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Prehospital Administration of Epinephrine in Pediatric Anaphylaxis – a Statewide Perspective
AB56 Abstracts
179
A Law Is Not Enough: Geographical Disparities in Stock Epinephrine Access in Kansas
SATURDAY
Marissa A. Love, MD, Madison Breeden, BS, Kyle Dack, BA, Alyssa Milner, BA, Andrew C. Rorie, MD, Selina A. Gierer, DO; University of Kansas Medical Center, Kansas City, KS. RATIONALE: We sought to identify geographic disparities and existing barriers to receiving life-saving epinephrine in Kansas schools. METHODS: A survey of school nurses was conducted at the 2015 Kansas School Nurse Association conference. Excel was used to analyze the descriptive data, which was compared to demographics published by the U.S. federal government. RESULTS: In 2009, the Kansas legislature authorized accredited schools to stock emergency epinephrine, pre-dating federal legislation in 2013. Unfortunately, stock epinephrine remains limited to only a few Kansas communities. Our survey revealed significant disparities in implementing stock epinephrine, with 59 of 105 counties reporting. Only 20 counties stocked epinephrine in at least 1 school. When stratifying by household income, 60% of schools that stocked epinephrine were in the top 10% of wealthy counties, whereas 41% that did not were in the bottom 50%. Of schools stocking epinephrine, 35% were in the wealthiest county. Further, 70% of schools with stock epinephrine were associated with the largest urban cores in Kansas. Nurses cited cost, legal liability, having a prescribing physician, lack of staff knowledge or training, and lack of administrator support as reasons why injectable epinephrine was not stocked in their schools. CONCLUSIONS: Our study reveals unequal access to life-saving epinephrine across Kansas, despite state and federal legislation. Further investigation is necessary to resolve this inequality, which disproportionately affects Kansas communities.
180
Anaphylaxis Cases Treated By out-of-Hospital EMS in Western Quebec
Magdalena J. Grzyb, MD1, Ann Clarke, MD, MSc2, Nofar Kimchi3, Colette Lachaine4, Sebastian La Vieille, MD5, Lawrence Joseph, PhD6, Christopher Mill, BSc, MPH7, Moshe Ben-Shoshan, MD, MSc8; 1Division of Pediatric Allergy & Clinical Immunology, McGill University, Montreal, QC, Canada, 2Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, AB, Canada, 3Technion American Medical Students Program, Israel, 4Direction adjointe de services prehospitaliers d’urgence, MSSS, Quebec, Canada, 5Food Directorate, Ottawa, ON, Canada, 6McGill University, Montreal, QC, Canada, 7School of Population and Public Health, University of British Columbia, Vancouver, BC, 8The Research Institute of the McGill University Health Centre, Meakins- Chrisitie Laboratories, Division of Paediatric Allergy and Clinical Immunology, Department of Paediatrics, Montreal Children’s Hospital, Montreal, QC, Canada. RATIONALE: To describe the rate and characteristics of anaphylaxis cases presenting to out-of-hospital emergency medical services (EMS). METHODS: Over a 2-year period from May 2013, paramedics responding to ambulance calls in the Outaouais region of Quebec collected data on patients with anaphylaxis, as part of the Cross-Canada Anaphylaxis Registry. Demographics, reaction characteristics and treatments were recorded at the time of patient evaluation. RESULTS: The incidence of anaphylaxis among the 67,220 ambulance calls received during the study period remained stable in years 1 and 2, at 0.31% [n5104; 95% CI 0.25%, 0.37%] and 0.36% [n5119; 95% CI 0.30%, 0.43%], respectively. The median age was 43.3 years [interquartile range: 20.9, 60.3], with female predominance (60.1%; 95% CI 53.3%, 66.5%). Food (37.2%; 31.0%, 44.0%), drugs (19.7%; 14.8%, 25.7%) and venom (17.9%; 13.3%, 23.7%) were the top triggers. Severe reactions (defined by the presence of cyanosis, SpO2<92%, respiratory arrest, hypotension, dysrhythmia, confusion or loss of consciousness) were more likely in males [OR 2.1; 1.1, 4.4] and during exercise [OR 5.2; 1.2, 22.4). Epinephrine was not administered for moderate-severe anaphylaxis in 25.0% of cases (95%
J ALLERGY CLIN IMMUNOL FEBRUARY 2016
CI 19.1, 32.0). The presence of serious reaction was the only factor associated with epinephrine administration [OR51.26; 1.1, 1.5]. CONCLUSIONS: Our results draw from the first prospectively documented data of anaphylaxis cases presenting to out-of-hospital EMS. The results reflect previously identified risk factors for anaphylaxis, with food, drugs and insect stings as the most common culprits. The suboptimal proportion of cases treated with epinephrine highlights an ongoing need for patient and health-care provider education.
