Venkatesh R. Bellamkonda

Epinephrine in Anaphylaxis: Higher Risk of Cardiovascular Complications and Overdose After Administration of Intravenous Bolus Epinephrine Compared with Intramuscular Epinephrine

BACKGROUND Epinephrine is the drug of choice for the management of anaphylaxis, and fatal anaphylaxis is associated with delayed epinephrine administration. Data on adverse cardiovascular (CV) complications and epinephrine overdose are limited. OBJECTIVE To compare rates of CV adverse events and epinephrine overdoses associated with anaphylaxis management between various routes of epinephrine administration among patients with anaphylaxis in the emergency department. METHODS This was an observational cohort study from April 2008 to July 2012. Patients in the emergency department who met diagnostic criteria for anaphylaxis were included. We collected demographics; route of epinephrine administration; trigger; overdose; and adverse CV events, including arrhythmia, cardiac ischemia, stroke, angina, and hypertension. RESULTS The study cohort included 573 patients, of whom, 301 (57.6%) received at least 1 dose of epinephrine. A total of 362 doses of epinephrine were administered to 301 patients: 67.7% intramuscular (IM) autoinjector, 19.6% IM injection, 8.3% subcutaneous injection, 3.3% intravenous (IV) bolus, and 1.1% IV continuous infusion. There were 8 CV adverse events and 4 overdoses with 8 different patients. All the overdoses occurred when epinephrine was administered IV bolus. Adverse CV events were associated with 3 of 30 doses of IV bolus epinephrine compared with 4 of 316 doses of IM epinephrine (10% vs 1.3%; odds ratio 8.7 [95% CI, 1.8-40.7], P = .006). Similarly, overdose occurred with 4 of 30 doses of IV bolus epinephrine compared with 0 of 316 doses of IM epinephrine (13.3% vs 0%; odds ratio 61.3 [95% CI, 7.5 to infinity], P < .001). CONCLUSION The risk of overdose and adverse CV events is significantly higher with IV bolus epinephrine administration. Analysis of the data supports the safety of IM epinephrine and a need for extreme caution and further education about IV bolus epinephrine in anaphylaxis.

A multifaceted intervention for patients with anaphylaxis increases epinephrine use in adult emergency department.

BACKGROUND Studies have documented inconsistent emergency anaphylaxis care and low compliance with published guidelines. OBJECTIVE To evaluate anaphylaxis management before and after implementation of an emergency department (ED) anaphylaxis order set and introduction of epinephrine autoinjectors, and to measure the effect on anaphylaxis guideline adherence. METHODS A cohort study was conducted from April 29, 2008, to August 9, 2012. Adult patients in the ED who were diagnosed with anaphylaxis were included. ED management, disposition, self-injectable epinephrine prescriptions, allergy follow-up, and incidence of biphasic reactions were evaluated. RESULTS The study included 202 patients. The median age of the patients was 45.3 years (interquartile range, 31.3-56.4 years); 139 (69%) were women. Patients who presented after order set implementation were more likely to be treated with epinephrine (51% vs 33%; odds ratio [OR] 2.05 [95% CI, 1.04-4.04]) and admitted to the ED observation unit (65% vs 44%; OR 2.38 [95% CI, 1.23-4.60]), and less likely to be dismissed home directly from ED (16% vs 29%, OR 0.47 [95% CI, 0.22-1.00]). Eleven patients (5%) had a biphasic reaction. Of these, 5 (46%) had the biphasic reaction in the ED observation unit; 1 patient was admitted to the intensive care unit. Six patients (55%) had reactions within 6 hours of initial symptom resolution, of whom 2 were admitted to the intensive care unit. CONCLUSIONS Significantly higher proportions of patients with anaphylaxis received epinephrine and were admitted to the ED observation unit after introduction of epinephrine autoinjectors and order set implementation. Slightly more than half of the biphasic reactions occurred within the recommended observation time of 4 to 6 hours. Analysis of these data suggests that the multifaceted approach to changing anaphylaxis management described here improved guideline adherence.

Ultrasound evaluation of appendicitis: Importance of the 3 × 2 table for outcome reporting

INTRODUCTION Despite a relatively high frequency of appendix nonvisualization when using ultrasound to diagnose appendicitis, many studies either fail to report these results or inconsistently analyze outcomes. OBJECTIVES The objective of this study is to determine the most transparent and accurate way of reporting and analyzing ultrasound results for the diagnosis of appendicitis. METHODS This was an observational cohort study of emergency department patients age 18 years or older who underwent right lower quadrant ultrasonography from September 2010 to October 2011. Patient characteristics, imaging, pathology, and follow-up data were analyzed. Test characteristics were calculated using conventional 2 × 2 contingency table analysis excluding inconclusive ultrasound results and an intention-to-diagnose approach with a 3 × 2 table. RESULTS Sixty-five patients were included. Forty-four (68%) patients had a nonvisualized appendix resulting in an overall diagnostic yield of 32%. Twenty-one patients had a visualized appendix (14 [22%] negative and 7 [11%] positive for appendicitis). Using 2 × 2 contingency table analysis, sensitivity and specificity were 100%. Using the 3 × 2 table with and the intention-to-diagnose principle, sensitivity was 70% and specificity was 25%. Three (7%) of 44 patients with a nonvisualized appendix had appendicitis (likelihood ratio = 0.40). DISCUSSION We suggest reporting ultrasound results using a 3 × 2 table (including nonvisualized findings) but using the traditional 2 × 2 type of analysis for test characteristic calculations. This approach allows for the determination of diagnostic yield and calculation of likelihood ratios when the appendix is not visualized. This approach to reporting should be considered for all types of diagnostic ultrasound studies.

