A 31-center retrospective cohort study derived and validated a clinical prediction model to identify children (6 months to <18 years) who received one pre-ED dose of epinephrine for allergic reactions (2016–2019) and were at risk of needing further epinephrine after ED arrival.
15.7% (364/2318) of children received epinephrine after ED arrival. In external validation, 30% (65/216) of encounters were classified as low risk. The model (any risk factor present) had sensitivity 0.93, specificity 0.35, PPV 0.25, and NPV 0.95 for predicting post-ED epinephrine need.
- Retrospective design limits causal inference and may introduce selection/documentation bias. - External validation used only 10% of the cohort (n=216), which is a small sample for robust generalizability. - Low specificity (0.35) means many children flagged as high risk would still be sent to the ED unnecessarily.
Children with anaphylaxis who received one pre-hospital epinephrine dose and have **none** of the following risk factors — asthma history, cardiovascular symptoms before epinephrine, persistent symptoms after epinephrine, or any new/recurrent respiratory, cardiovascular, GI, or non-specific post-epinephrine symptoms — may be candidates to safely avoid an ED visit (NPV 0.95). Clinicians should use this tool cautiously until prospective validation is available.
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