Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Most Common Cause of Death in Anaphylaxis is Failure to Give Epinephrine

ResearchBlogging.org

The most common cause of death in anaphylaxis is failure to give epinephrine.

That is according to Dr. Corey Slovis, presenting at the 2012 Gathering of Eagles Conference.[1]

This is shocking news. Where do we have any evidence of that?

Although five of the six children and adolescents had experienced definite allergic reactions to the incriminated food on previous occasions, none had had a near-fatal reaction.[2]

No problem. There is no reason to expect that they will have a severe reaction this time, either.

Well, we can always use epinephrine to resuscitate them. 😳

Near-fatal reactions were not that much better.

Three of the six children and adolescents appeared to be improving before the occurrence of terminal cardiorespiratory arrest.[2]

With anaphylaxis, symptoms can mislead. Do not underestimate the condition of patients who have a history of anaphylaxis.

What did they have in common?

All the patients received epinephrine and appropriate medical care once they reached a hospital emergency room, but by then all were unresponsive and had had extended hypoxia and hypotension.[2]

All the patients had asthma and were taking bronchodilator medications.[2]

The asthma in all but one of the patients with nonfatal reactions appeared to be well controlled by medication, whereas two patients with fatal reactions and one with a nonfatal reaction had serious wheezing in the two weeks before the anaphylactic reaction.[2]

All the patients had a history of serious anaphylactic reactions to food, and all but two had had such reactions to the food responsible for the fatal or near-fatal reaction.[2]

A history of anaphylaxis is a good reason to give epinephrine to someone with minor, or moderate, symptoms. I will assume that nobody is withholding epinephrine from patients with severe symptoms.

Do we need to give an auto-injector, or an intramuscular injection?

No. We can approach this more gradually with a slow epinephrine drip –

1 mg in 1 liter starting at 1 ml per minute.

Corrected at 12:15 4/13/2012 from 1 mg in 1 ml starting at 1 ml per minute. It is 1 mg in 1,000 ml (1 liter) starting at 1 ml per minute. Thank you to Jeffrey R. Vaughn and Tony Heibel for pointing this out.

The starting dose epinephrine by IV infusion is 1-2 micrograms/minute.[1]

If there is no protocol for this, calling medical command is always an option. Even though there may be systems that foolishly forbid medics from deviating from protocol with orders from medical command.

None of the patients were aware that the implicated allergen was in the food they ate, indicating that attempts at strict avoidance are often unsuccessful.[2]

Even if the patient does not know of an exposure, there can still be a deadly exposure.

Too simple? Not simple enough? Just right?

Another explanation of how to treat anaphylaxis.[3]

Read the PDF[1] and listen to the recording from Free Emergency Medicine Talks and you should become comfortable with it.

Footnotes:

[1] Using IV Epinephrine Expertly
Dr. Corey Slovis
2012 Gathering of Eagles
Presentation in PDF format

Care of the Wheezing Patient – Slovis, from Free Emergency Medicine Talks

[2] Fatal and near-fatal anaphylactic reactions to food in children and adolescents.
Sampson HA, Mendelson L, Rosen JP.
N Engl J Med. 1992 Aug 6;327(6):380-4.
PMID: 1294076 [PubMed – indexed for MEDLINE]

Free Full Text from NEJM

[3] Anaphylactic reactions – 5 things.
Sunday, September 4, 2011
Doc Cottle’s Desk
Article

Sampson, H., Mendelson, L., & Rosen, J. (1992). Fatal and Near-Fatal Anaphylactic Reactions to Food in Children and Adolescents New England Journal of Medicine, 327 (6), 380-384 DOI: 10.1056/NEJM199208063270603

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Comments

  1. Was this a typo:

    Do we need to give an auto-injector, or an intramuscular injection?

    No. We can approach this more gradually with a slow epinephrine drip –

    1 mg in 1 ml starting at 1 ml per minute.

    do you intend

    1 mg in 1 liter starting at 1 ml per minute?

    It seems thats the dose on slides 17 and 18

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