Discrepancies in Anaphylaxis Protocols Across Emergency Medical Services in the United States - Opportunities for Improvement.

Background: Across the United States, there are significant inconsistencies in the protocols used by Emergency Medical Services (EMS) in the prehospital treatment of anaphylaxis. These discrepancies include variations in the definition of anaphylaxis as well as treatment recommendations.

Objective: This study performed an analysis of statewide anaphylaxis protocols to identify gaps in the recognition of anaphylaxis and to provide areas for improvement in prehospital management.

Methods: States with mandatory or model state-wide protocols were included (total of 30). Each allergic reaction and/or anaphylaxis protocol was reviewed - emphasis was placed on the definitions used to identify reactions and treatment algorithms.

Results: Of the 30 states, only 50% (15) included gastrointestinal symptoms in the definition of anaphylaxis, and only 40% (12) included neurologic manifestations. 47% (14) used a two-organ system definition. For anaphylactic reactions, 100% (30) of protocols recommended diphenhydramine and epinephrine. 90% (27) recommended albuterol if respiratory symptoms were present, and 60% (18) recommended steroids. Epinephrine was the first line recommendation for anaphylaxis in 97% (29) of protocols. 25 states (83%) allowed epinephrine autoinjectors and 17 (57%) provided autoinjectors.

Conclusion: Many EMS anaphylaxis protocols are incomplete and/or outdated. Many protocols do not consider gastrointestinal or neurologic manifestations. Additionally, many contain outdated recommendations, including the use of steroids and first-generation antihistamines. Despite the convenience of epinephrine autoinjectors, many protocols do not permit or provide them. Given the frequency of EMS activation for allergic reactions, our communities would benefit from standardized protocols using current evidence-based guidelines for the management of anaphylaxis.