Predictors of Repeat Epinephrine Administration for Emergency Department Patients with Anaphylaxis

BACKGROUND Risk factors that predict which patients with anaphylaxis might require repeat doses of epinephrine are poorly understood. OBJECTIVE The objective of this study was to identify risk factors associated with the need for multiple doses of epinephrine during an anaphylactic reaction. METHODS Patients were included if they met diagnostic criteria for anaphylaxis on presentation to the emergency department (ED) at our academic medical center between April 2008 and February 2014. Data were collected on allergic history, presenting signs and symptoms, anaphylaxis management, and disposition. Univariable and multivariable analyses were performed to estimate associations between possible risk factors and the need for multiple doses. RESULTS Of 582 ED patients with anaphylaxis, 45 (8%) required multiple doses of epinephrine. By multivariable analysis, factors associated with the need for repeat doses were a history of anaphylaxis (odds ratio [OR], 2.5 [95% CI, 1.3-4.7]; P = .005), the presence of flushing or diaphoresis (OR, 2.4 [95% CI, 1.3-4.5]; P = .007), and the presence of dyspnea (OR, 2.2 [95% CI, 1.0-5.0]; P = .046). Patients who received more than 1 dose were more likely to be admitted to the general medical floor (OR, 2.8 [95% CI, 1.1-7.2]; P = .03) or intensive care unit (OR, 7.6 [95% CI, 3.7-15.6]; P < .001). CONCLUSION Patients with a history of anaphylaxis, flushing or diaphoresis, or dyspnea may require multiple doses of epinephrine to treat anaphylactic reactions. Patients who require more than 1 dose are more likely to be admitted to the hospital, thus increasing health care resource utilization.

Ultrasound credentialing in North American emergency department systems with ultrasound fellowships: a cross-sectional survey

Objective To describe the credentialing systems of North American emergency department systems (EDS) with emergency ultrasound (EUS) fellowship programmes. Methods This is a prospective, cross-sectional, survey-based study of North American EUS fellowships using a 62-item, pilot-tested, web-based survey instrument assessing credentialing and training systems. The American College of Emergency Physicians (ACEP) distributed the surveys using SNAP survey (Snap Surveys Ltd, Portsmouth, New Hampshire, USA). Results Over 6 months, 75 eligible programmes were surveyed, 55 responded (73% response rate); 1 declined to participate leaving 54 participating programmes. Less than 20% of EDS credential nurses, physician assistants, nurse practitioners and students in EUS. Respondent EDS reported having an average of 4.2±3.3 ultrasound faculty members (faculty identifying their career focus as EUS). The median number of annual point-of-care ultrasounds reported was 5000 (IQR 3000–8000). 30 EDS (56%) credential each examination individually and 48 EDS (89%) use ACEP credentialing criteria. 61% of fellowship leadership believe their credentialing system is either satisfactory or very satisfactory (Cronbachs coefficient α=0.84). Conclusions The data show heterogeneity among North American EDS with EUS fellowship programmes with regard to credentialing systems despite published guidelines from the ACEP and Canadian Emergency Ultrasound Society.

Effect of spinal needle characteristics on measurement of spinal canal opening pressure

Objective: A wide variety of spinal needles are used in clinical practice. Little is currently known regarding the impact of needle length, gauge, and tip type on the needles ability to measure spinal canal opening pressure. This study aimed to investigate the relationship between these factors and the opening‐pressure measurement or time to obtain an opening pressure. Methods: Thirteen distinct spinal needles, chosen to isolate the effects of length, gauge, and needle‐point type, were prospectively tested on a lumbar puncture simulator. The key outcomes were the opening‐pressure measurement and the time required to obtain that measure. Pressures were recorded at 10‐s intervals until 3 consecutive, identical readings were observed. Results: Time to measure opening pressure increased with increasing spinal needle length, increasing gauge, and the Quincke‐type (cutting) point (P < 0.001 for all). The time to measurement ranged from 30 s to 530 s, yet all needle types were able to obtain a consistent opening pressure measure. Conclusion: Although opening pressure estimates are unlikely to vary markedly by needle type, the time required to obtain the measurement increased with increasing needle length and gauge and with Quincke‐type needles.

Traumatic lens dislocation.

BackgroundPoint-of-care ultrasound has been widely used by clinicians, particularly those in emergency care settings.FindingsA 44-year-old male who sustained a blunt ocular trauma resulting in acute vision loss due to posterior dislocation of the crystalline lens identified by point-of-care ultrasound is described in the study. Point-of-care ultrasound with a high linear-array transducer was used to gain the sagittal view of the eye globe.ConclusionsPoint-of-care ultrasound can be a useful tool to make a rapid diagnosis of ocular emergency including lens abnormality.