An earlier study of food-related anaphylaxis in the emergency department (ED) suggested low concordance with national guidelines for anaphylaxis management.
To extend these findings, we performed a chart review study to describe current ED management of insect sting allergy.
The Multicenter Airway Research Collaboration performed a chart review study in 15 North American EDs. Investigators reviewed 617 charts of patients with insect sting allergy. Patients were identified by using International Classification of Diseases, 9th Revision, codes 989.5 (toxic effect of venom), 995.0 (other anaphylactic shock), and 995.3 (allergy, unspecified).
The cohort was 42% female and 61% white, with a mean age of 36+/-19 years. In this cohort, 58% had local reactions, 11% had mild systemic reactions, and 31% had anaphylactic reactions, as defined by multisystem organ involvement or hypotension. Among patients with systemic reactions (mild or anaphylaxis), most (75%) were stung within 6 hours of ED arrival. While in the ED, 69% of systemic reaction patients received antihistamines, 50% systemic corticosteroids, and 12% epinephrine. Almost all systemic reaction patients (95%) were discharged to home. At ED discharge, 27% (95% CI, 22% to 33%) of systemic reaction patients received a prescription for self-injectable epinephrine. Only 20% (95% CI, 15% to 26%) had documentation of referral to an allergist.
Although guidelines suggest specific approaches for the emergency management of insect sting allergy, concordance with these guidelines appears low in patients with a severe insect sting reaction.
"Studies also indicate discordance with guideline recommendations for discharge in the US: approximately 45% of patients treated for anaphylaxis in the ED received a discharge prescription for epinephrine (range 16%–63%);[8–10,27,29,31,33,34] and even fewer were given a referral to an allergist (21.6%, range 11%–33%)[8–10,27,29,33,34] and/or information about avoiding causative agents (23.5%, range 3%–40%).[9,10,33,34] Treatment with epinephrine in the ED may predict the likelihood of a prescription for epinephrine at discharge and referral to an allergist.[9,27,29] "
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND:
Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting. Current guidelines recommend: 1) quick diagnosis using standard criteria; 2) first-line treatment with epinephrine; and 3) discharge with a prescription for an epinephrine auto-injector, written instructions regarding long-term management, and a referral (preferably, allergy) for follow-up. However, studies suggest low concordance with guideline recommendations by emergency medicine (EM) providers. The study aimed to evaluate how emergency departments (EDs) in the United States (US) manage anaphylaxis in relation to guideline recommendations.
This was an online anonymous survey of a random sample of EM health providers in US EDs.
Data analysis included 207 EM providers. For respondent EDs, approximately 9% reported using agreed-upon clinical criteria to diagnose anaphylaxis; 42% reported administering epinephrine in the ED for most anaphylaxis episodes; and <50% provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge. Most provided some written materials, and follow-up with a primary care clinician was recommended.
This is the first cross-sectional survey to provide “real-world” data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis, treatment, and follow-up of patients with anaphylaxis. The primary gaps are low (or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine. Prospective research is recommended.
[Show abstract][Hide abstract] ABSTRACT: This study was conducted to estimate the burden of non-canine-related bite and sting injuries in the U.S.; describe the affected population, injury severity, and bite or sting source; and provide considerations for prevention strategies.
Data were from the 2001 through 2004 National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) (a stratified probability sample of U.S. hospitals). Records included information about age, body part affected, cause, diagnosis, disposition, and gender. Narrative descriptions were coded for the source of the bite or sting.
Between 2001 and 2004, an estimated 3.6 million people were treated in emergency departments for injuries related to non-canine bites and stings. Results detail the reported sources of the bite or sting, and examine sources by gender and age group. Common sources included bees (162,000 cases annually), spiders (123,000 cases annually), and cats (66,000 cases annually). Female adults were more likely than male adults to be treated for cat bites. Although rare, of the known venomous snakebites, more than half (58.4%) of the patients were hospitalized.
Our results demonstrate the public health burden of non-canine-related bite and sting injuries. More than 900,000 people were treated in emergency departments annually for non-canine bite or sting injuries, or roughly 1.7 injuries per minute. Treatment consumes substantial health-care resources. While preventing these injuries should be the first line of defense, resources could be conserved by educating the public about immediate first aid and when warning signs and symptoms indicate the need for professional or emergency care.
Public Health Reports 12/2007; 122(6):764-75. · 1.55 Impact Factor
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