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ER Responses to Allergic Reactions Questioned

Many emergency rooms don't follow allergists' recommendations

MONDAY, Feb. 9, 2004 (HealthDayNews) -- If you wind up in the emergency room with an allergic reaction to food, chances are you won't be treated according to allergists' guidelines.

That's the conclusion of a new study that also finds too few emergency room patients receive epinephrine, the recommended standard treatment for allergic reactions to food.

The problem, says lead researcher Dr. Carlos A. Camargo, of the Emergency Department at Massachusetts General Hospital, is that many patients with allergic reactions receive different care than that recommended by allergists.

"For many patients, this is fine," Camargo says. "But the care that allergists recommend probably would benefit a great number of them." And that includes an injection of epinephrine, which is produced by your body and also called adrenaline. It stimulates your heart and opens your airways.

The study appears in the February issue of the Journal of Allergy and Clinical Immunology.

Anne Munuz-Furlong is the founder and chief executive officer of the Food Allergy and Anaphylaxis Network (FAAN). She says, "This study shows that there is a tremendous gulf between what the guidelines for managing food allergy are and what the actual practice is."

"There is a lot of work to be done with allergists and emergency physicians to ensure that these patients get the care they need," she says.

An estimated 5 million Americans are allergic to one or more foods. These include 5 percent to 8 percent of children and 1 percent to 2 percent of adults, according to FAAN.

An allergic reaction to food can range from merely annoying to life-threatening. While symptoms differ among individuals, common problems include skin irritation, such as rashes, hives and eczema; gastrointestinal symptoms, such as nausea, diarrhea, and vomiting; and sneezing, runny nose and shortness of breath.

But an allergic reaction can lead to what doctors call anaphylaxis. This is a rare but potentially fatal condition in which several different parts of the body show allergic symptoms. These can include itching, hives and swelling of the throat leading to difficulty breathing.

In addition, in severe cases called anaphylactic shock, blood pressure can drop rapidly and the patient may become unconscious and die.

Anaphylaxis usually sets in rapidly, sometimes within minutes of exposure to the allergen, experts say.

In their study of emergency department practices, Camargo and his colleagues looked at the medical charts of 678 patients who were treated for food allergies in 21 hospitals. A variety of foods had caused the allergic reactions, including fruit, nuts, fish and shellfish.

Camargo's team found that only 18 percent of the patients arrived at the hospital by ambulance. And only 16 percent were treated with epinephrine, which is the recommended standard treatment for allergic reactions to food. Seventy-two percent were given antihistamines, and 48 percent were given steroids.

The more severe the attack, the more likely patients were to get epinephrine, Camargo says: "The problem is that there clearly were severe attacks that didn't get the treatment that would have helped them."

Almost all of the patients, 97 percent, were discharged from the hospital. Only 16 percent were prescribed self-injectable epinephrine, and only 12 percent were advised to see an allergist, the researchers found.

Camargo says this lack of treatment occurs because emergency department doctors don't have a clear understanding of anaphylaxis and when it occurs. "So many people who could benefit from the treatment aren't getting it," he adds.

Camargo believes emergency room doctors need a simple protocol that will aid them in making a quick decision to use epinephrine. This protocol should recommend the use of the drug in most cases, he notes.

He also believes that anyone who has had an allergic reaction severe enough to send them to the emergency room should be given a prescription for self-injectable epinephrine and instructions on how and when to use it.

In another study, just completed, Camargo's team looked at the treatment of allergic reactions to bee stings, and found the same under use of epinephrine. These patients also were discharged without self-injectable epinephrine, he says.

"Patients need to learn more about their allergies because they can be fatal, Camargo says. "For those who have severe enough reactions that cause them to go to the hospital, they should carry self-injectable epinephrine and learn how to use it."

Dr. Scott H. Sicherer is an assistant professor of pediatrics at the Jaffe Food Allergy Institute at the Mount Sinai School of Medicine in New York City. He says he finds it worrisome that "people who have experienced food-induced allergic reactions are leaving the emergency room possibly ill-prepared to address their potentially life-threatening food allergy."

"More education is needed to ensure that these patients receive a definitive diagnostic evaluation by an allergist and the correct counseling to avoid the problematic food," he adds.

Dr. David L. Katz, director of the Yale Prevention Research Center at Yale University, says "when we examine medical practice closely, we almost invariably find marked discrepancy between prevailing guidelines and what is actually done."

"This study suggests that emergency treatment of acute food allergy can and should be improved, and this is doubtless true," he says.

However, Katz finds fault with the method the researchers used in their study. He notes that chart review studies can only draw conclusions based on what was documented in the medical record. "However, in a busy emergency department, this may not, in fact, represent everything that was actually done."

Katz adds that chart review studies also fail to take into account medical judgment. For example, a patient with an acute food allergy might not need epinephrine if treated early enough.

Also, if a patient already had used injectable epinephrine at home, there would be no need to repeat it, he says.

More information

For more on food allergies and anaphylaxis, visit the American Academy of Allergy Asthma and Immunology and the Food Allergy and Anaphylaxis Network.

SOURCES: Carlos A. Camargo, M.D., Dr.PH., Emergency Department, Massachusetts General Hospital, and associate professor, medicine, Harvard Medical School, Boston; Scott H. Sicherer, M.D., assistant professor, pediatrics, Jaffe Food Allergy Institute, Mount Sinai School of Medicine, New York City; David L. Katz, M.D., M.P.H., director, Yale Prevention Research Center, Yale University, New Haven, Conn.; Anne Munuz-Furlong, founder and chief executive officer, Food Allergy and Anaphylaxis Network, Fairfax, Va.; February 2004 Journal of Allergy and Clinical Immunology
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