Updated anaphylaxis guidelines: management in infants and children

A novel scoring system for early prediction of massive transfusion requirement in trauma patients

Early resuscitation using blood products is critical for patients with severe hemorrhagic shock. We aimed to develop and validate a new scoring system, hemorrhagic shock transfusion prediction (HSTP) score, to predict the need for massive transfusion (MT) in these patients, compared to the widely used Assessment of Blood Consumption (ABC) score. Trauma patients admitted to Emtiaz Hospital in Iran from 2017 to 2021 were retrospectively included. Patients assigned a code 1 or 2 according to the Emergency severity index (ESI) triage system have been divided into MT and non-MT groups. MT was defined as receiving ≥ 10 units of packed cells (PCs) in 24 h. Demographic information, admission vital signs, and lab results available within 15 min were compared between the groups. A new predictive score was developed using logistic regression of statistically significant parameters. Out of 1029 patients, 651 (63.3%) required MT. An arrival, diastolic blood pressure < 79.5 mm Hg, absolute lymphocyte count > 1850/μL, base excess < - 4.25, and blood glucose > 156 mg/dL were independent predictors included in the HSTP score. The sensitivity and specificity were 74.36% and 53.87% for the HSTP score, compared to 31.03% and 76.16% for the ABC score. Moreover, the positive and negative predictive values were 77.88% and 49.03% for the HSTP score, versus 74.15% and 33.66% for ABC. The new scoring system demonstrated higher sensitivity and improved positive and negative predictive values compared to the ABC score. This score can assist physicians in making accurate transfusion decisions quickly, but further prospective studies are warranted to validate its clinical utility.

Impact of public health interventions for food allergy prevention on rates of infant anaphylaxis

BACKGROUND

Eleven percent of Australian infants have confirmed food allergy. We hypothesized earlier introduction may lead to higher rates of infant anaphylaxis, irrespective of whether the overall rate of food allergy in the population was ultimately reduced.

OBJECTIVE

To determine whether a public health campaign, targeting earlier introduction of allergenic foods, affected rates of infant anaphylaxis.

METHODS

Data were obtained from St John Ambulance (SJA) Western Australia and Western Australian emergency departments (ED) on infant (≤12 months) anaphylaxis over a 5-year period (July 1, 2015 to June 30, 2020). Adrenaline administration data were collected in the SJA dataset. Poisson regression was undertaken to assess trends in anaphylaxis over time. Segmented regression analysis was undertaken to assess differences in anaphylaxis rates before and after intervention.

RESULTS

The SJA and ED datasets included 172 and 294 events, respectively, coded as infant anaphylaxis. Rates of infant anaphylaxis increased over time for both SJA and ED datasets, with a 1-year increase rate ratio of 1.21 (95% confidence interval, 1.09-1.35; P value < .01) and 1.11 (95% confidence interval, 1.02-1.20; P = .01), respectively. Segmented regression indicated no significant difference in rates after intervention. Adrenaline was not coded as being administered in 109 of the 172 anaphylaxis events.

CONCLUSION

Rates of infant anaphylaxis increased over the 5-year reporting period; however, there was no clear increase related to the timing of the public health campaign implementation. Reported adrenaline use was suboptimal. Assessing rates of food allergy in all age groups is required to determine whether there has been an overall reduction in food allergy owing to the intervention.

Who Needs Epinephrine? Anaphylaxis, Autoinjectors, and Parachutes

International guidelines stipulate that intramuscular (IM) epinephrine (adrenaline) is the first-line treatment for anaphylaxis, with an established good safety profile. The availability of epinephrine autoinjectors (EAI) has greatly facilitated the lay administration of IM epinephrine in community settings. However, key areas of uncertainty remain around epinephrine usage. These include variations in prescribing EAI, what symptoms should prompt epinephrine administration, whether emergency medical services (EMS) need to be contacted after administration, and whether epinephrine administered via EAI reduces mortality from anaphylaxis or improves quality of life measures. We provide a balanced commentary on these issues. There is increasing recognition that a poor response to epinephrine, particularly after 2 doses, is a useful marker of severity and the need for urgent escalation. It is likely that patients who respond to a single epinephrine dose do not require EMS activation or emergency department transfer, but data are needed to demonstrate the safety of this approach. Lastly, patients at risk of anaphylaxis must be counseled against over-reliance on EAI alone.

Controls of Central and Peripheral Blood Pressure and Hemorrhagic/Hypovolemic Shock

The pressure exerted on the heart and blood vessels because of blood flow is considered an essential parameter for cardiovascular function. It determines sufficient blood perfusion, and transportation of nutrition, oxygen, and other essential factors to every organ. Pressure in the primary arteries near the heart and the brain is known as central blood pressure (CBP), while that in the peripheral arteries is known as peripheral blood pressure (PBP). Usually, CBP and PBP are correlated; however, various types of shocks and cardiovascular disorders interfere with their regulation and differently affect the blood flow in vital and accessory organs. Therefore, understanding blood pressure in normal and disease conditions is essential for managing shock-related cardiovascular implications and improving treatment outcomes. In this review, we have described the control systems (neural, hormonal, osmotic, and cellular) of blood pressure and their regulation in hemorrhagic/hypovolemic shock using centhaquine (Lyfaquin^®) as a resuscitative agent.