SELECTED ARTICLES FROM THE RECENT LITERATURE 2005
12/6/05
Emergency Department treatment of insect sting reactions
Summary
Background – National guidelines recommend Emergency Dept (ED) treatment with epinephrine (Epi) injection for systemic anaphylaxis reactions to hymenoptera insect stings. Previous studies have suggested under utilization of Epi injection for An reactions induced by other allergens.
Findings – Clark et al of the Massachusetts General Hospital in Boston, MA, and other institutions carried out a chart review study of the treatment in 15 N. American ED units of systemic anaphylactic reactions to insect sting. Most patients with such reactions were stung within 6 hours of arrival in the ED.
The authors found that 69% of these patients were treated with antihistamines, 50% received systemic corticosteroids and 12% received Epi injections. Almost all (95%) of these patients were discharged to home, with 27% having received a prescription for self-injected Epi. In only 20% of cases was there referral to an allergist.
Reference
J Allergy Clin Immunol 2005;116:643-9 Editor's Comments
Experts in the treatment of anaphylaxis, particularly that induced by insect stings, agree that an injection of Epi should be given as soon as possible. Antihistamines are considered to have an ancillary role while corticosteroids (even given IV) work too slowly to combat the early, potentially fatal manifestations of.anaphylaxis The findings described above suggest that ED physicians either are not sufficiently aware of such recommendations or have a different therapeutic philosophy in such cases. Since almost all the patients surveyed were discharged from the ED to home, one could argue that the use of Epi in only 12% of cases indicates that immediate Epi use is not really that essential. Guidelines published recently by a committee of the European Avademy of Allergy and Clinical Immunology stated that mild-moderate systemic insect sting reactions limited to skin manifestions could be controlled by antihistamines (w/wo corticosteroids) without Epi injections. However, multi-organ involvement in anaphylaxis can follow quite rapidly after what appears to be just skin manifestations. All one needs is one catastrophic outcome (death or severe morbidity) to convince treating physicians about the need for early Epi treatment.
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