181
Prehospital Administration of Epinephrine in Pediatric Anaphylaxis – a Statewide Perspective
Leslie M. Cristiano, MD1, Brian C. Hiestand, MD1, William A. Gower, MD1, Katherine C. Gilbert, MD1, Jason W. Caldwell, DO, FAAAAI1, Antonio R. Fernandez, PhD2, James E. Winslow, MD1; 1 Wake Forest School of Medicine, Winston-Salem, NC, 2EMS Performance Improvement Center, University of North Carolina, Chapel Hill, NC. RATIONALE: Timely administration of epinephrine is critical in the treatment of anaphylaxis. Very little information is available on the rates of administration of epinephrine by EMS providers caring for pediatric patients in the prehospital setting. METHODS: We examined data from the NC EMS database (PreMIS) from 2010-2013 to determine rates of epinephrine administration in pediatric patients with anaphylaxis. We studied patients <18 years of age with an EMS provider impression of ‘‘allergic reaction.’’ Anaphylaxis was present if there was hypotension (defined as SBP <90 or DBP <45 for patients age 11 and older, and SBP <70 + (2 x age) for patients ages 0-10), or impaired respirations (defined as description of labored or absent respirations, or RR <12 or >30). We determined the overall rate of epinephrine administration. A multivariate logistic regression was then constructed to examine the impact of the following variables on appropriate epinephrine administration: age <7, non-white race, rural county of case origin, duration of transportation from scene, and presence of a paramedic. RESULTS: 504 patients met inclusion criteria, of which 471 demonstrated anaphylaxis as defined above. 157 patients received epinephrine (33.3%, 95% CI 29-38%). Age <7 was associated with increased odds of not receiving epinephrine appropriately (OR 3.36, 95% CI 2.14-5.27, p <0.001). Other variables did not have statistically significant impact on epinephrine administration. CONCLUSIONS: There are missed opportunities for prehospital administration of epinephrine in pediatric patients with anaphylaxis. Very young children (age <7) had increased odds of not receiving epinephrine.
179
A Law Is Not Enough: Geographical Disparities in Stock Epinephrine Access in Kansas
SATURDAY
Marissa A. Love, MD, Madison Breeden, BS, Kyle Dack, BA, Alyssa Milner, BA, Andrew C. Rorie, MD, Selina A. Gierer, DO; University of Kansas Medical Center, Kansas City, KS. RATIONALE: We sought to identify geographic disparities and existing barriers to receiving life-saving epinephrine in Kansas schools. METHODS: A survey of school nurses was conducted at the 2015 Kansas School Nurse Association conference. Excel was used to analyze the descriptive data, which was compared to demographics published by the U.S. federal government. RESULTS: In 2009, the Kansas legislature authorized accredited schools to stock emergency epinephrine, pre-dating federal legislation in 2013. Unfortunately, stock epinephrine remains limited to only a few Kansas communities. Our survey revealed significant disparities in implementing stock epinephrine, with 59 of 105 counties reporting. Only 20 counties stocked epinephrine in at least 1 school. When stratifying by household income, 60% of schools that stocked epinephrine were in the top 10% of wealthy counties, whereas 41% that did not were in the bottom 50%. Of schools stocking epinephrine, 35% were in the wealthiest county. Further, 70% of schools with stock epinephrine were associated with the largest urban cores in Kansas. Nurses cited cost, legal liability, having a prescribing physician, lack of staff knowledge or training, and lack of administrator support as reasons why injectable epinephrine was not stocked in their schools. CONCLUSIONS: Our study reveals unequal access to life-saving epinephrine across Kansas, despite state and federal legislation. Further investigation is necessary to resolve this inequality, which disproportionately affects Kansas communities.
