been prescribed an Epipen are often unable to demonstrate its correct administration. One contributory factor may be that doctors are unfamiliar with the …. One-hundred doctors were recruited (Residents n = 31, Senior Residents n = 39, Fellow/Consultants n = 30). … Only two doctors (2%) demonstrated all 6 administration steps correctly. The most frequent errors made were not holding the pen in place for >5 seconds (57%), failure to apply pressure to activate (21%), and self-injection into the thumb (16%). Ninety five doctors needed to read the instructions, and of these, only 39 (41%) then proceeded to correctly demonstrate the remaining 5 steps. Forty-five doctors had previously dispensed an EpiPen, but only three demonstrated its use to parents/children with a trainer. The majority of doctors do not know how to use an Epipen and are unable to provide appropriate education to parents/children. In 37% of cases, the demonstration would not have delivered adrenaline to a patient.

Evaluating the results of teaching Epinephrine Auto-Injector use in an allergy clinic.

Huang S. Evaluating the results of teaching Epinephrine Auto-Injector use in an allergy clinic.  Pediatric Asthma, Allergy & Immunology. March 1, 2007, 20(1): 19-22.

… We enrolled parents of pediatric patients (n = 224) with a history of anaphylaxis in a study to evaluate teaching of the use of the EpiPen. Parents were taught nine steps to the correct use of the EpiPen…. We found that only 22% (49 of 224) of parents passed all nine tests in the first visit; 68% (152 of 224) passed the tests on the second visit; 94% (211 of 224) passed all of the tests after the third visit; and 6.5% (15 of 224) of parents failed to pass the test even after five visits. The highest failure rates were for the instructions to “press the device until it clicks” and to “press the device steadily for 10 seconds.” …We concluded that: (1) many parents of children with a history of anaphylaxis lack the skill to administer EpiPen effectively; (2) staff in allergy clinics should take an active role in teaching and continuing to explain the use of EpiPen; and (3) prescriptions for EpiPen should include a demonstrator.

Recognition, evaluation, and treatment of anaphylaxis in the child care setting.

Bansal PJ, Marsh R, Patel B, Tobin MC.  Recognition, evaluation, and treatment of anaphylaxis in the child care setting. Ann Allergy Asthma Immunol. 2005 Jan;94(1):55-9.
BACKGROUND: … little is known about the centers' knowledge of, experience with, and capability to manage anaphylaxis. OBJECTIVE: To evaluate the ability of child care centers to recognize, evaluate, and treat anaphylactic episodes in children aged 1 to 6 years. … 44 of 85 centers contacted agreed to participate. 42 surveys were completed before the seminar and 39 after the seminar. On average, each center has up to 7 children with an identifiable food allergy…Before seminar completion, only 24% of child care centers would administer intramuscular epinephrine for a severe allergic reaction. After the seminar, 77% of centers stated that they would administer intramuscular epinephrine (P < .001). Also, center staff significantly improved their knowledge of typical allergy symptoms and of the correct method of intramuscular epinephrine administration. CONCLUSIONS: There is a need for greater anaphylaxis education among child care providers. Our intervention significantly increased the ability of child care staff to recognize, evaluate, and treat anaphylaxis

The preparedness of schools to respond to emergencies in children: a survey of school nurses.

Olympia RP, Wan E, Avner JR. The preparedness of schools to respond to emergencies in children: a national survey of school nurses. Pediatrics. 2005 Dec;116(6):e738-45. 

…The objective of this study was to use published guidelines by the American Academy of Pediatrics and the American Heart Association to examine the preparedness of schools to respond to pediatric emergencies…  68% (391 of 573 [95% confidence interval (CI): 64-72%]) of school nurses have managed a life-threatening emergency requiring EMS activation during the past school year. 86% (95% CI: 84-90%) of schools have an MERP, although 35% (95% CI: 31-39%) of schools do not practice the plan.

Update on epinephrine for the treatment of anaphylaxis

Pongracic JA, Kim JS. Update on epinephrine for the treatment of anaphylaxis. Curr Opin Pediatr. 2007 Feb;19(1):94-8.  jpongracic@childrensmemorial.org

PURPOSE OF REVIEW: Epinephrine is the treatment of choice for anaphylaxis--a life-threatening and potentially fatal event. The purpose of this review is to highlight recent publications relevant to the management of anaphylaxis and identify potential barriers which prevent or delay appropriate administration of epinephrine. RECENT FINDINGS: …Epinephrine injected intramuscularly is the treatment of choice, but there remain gaps in physician knowledge despite increases in hospitalization rates for anaphylaxis. Epinephrine is also underused by parents, day-care centers and schools….. Given these issues, other routes of administration of epinephrine have been explored. Epinephrine delivered via a sublingual route has been successful in animal studies. SUMMARY: Epinephrine is the primary therapy for anaphylaxis, yet studies show that it is underutilized. By addressing the contributory factors that have been identified, acute and long-term care of individuals with this potentially life-threatening disorder can be optimized.

Further fatalities caused by anaphylactic reactions to food: 2001 to 2006.

Bock SA, Munoz-Furlong A, Sampson HA.  Further fatalities caused by anaphylactic reactions to food: 2001 to 2006. J Allergy Clin Immunol. 2007 Feb 13.

RECOMMENDATIONS: 1) education of the medical profession to ask about food allergy, diagnose it, educate patients, and prescribe epinephrine continues to be inadequate; (2) patients’ education regarding diagnosis, allergen avoidance, symptom recognition, and discrimination between asthma flares and anaphylaxis remains very inadequate; (3) patients need to inquire in detail about ingredients and avoid eating desserts and bakery goods, especially when away from home; (4) patients’ knowledge of and compliance with the importance of carrying epinephrine needs improvement; (5) availability of epinephrine to emergency medical technicians and prompt dispatch of paramedics or emergency medical technicians who can carry and administer epinephrine needs to be improved in many locales; (6) school education including food preparation and staff training needs improvement; (7) public education about the potential fatal nature of food allergy needs to be disseminated…

“A lack of education at all levels, a lack of preparedness of allergic individuals and their families to respond appropriately, and a lack of prompt reporting of the abrupt onset of serious allergic symptoms appears unchanged from our previous report.”