U.S. Needs Consistent EMS Protocols for Severe Allergic Reactions

EMS protocols in the United States for managing severe allergic reactions—aka anaphylaxis—vary from state to state. Worse yet, many of these anaphylaxis response protocols are incomplete, outdated, or both.

That’s the conclusion of a recent study conducted by Nicole Akar-Ghibril, MD and Carly Gunderson, DO, Sandra Lopez, MD, and Karishma Lukose. They compiled and analyzed 30 state anaphylaxis EMS protocols, including their descriptions of symptoms and recommended treatments.

The results were startling. Half the protocols studied did not include GI symptoms, such as diarrhea, nausea, stomach pain, and vomiting, which are common in severe allergic reactions. Sixty percent of the EMS anaphylaxis protocols didn’t include neurologic symptoms such as confusion and lethargy, which are common in younger children and babies. This group can also experience inconsolable crying, irritability, or social withdrawal, while adults have reported experiencing a “sense of impending doom.”

The study was inspired by several patients, followed by the research team, who experienced anaphylaxis. These patients had received EMS care for anaphylaxis without being administered epinephrine, which is an accepted treatment for severe allergic reactions.

“When we asked why epinephrine wasn't given in these cases, we were told that these patients had not met the EMS criteria for anaphylaxis,” Akar-Ghibril said. “That led us to wonder: What is the criteria that's being used? So, we started looking within our local area and found that there were a number of different protocols that were available, which prompted us to look throughout the country. That’s how we discovered the problems with so many EMS anaphylaxis protocols.”

Akar-Ghibril and the writing team did not develop consistent and complete EMS anaphylaxis protocols nationwide. But they are hoping that publicizing their surprising results will motivate those in charge of these standards to improve them; if not nationwide, then at least on a state-by-state basis.

“After all, we know that early treatment of anaphylaxis does improve outcomes,” Akar-Ghibril said. “If we don't have the proper EMS protocols in place to be able to identify anaphylaxis early, then of course that can lead to worse outcomes and management.”

Fortunately, the study’s results are generating interest in the U.S. EMS community. “I am excited that this is on the radar now,” Akar-Ghibril said. “Hopefully states and EMS agencies will take a look at their own EMS anaphylaxis protocols and see how well they stack up. And remember: Epinephrine is the first line treatment for anaphylaxis, and there are no true contraindications to using epinephrine in the treatment of anaphylaxis.”