180
Anaphylaxis Cases Treated By out-of-Hospital EMS in Western Quebec
Magdalena J. Grzyb, MD1, Ann Clarke, MD, MSc2, Nofar Kimchi3, Colette Lachaine4, Sebastian La Vieille, MD5, Lawrence Joseph, PhD6, Christopher Mill, BSc, MPH7, Moshe Ben-Shoshan, MD, MSc8; 1Division of Pediatric Allergy & Clinical Immunology, McGill University, Montreal, QC, Canada, 2Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, AB, Canada, 3Technion American Medical Students Program, Israel, 4Direction adjointe de services prehospitaliers d’urgence, MSSS, Quebec, Canada, 5Food Directorate, Ottawa, ON, Canada, 6McGill University, Montreal, QC, Canada, 7School of Population and Public Health, University of British Columbia, Vancouver, BC, 8The Research Institute of the McGill University Health Centre, Meakins- Chrisitie Laboratories, Division of Paediatric Allergy and Clinical Immunology, Department of Paediatrics, Montreal Children’s Hospital, Montreal, QC, Canada. RATIONALE: To describe the rate and characteristics of anaphylaxis cases presenting to out-of-hospital emergency medical services (EMS). METHODS: Over a 2-year period from May 2013, paramedics responding to ambulance calls in the Outaouais region of Quebec collected data on patients with anaphylaxis, as part of the Cross-Canada Anaphylaxis Registry. Demographics, reaction characteristics and treatments were recorded at the time of patient evaluation. RESULTS: The incidence of anaphylaxis among the 67,220 ambulance calls received during the study period remained stable in years 1 and 2, at 0.31% [n5104; 95% CI 0.25%, 0.37%] and 0.36% [n5119; 95% CI 0.30%, 0.43%], respectively. The median age was 43.3 years [interquartile range: 20.9, 60.3], with female predominance (60.1%; 95% CI 53.3%, 66.5%). Food (37.2%; 31.0%, 44.0%), drugs (19.7%; 14.8%, 25.7%) and venom (17.9%; 13.3%, 23.7%) were the top triggers. Severe reactions (defined by the presence of cyanosis, SpO2<92%, respiratory arrest, hypotension, dysrhythmia, confusion or loss of consciousness) were more likely in males [OR 2.1; 1.1, 4.4] and during exercise [OR 5.2; 1.2, 22.4). Epinephrine was not administered for moderate-severe anaphylaxis in 25.0% of cases (95%
J ALLERGY CLIN IMMUNOL FEBRUARY 2016
CI 19.1, 32.0). The presence of serious reaction was the only factor associated with epinephrine administration [OR51.26; 1.1, 1.5]. CONCLUSIONS: Our results draw from the first prospectively documented data of anaphylaxis cases presenting to out-of-hospital EMS. The results reflect previously identified risk factors for anaphylaxis, with food, drugs and insect stings as the most common culprits. The suboptimal proportion of cases treated with epinephrine highlights an ongoing need for patient and health-care provider education.
181
Prehospital Administration of Epinephrine in Pediatric Anaphylaxis – a Statewide Perspective
Leslie M. Cristiano, MD1, Brian C. Hiestand, MD1, William A. Gower, MD1, Katherine C. Gilbert, MD1, Jason W. Caldwell, DO, FAAAAI1, Antonio R. Fernandez, PhD2, James E. Winslow, MD1; 1 Wake Forest School of Medicine, Winston-Salem, NC, 2EMS Performance Improvement Center, University of North Carolina, Chapel Hill, NC. RATIONALE: Timely administration of epinephrine is critical in the treatment of anaphylaxis. Very little information is available on the rates of administration of epinephrine by EMS providers caring for pediatric patients in the prehospital setting. METHODS: We examined data from the NC EMS database (PreMIS) from 2010-2013 to determine rates of epinephrine administration in pediatric patients with anaphylaxis. We studied patients <18 years of age with an EMS provider impression of ‘‘allergic reaction.’’ Anaphylaxis was present if there was hypotension (defined as SBP <90 or DBP <45 for patients age 11 and older, and SBP <70 + (2 x age) for patients ages 0-10), or impaired respirations (defined as description of labored or absent respirations, or RR <12 or >30). We determined the overall rate of epinephrine administration. A multivariate logistic regression was then constructed to examine the impact of the following variables on appropriate epinephrine administration: age <7, non-white race, rural county of case origin, duration of transportation from scene, and presence of a paramedic. RESULTS: 504 patients met inclusion criteria, of which 471 demonstrated anaphylaxis as defined above. 157 patients received epinephrine (33.3%, 95% CI 29-38%). Age <7 was associated with increased odds of not receiving epinephrine appropriately (OR 3.36, 95% CI 2.14-5.27, p <0.001). Other variables did not have statistically significant impact on epinephrine administration. CONCLUSIONS: There are missed opportunities for prehospital administration of epinephrine in pediatric patients with anaphylaxis. Very young children (age <7) had increased odds of not receiving epinephrine.