TOPLINE 

A validated model identified children with anaphylaxis who were at a low risk of requiring additional epinephrine and might not require emergency department (ED) care, potentially reducing unnecessary ED visits for anaphylaxis.

METHODOLOGY 

• Researchers conducted a secondary analysis of a multicenter retrospective cohort study to derive and validate a prediction model to identify children with anaphylaxis who were at a low risk of requiring additional epinephrine in the ED or inpatient setting.
• The study included 2318 children with anaphylaxis (median age, 8.3 years; 44.7% girls) who received a single prehospital dose of epinephrine; the cohort was split into the derivation (72.7%), internal validation (18.0%), and external validation (9.3%) cohorts.
• The prediction model was derived using data from the derivation cohort to identify prehospital factors associated with the receipt of additional epinephrine. The model was then verified in the internal validation cohort, with its robustness confirmed in the external validation cohort, using a later, distinct time period.
• The primary outcome was the receipt of additional epinephrine via the intramuscular, subcutaneous, or intravenous route in the ED or inpatient setting.

TAKEAWAY 

• The pre-ED factors associated with the receipt of epinephrine after arrival at the ED were a history of asthma; cardiovascular symptoms before prehospital administration of epinephrine; and persistent, new, or recurrent symptoms after prehospital administration of epinephrine before arrival at the ED.
• In the external validation cohort, if any risk factor was present, the model identified 93% of patients who required epinephrine after arriving at the ED; among those it classified as low risk, 95% did not receive epinephrine. The model’s specificity and positive predictive value were 0.35 and 0.25, respectively.
• When applied to the overall cohort, 28.0% of encounters were classified as low risk. Only a small proportion (4.3%) of these low-risk patients went on to receive additional epinephrine, suggesting that a substantial number of cases might be managed without unnecessary escalation.
• The model identified 38 of 41 patients with refractory anaphylaxis, capturing 93% of cases. With a negative predictive value of 99%, it effectively ruled out patients with life-threatening presentations who required ED care. The specificity and positive predictive value were 0.28 and 0.02, respectively.

IN PRACTICE 

“Our findings reinforce the safety of the 2023 Practice Parameter recommendations. Prospective refinement and validation of this model, along 
 with its clinical application, could help reduce unnecessary ED visits for children with anaphylaxis who can be safely managed in the community ,” the authors of the study wrote. 

SOURCE 

Timothy E. Dribin, MD, with the Cincinnati Children’s Hospital Medical Center, Cincinnati, was the corresponding author of the study, which was published online on June 24 in The Journal of Allergy and Clinical Immunology: In Practice.

LIMITATIONS 

The study considered the receipt of epinephrine after arrival at the ED as the primary outcome, despite the known underuse of epinephrine in practice. The findings were limited to children with predominantly food-triggered reactions and may not have been extended to adults or nonfood triggers.

DISCLOSURES 

The research was supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health. One of the authors reported holding stock options and receiving advisory board or consulting fees, royalties, and research support from multiple sources. Detailed disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.