Q: My 12-year-old (egg and peanut allergies) recently experienced full body hives, coughing and a swollen eye after eating out. I followed our emergency care plan, giving him the auto-injector and going to the hospital. An ER doctor said an antihistamine would have been fine, and that “there was no need to ‘epi’ since he didn’t have breathing difficulty.” I was following the protocol. Did I over-react?
Dr. Sicherer: First, I totally agree with your decision to inject epinephrine.
The allergy and anaphylaxis emergency plans are developed for first-aid management of allergic reactions. That is, they are designed for non-medical personnel and for use outside of the ER and hospital. They are written with an awareness that people could have trouble determining severity of symptoms.
The plans consider the safety of using self-injectable epinephrine, and the benefit of giving the medication before symptoms become severe and potentially less responsive to treatment.
As was the case for your son, your plan should instruct you to give epinephrine when there is an allergen ingestion resulting in many hives over the body and coughing.
What’s Different in the Hospital
In a hospital setting, a physician may decide they would only give epinephrine for “medically diagnosed” anaphylaxis.
There are expert consensus definitions of anaphylaxis, but evaluation of the symptoms could require equipment to measure blood pressure, a stethoscope to listen for wheezing, and medical expertise in evaluating multiple symptoms accurately. The ER doctor may be able to rule out “breathing difficulty,” and decide to monitor and then treat if there is progression.
A person can absolutely have anaphylaxis without breathing difficulty – for example with vomiting and hives, or with low blood pressure alone. This is why the evaluation includes a comprehensive examination and monitoring.
Clearly, epinephrine should be given for anaphylaxis. But it can also be administered for relief of progressive symptoms. As well, you may give epinephrine for the reasons described in written plans – even when some of the details fall short of medically defined anaphylaxis.
Dr. Scott Sicherer is a practicing allergist, clinical researcher and professor of pediatrics. He is Director of the Jaffe Food Allergy Institute and Chief of Pediatric Allergy and Immunology at the Icahn School of Medicine at Mount Sinai in New York. He’s also the author of Food Allergies: A Complete Guide for Eating When Your Life Depends On It.
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