Part 8: Advanced Challenges in Resuscitation: Section 3: Special Challenges in ECC 3D: Anaphylaxis

2017 marks the 25th anniversary of the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1992 to create a forum for collaboration among principal resuscitation councils worldwide. Since then, ILCOR has established and distinguished itself for its pioneering vision and leadership in resuscitation science.

By systematically assessing the evidence for resuscitation standards and guidelines and by identifying national and regional differences, ILCOR reached consensus on international resuscitation guidelines in 2000, and on international science and treatment recommendations in 2005, 2010 and 2015. However, local variation and contextualization of guidelines are evident by subtle differences in regional and national resuscitation guidelines. ILCOR’s efforts to date have enhanced international cooperation, and progressively more transparent and systematic collection and analysis of pertinent scientific evidence. Going forward, this sets the stage for ILCOR to pursue its vision to save more lives globally through resuscitation.

We report a case of anaphylaxis with pulseless electrical activity (PEA)(verified by ECG and a radial intra-arterial line) in a 30-year-old woman who received 3G Promiten (dextran-1) and a prophylactic intra-venous infusion of Macrodex (dextran) for postoperative thromboembolism during caesarean section for pre-eclampsia in the 24th week of gestation. Manual chest compressions, followed by mechanical chest compressions (LUCAS, Jolife, Lund, Sweden), were performed for 50 min before restoration of spontaneous circulation (ROSC). She awoke the next day with no sequelae. She had some suction cup marks on the sternum but otherwise no complications of the chest compressions. At follow up by phone 1 month later, she and her baby were doing well.

Les pathologies allergiques étant peu décrites en pré-hospitalier, nous avons souhaité en évaluer les modes de présentation, la fréquence et les modalités de prise en charge.

Etude rétrospective incluant les dossiers médicaux concernant les interventions primaires de notre SMUR. Deux périodes ont été définies en fonction de la mise en place dans le service d’une procédure thérapeutique « allergie » : P 1 (1^er juillet 2000 – 30 novembre 2001) et P 2 (1^er décembre 2001 – 30 juin 2003) correspondant respectivement aux dossiers des patients pris en charge avant et après la mise en place de la procédure. Eléments analysés : différents tableaux cliniques, thérapeutiques administrées, devenir des patients, impact de la procédure thérapeutique sur les pratiques médicales.

Les situations cliniques les plus souvent rencontrées sont l’urticaire superficielle et l’urticaire profonde sans atteinte ORL. Les traitements prescrits sont en adéquation avec les données de la littérature pour les pathologies les plus graves. Les corticoïdes sont, même pour les pathologies les moins importantes, très largement utilisés au détriment des antiH1, même si l’utilisation de ces derniers augmentent nettement entre les deux périodes. Les patients sont orientés dans 63,3 % des cas vers un service d’Urgences. La procédure thérapeutique est respectée dans 25,4 % des situations en période 2.

Les SMUR sont rarement confrontés à la pathologie allergique et la prise en charge est peu homogène. Des recommandations s’appuyant sur la littérature sont nécessaires pour harmoniser les pratiques.

We investigated the presentation, frequency and management of allergic disease in the prehospital intensive care setting.

We conducted a retrospective study of the medical records of patients with a diagnosis of allergy who were managed by the Garches prehospital intensive care unit. Two periods were defined, before and after institution of an “allergy” therapeutic protocol: P1 (from July 1^st 2000, to November 30^th 2001), and P2 (from December 1st 2001, to June 30^th 2003). We analyzed clinical presentation, medication administered and impact of the protocol on medical practices.

The clinical situations most often encountered were urticaria and angioedema without laryngeal involvement. Treatments complied with recommendations in the literature for the most serious cases. Corticosteroids were used too frequently, often when antihistaminics would have been appropriate. Use of antihistaminics increased between the two study periods. 63.3% of patients were transferred to the hospital emergency unit. The therapeutic protocol was correctly applied in 25.4% of cases during the second study period.

Prehospital intensive care units are infrequently confronted with allergic diseases. Management practices vary greatly. Evidence-based guidelines are needed to harmonize our practices.

Many Emergency Medical Services (EMS) systems have adopted epinephrine auto-injector (EAI) use by Basic Life Support (BLS) personnel, and several states now require that BLS personnel be trained and authorized to use EAIs. The objectives of this observational study were: 1) to examine EMS case definitions of allergy/anaphylaxis, 2) to ascertain the incidence of EMS calls for allergy/anaphylaxis and administration of epinephrine, and 3) to quantify the rate of deaths due to anaphylaxis. Data were solicited by e-mail, mail, and telephone from National Association of State EMS Directors (NASEMSD) members, state EMS offices, and state medical examiner and vital statistics offices. Simple descriptive statistics were used to analyze the data. The following was found: 1) there is no standardization of case definitions among states. Some use the terms “allergic reaction” and “anaphylaxis” in EMS protocols without definition, whereas others provide lengthy, specific definitions, with detailed criteria for epinephrine administration; 2) excluding two outliers at 0.04% and 3.9%, nine EMS system databases totaling over 2.8 million runs contained between 0.34% and 0.82% of runs for allergy/anaphylaxis. Seven of these databases reported on epinephrine administration, with rates between 0.16% and 31.1%, and four of the seven clustered between 8.8% and 14.8%. There was little uniformity in the data provided by seven states on deaths due to anaphylaxis, with rates from 0% to 0.94%. Although limited by the lack of data from many states, roughly 0.5% of EMS runs are for allergy/anaphylaxis complaints, with epinephrine administered in roughly one-tenth of these. State death rates from anaphylaxis vary considerably, with rates from 0% to 0.94% reported.

The use of epinephrine for the treatment of anaphylaxis by emergency medical technicians (EMTs) has not been rigorously evaluated. The aim of this study was to determine whether first-tier EMTs use epinephrine safely and appropriately for anaphylactic reactions.

The study used a case–control design. Cases were persons treated by EMTs with epinephrine for presumed anaphylaxis from January 1, 2000, through January 31, 2003, in King County, Washington (n = 22). Controls were emergency medical services (EMS)-treated persons matched to cases by diagnosis category, patient age, fire department, and year, but who had not been administered epinephrine by EMTs (n = 44). Cases and controls were compared with regard to history, symptoms, and examination characteristics. In a second assessment, physicians blinded to treatment (case/control) status reviewed events to determine whether they would have treated the patient with epinephrine.

When cases were compared with controls, cases were more likely to report a history of anaphylaxis (27% vs. 2%), upper airway symptoms (59% vs. 18%), and shortness of breath (77% vs. 27%). Cases were also more likely to have tachypnea (32% vs. 5%), hypotension (41% vs. 9%), decreased level of consciousness (32% vs. 2%), abnormal breath sounds (46% vs. 16%), and rash (50% vs. 23%) (p ≤ 0.01 for all comparisons). The physicians agreed with the EMTs' decisions regarding epinephrine use (or nonuse) in 86% (57/66) of events: 86% (19/22) in which the EMTs used epinephrine and 86% (38/44) in which the EMTs did not use epinephrine.

In this EMS system, the EMTs used epinephrine for presumed anaphylaxis in a discriminating manner that typically agreed with physician review.