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Background: Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged durations often prompt admission for ongoing observation., Methods: In a multidisciplinary quality improvement initiative, we revised our emergency department (ED) anaphylaxis clinical pathway. Our primary aim was to safely decrease the recommended length of observation from 8 to 4 hours and thereby decrease unnecessary hospitalizations. Secondary aims included provider education on anaphylaxis diagnostic criteria, emphasizing epinephrine as first-line therapy, and implementing a practice of discharging ED patients with an epinephrine autoinjector in hand. The study period consisted of the 18 months before pathway revision (baseline) and the 18 months after revision., Results: The overall admission rate decreased from 58.2% (106 of 182) in the baseline period to 25.3% (65 of 257) after pathway revision ( P < .0001). There was no significant difference in the percentage of patients returning to the ED within 72 hours, and there were no adverse outcomes or deaths throughout the study period. After pathway revision, the median time to first epinephrine administration for the most critical patients was 10 minutes, and 85.4% (164 of 192) of patients were discharged with an epinephrine autoinjector in hand., Conclusions: By revising an anaphylaxis clinical pathway, we were able to streamline the care of patients with anaphylaxis presenting to a busy pediatric ED, without any compromise in safety. Most notably, decreasing the recommended length of observation from 8 to 4 hours resulted in a near 60% reduction in the average rate of admission., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Anaphylaxis is a severe, generalized allergic or hypersensitivity reaction that is rapid in onset and may cause death. Epinephrine (adrenaline) can be life-saving when administered as rapidly as possible once anaphylaxis is recognized. This clinical report from the American Academy of Pediatrics is an update of the 2007 clinical report on this topic. It provides information to help clinicians identify patients at risk of anaphylaxis and new information about epinephrine and epinephrine autoinjectors (EAs). The report also highlights the importance of patient and family education about the recognition and management of anaphylaxis in the community. Key points emphasized include the following: (1) validated clinical criteria are available to facilitate prompt diagnosis of anaphylaxis; (2) prompt intramuscular epinephrine injection in the mid-outer thigh reduces hospitalizations, morbidity, and mortality; (3) prescribing EAs facilitates timely epinephrine injection in community settings for patients with a history of anaphylaxis and, if specific circumstances warrant, for some high-risk patients who have not previously experienced anaphylaxis; (4) prescribing epinephrine for infants and young children weighing <15 kg, especially those who weigh 7.5 kg and under, currently presents a dilemma, because the lowest dose available in EAs, 0.15 mg, is a high dose for many infants and some young children; (5) effective management of anaphylaxis in the community requires a comprehensive approach involving children, families, preschools, schools, camps, and sports organizations; and (6) prevention of anaphylaxis recurrences involves confirmation of the trigger, discussion of specific allergen avoidance, allergen immunotherapy (eg, with stinging insect venom, if relevant), and a written, personalized anaphylaxis emergency action plan; and (7) the management of anaphylaxis also involves education of children and supervising adults about anaphylaxis recognition and first-aid treatment., (Copyright © 2017 by the American Academy of Pediatrics.)

Objective: To determine the appropriate needle length for intramuscular injection of vaccines to early adolescents by measuring muscle depth at the deltoid injection site., Methods: Students from Nassau County, New York, and patients attending an adolescent clinic were invited to participate. Height, weight, and arm circumference were measured. BMI percentiles were obtained. Depths of muscle and bone underlying the deltoid injection site were measured by using ultrasonography while the deltoid area was bunched or flattened. A sufficiently long needle length was defined as greater than or equal to the skin-to-muscle depth plus 5 mm (based on measurement, no needle used). Too long was considered greater than or equal to skin-to-bone depth., Results: The age range of the 141 subjects was 11 to 15 years. Fifty-five percent were female. Twenty-six percent weighed <40 kg, and 20% were between 60 and 108 kg. The mean and median BMI percentiles were 58th and 62th, respectively, with 6% of the subjects at <10th percentile and 28% of subjects at >85th percentile. Using the bunch technique, we found that a 25-mm (1-in) needle is acceptable in 86% of subjects; in the subgroup of >or=60 kg, it is acceptable in 100% of subjects. A 16-mm (-in) needle is acceptable in 88%; in the subgroup of <60 kg, it is acceptable in 98% of subjects. Using the flatten technique, a 25-mm needle is acceptable in 39%; in the subgroup of >or=60 kg, it is acceptable in 93% of subjects. A 16-mm needle is acceptable in 92%; in the subgroup of <60 kg, it is acceptable in 96% of subjects., Conclusions: For intramuscular immunization of early adolescents, a 16-mm needle is appropriate for those weighing <60 kg, and a 25-mm needle is appropriate for those weighing 60 to 70 kg, using either technique.

