title: Multiple epinephrine doses for stinging insect hypersensitivity reactions treated in the emergency department.
abstract: BACKGROUND
  Data are sparse on epinephrine treatment for stinging insect hypersensitivity (SIH) reactions.
  
  
  OBJECTIVE
  To establish the frequency of receiving more than 1 dose of epinephrine in patients presenting to the emergency department (ED) with SIH reactions.
  
  
  METHODS
  We performed a medical record review of all 153 patients with SIH reactions presenting to 3 EDs in Boston, Massachusetts, between January 1, 2001, and December 31, 2006. Patients were identified by International Classification of Diseases, Ninth Revision (ICD-9) codes (989.5, 995.0, and 995.3). We focused on clinical presentations and treatments, including epinephrine treatments given before and during the ED visit.
  
  
  RESULTS
  The cohort was 54% male, with a median age of 33 years. Bees were the most frequently reported triggering insect (74%). A total of 59% of patients experienced large local reactions, whereas 36% had systemic reactions (10% cutaneous systemic and 26% anaphylaxis). The remaining 5% presented with normal local reactions to insect stings. Among patients with systemic reactions, 82% were stung within 3 hours of arrival at the ED. Most (60%) received treatments before arrival at the ED, including 26% who received epinephrine. While in the ED, these patients received antihistamines (76%), systemic corticosteroids (55%), and epinephrine (9%). Overall, 35% of patients with systemic reactions received epinephrine, and among this subset, 16% received more than 1 dose. Most patients with systemic reactions (67%) were discharged to home. At ED discharge, 68% received a prescription for self-injectable epinephrine, but only 11% had documentation of referral to an allergist.
  
  
  CONCLUSIONS
  Among patients with systemic SIH reactions who received epinephrine, 16% received a second dose. Physicians should consider prescribing 2 doses of self-injectable epinephrine for patients at risk for systemic SIH reactions.
authors.affiliation: Division of Allergy and Immunology, Children's Hospital Boston, Boston, Massachusetts, USA.
authors.forename: Susan A
authors.initials: SA
authors.lastname: Rudders
authors.forename: Aleena
authors.initials: A
authors.lastname: Banerji
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Katzman
authors.forename: Sunday
authors.initials: S
authors.lastname: Clark
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Camargo
mesh_terms: D000293:Adolescent; D000328:Adult; D000799:Angioedema; D000818:Animals; D001514:Bee Venoms / Q000009:adverse effects; D001516:Bees; D004334:Drug Administration Schedule; D004632:Emergency Medical Services; D004636:Emergency Service, Hospital; D004837:Epinephrine / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006801:Humans; D006969:Hypersensitivity, Immediate / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D007299:Insect Bites and Stings; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D014581:Urticaria
chemical_list: D001514:Bee Venoms; D004837:Epinephrine