Emergency medical services (EMS) protocols for treating anaphylaxis are inconsistent across the United States. Many states have protocols that are either incomplete, outdated, or both, a new analysis finds.
The study examined 30 statewide EMS protocols for anaphylaxis, detailing symptoms and recommended treatments. The findings revealed key gaps.
Only 50 percent of protocols noted gastrointestinal symptoms like nausea, vomiting, stomach pain, and diarrhea, which are common in severe allergic reactions.
Just 40 percent included neurologic symptoms, such as confusion and lethargy. Neurological symptoms can be a sign of anaphylaxis, especially in infants and younger children, says Dr. Nicole Akar-Ghibril, senior study author.
Children may show behavioral changes such as inconsolable crying, withdrawing, or irritability. Adults experiencing anaphylaxis have also described feeling an “impending sense of doom.”
Clearer definitions could help EMS teams identify anaphylaxis more accurately and use epinephrine more consistently, says Akar-Ghibril.
“First responders have so many things they manage – cardiac arrest, stroke, seizures,” says the allergist-immunologist with Memorial Healthcare System in Hollywood, Florida.
To know the nuances of anaphylaxis when they don’t deal with it every day is a huge ask,” Akar-Ghibril says. Accurate criteria are “Step One to overcoming low rates of epinephrine administration in the field.”
Alarming Incidents Prompt Closer Look
Akar-Ghibril and Dr. Carly Gunderson, an allergy-immunology fellow, delved into EMS protocols after several incidents. These involved patients who met the criteria for anaphylaxis, but who didn’t receive epinephrine after calling 911. The doctors wanted to know why, since “EMS is really the first line of defense for us,” Akar-Ghibril says.
They learned that Florida, like 19 other states, lacks a statewide EMS protocol for anaphylaxis. This leaves each county or individual EMS agency to set its own standards. EMS agencies include fire departments or ambulance companies who employ EMTs and paramedics.
The result is a patchwork of protocols, some with outdated or confusing guidelines. “There were a lot of variations and differences between them,” she says.
EMS and Anaphylaxis Key Symptoms
Among the 30 states that do have statewide protocols, researchers also found issues. About 47 percent of state protocols instructed EMTs and paramedics to look for symptoms affecting two organ systems, such as hives (skin) and coughing (lungs).
Symptoms involving two organ system are a telltale indicator for using epinephrine. Yet, many state protocols instead simply list potential symptoms, without indicating the need for epinephrine when two systems are engaged.
Another concern: Some state protocols included vague warnings about “contraindications” for epinephrine use, without specifying what those are.
“That stuck out to us,” Akar-Ghibril says. Epinephrine is very safe, but the warning may create the impression among first responders that the drug is potentially dangerous. “To put that cautionary statement in there induces a feeling of hesitation,” she says.
In surveys, fear of using epinephrine is often cited by families for avoiding the use of auto-injectors. First responders may have a similar reluctance if they have the impression that there are lots of contraindications to its use, which isn’t accurate, she adds. According to allergist practice parameters, there are “no absolute contraindications” for the use of intramuscular epinephrine in anaphylaxis.
Epinephrine Should Come First
On the plus side, 29 of 30 state protocols recommended epinephrine as the first-line treatment for anaphylaxis. However, protocols also recommend the use of other medications, which may muddy that message.
All state protocols also recommended giving diphenhydramine (such as the brand Benadryl). Antihistamines can relieve skin-related allergic reactions such as hives and itch, but it won’t halt anaphylaxis, the researcher notes.
About 90 percent of state protocols recommend albuterol for wheezing related to anaphylaxis. Seventy-three percent recommended IV fluids for low blood pressure, and 60 percent recommended oral steroids, such as prednisone. Steroids take time to work and typically aren’t very useful in emergency situations, Akar-Ghibril says.
None of these medications are a substitute for epinephrine. “We need to drive home the message: epinephrine is lifesaving and epinephrine is the treatment for anaphylaxis,” she says.
Nationwide Standard Could Be Solution
The analysis found that 83 percent of states permit EMS use of epinephrine auto-injectors, though only 57 percent provide them. Some patients have reported calling 911 during an anaphylactic episode, only to find that the responding crew didn’t have epinephrine on-board or was not authorized to administer it.
The researchers aim to create a model protocol for EMS to adopt nationwide, providing clear criteria and ensuring epinephrine is prioritized.
“I have so much respect for EMS,” says Akar-Ghibril. “When they walk into a situation, they have no idea what they’re facing, and they have to assess the patient so quickly.” She views it as a duty “to give them the criteria and clear definition of anaphylaxis, and make sure they know epinephrine is the first and only treatment for anaphylaxis.”
The study was presented at the 2024 American College of Allergy, Asthma & Immunology’s Annual Scientific Meeting in Boston.
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