Objective: Studies show that intramuscular epinephrine results in peak plasma concentrations of epinephrine faster than the subcutaneous route, and therefore, epinephrine is recommended to be administered intramuscularly. The objective of this study was to determine if the needle length on epinephrine auto-injectors is adequate to deliver epinephrine intramuscularly in children., Methods: Patients between the ages of 1 and 12 years who presented to a children's hospital were enrolled in the study. Ultrasound was used to determine the depth from the skin to the vastus lateralis muscle. The patient's body mass index was recorded. The data were analyzed using simple descriptive statistics, and logistic regression was used to identify variables that might predict whether or not the needle length was exceeded., Results: A total of 256 children were enrolled. Of these, 158 children weighed less than 30 kilograms and would be prescribed the 0.15 mg epinephrine auto-injector. Nineteen of these children (12%) had a skin to muscle surface distance of >(1/2)'' and would not receive epinephrine intramuscularly from current auto-injectors. There were 98 children weighing >or=30 kilograms who would receive the 0.3 mg epinephrine auto-injector. Of these 98 children, a total of 29 (30%) had a skin to muscle surface distance of >(5/8)'' and would not receive epinephrine intramuscularly., Conclusion: The needle on epinephrine auto-injectors is not long enough to reach the muscle in a significant number of children. Increasing the needle length on the auto-injectors would increase the likelihood that more children receive epinephrine by the recommended intramuscular route.

Objective: The US Centers for Disease Control and Prevention has needle-length recommendations for intramuscular vaccinations in the thigh and shoulder on the basis of the age of the child. Underpenetration of the intramuscular layer with short needles has been documented; however, few studies have focused on the risk for overpenetration of the intramuscular level with needles that are too long. The purpose of this study was to determine the optimal needle length for intramuscular vaccination of children of various ages and sizes at the shoulder and thigh levels by using MRI and computed tomography scan measurements., Methods: A total of 250 MRI and computed tomography scans of shoulders and thighs of children who were 2 months to 18 years of age at a large children's hospital were reviewed. The thicknesses of the subcutaneous fat tissue and muscle layers were measured. Measurements were correlated with age and weight, and regression analysis was performed., Results: Use of the Centers for Disease Control and Prevention's recommended 1- and 1 (1/4)-in needles for intramuscular vaccination in the thigh of children >/=1 year of age would result in 11% (11 of 100) and 39% (34 of 88) overpenetration, respectively, with a minimal risk for underpenetration at 2% (2 of 100). Patients with vaccinations in the shoulder with the Centers for Disease Control and Prevention-recommended 58-, 78-, and 1-in needles would experience 11% (16 of 150), 55% (83 of 150), and 61% (92 of 150) overpenetration, respectively., Conclusions: There is a substantial risk for overpenetration of the intramuscular layer when using current Centers for Disease Control and Prevention recommendations for vaccination needle lengths. We recommend a revision of the needle-length guidelines for thigh and shoulder injections to minimize the risk for needle overpenetration on the basis of the variability observed in the fat thickness.

In order to elucidate whether tissue damage produced on occasion by intramuscular injection of long-acting penicillin is due to accidental intra-arterial injection or vasospasm, two types of experiments were carried out in rabbits. In the first set of experiments, six New Zealand White rabbits were given intra-arterial injections of 0.4 mL of a mixture containing 300,000 U of penicillin G benzathine and 300,000 units of penicillin procaine per milliliter (Bicillin C-R) into the left femoral artery and 0.4 mL of normal saline into the right femoral artery as autocontrol. In a second set of experiments, 0.4 mL of the same penicillin preparation was injected in the space surrounding the left femoral artery in five New Zealand rabbits, and 0.4 mL of normal saline was injected in a similar fashion around the right femoral artery as control. The legs of the rabbits that received the intra-arterial injection of penicillin invariably developed ischemic manifestations. None of the legs of rabbits given intra-arterial injections of normal saline had pathologic manifestations. None of the rabbits that received the periarterial penicillin preparation or normal saline developed abnormalities. These results strongly suggest that the tissue damage produced by penicillin is secondary to the intra-arterial administration of the drug.