Brittany Boswell

All Publications

• Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. The Lancet. Child & adolescent health Dribin, T. E., Sampson, H. A., Zhang, Y., Boyd, S., Zhang, N., Michelson, K. A., Neuman, M. I., Brousseau, D. C., Mistry, R. D., Freedman, S. B., Aronson, P. L., Bergmann, K. R., Boswell, B., Chinta, S. S., Chua, W. J., Cohen, A. R., Cohen, J. S., Daggett, A., Davis, J. R., Freeman, J. F., Khanna, K., Knoles, C. L., Kwan, K. Y., Larsen, C. D., Lee, J., Lubell, T. R., Metcalf, A. M., Moake, M. M., Nesiama, J. O., Ngo, T. L., Pulcini, C. D., Russo, C. J., Singh, N. V., Srivastava, G., Strutt, J., Thapar, V., Wyst, C. V., Walsh, P. S., Wolnerman, Y., Schnadower, D. 2025; 9 (7): 484-496

  Abstract

  Children presenting to the emergency department with anaphylaxis typically receive at least one dose of epinephrine and are observed in the emergency department or monitored for recurrent (biphasic anaphylaxis) or persistent symptoms on hospital wards for variable durations before discharge is considered safe. We aimed to calculate the incidence rate and timing of repeat epinephrine dosing to determine the observation threshold at which the cumulative incidence of repeat epinephrine was less than 2% for every 1 h increase in observation time.This multicentre, retrospective cohort study across 30 emergency departments in the USA and one emergency department in Canada included children aged 6 months to 17 years who, according to electronic medical records, presented to one of the participating emergency departments with an acute allergic reaction that was treated with intramuscular, subcutaneous, or intravenous epinephrine before arrival at the emergency department or in the emergency department between Jan 1, 2016, and Dec 31, 2019. We excluded patients who had no documentation of symptoms or examination findings before presenting to the emergency department, were transferred from outside health-care facilities, had reactions secondary to medications administered in the emergency department, or had comorbidities requiring tailored management decisions. Demographics, medical history, and emergency department revisits within 72 h of discharge were extracted from electronic medical records. The primary outcome was the time from first to last administration of epinephrine. For patients on intravenous epinephrine infusions, the relevant time interval was from infusion initiation to discontinuation. Kaplan-Meier analyses were used to compare time to last epinephrine dose by initial reaction severity, stratified by respiratory and cardiovascular involvement (no respiratory or cardiovascular involvement, respiratory but no cardiovascular involvement, and cardiovascular involvement).Of 7717 patients with ICD-10 Clinical Modification codes for anaphylaxis, 5641 were eligible for inclusion (median age 7·9 years [IQR 3·3-13·1]; 2475 [43·9%] female; 3166 [56·1%] male). Of the 5139 patients who reported ethnicity, 1131 (22·0%) identified as Hispanic and 4008 (78·0%) identified as non-Hispanic. 263 (4·7%) of 5641 patients received a repeat epinephrine after 2 h of the first dose, whereas 109 (1·9%) received repeat epinephrine after 4 h, 64 (1·1%) after 6 h, and 46 (0·8%) after 8 h. The observation period at which the increase in cumulative incidence of repeat epinephrine was less than 2% was 115 min (95% CI 105-122) for all patients, 105 min (54-135) for patients without respiratory or cardiovascular involvement (n=1070), 109 min (98-118) for patients with respiratory but no cardiovascular involvement (n=4076), and 161 min (125-249) for patients with cardiovascular involvement (n=495). These findings suggest that 5378 (95·3%) patients in our cohort would have been safely discharged 2 h after receiving the first epinephrine dose and that 5532 (98·1%) patients would have been safely discharged 4 h after the first epinephrine dose.A 2-h observation period is probably safe for most children who present to an emergency department with an acute allergic reaction requiring epinephrine. A 4-h observation period might be enough for patients with cardiovascular involvement who appear well.The National Center for Advancing Translational Sciences and The National Institute of Allergy and Infectious Diseases of the National Institutes of Health.

  View details for DOI 10.1016/S2352-4642(25)00139-7

  View details for PubMedID 40506197

• Pediatric Emergency Medicine Didactics and Simulation: JumpSTART Secondary Triage for Mass Casualty Incidents. Cureus Tan, Y. T., Shin, C. K., Park, B., Bharath, A., Wing, R., Monteilh, C., Sanseau, E., Boswell, B., Pearce, J. I., Luetje, M., Enriquez, B., Cicero, M., Thomas, A. 2023; 15 (6): e40009

  Abstract

  Mass casualty incidents (MCI), particularly involving pediatric patients, are high-risk, low-frequency occurrences that require exceptional emergency arrangements and advanced preparation. In the aftermath of an MCI, it is essential for medical personnel to accurately and promptly triage patients according to their acuity and urgency for care. As first responders bring patients from the field to the hospital, medical personnel are responsible for prompt secondary triage of these patients to appropriately delegate hospital resources. The JumpSTART triage algorithm (a variation of the Simple Triage and Rapid Treatment, or START, triage system) was originally designed for prehospital triage by prehospital providers but can also be used for secondary triage in the emergency department setting. This technical report describes a novel simulation-based curriculum for pediatric emergency medicine residents, fellows, and attendings involving the secondary triage of patients in the aftermath of an MCI in the emergency department. This curriculum highlights the importance of the JumpSTART triage algorithm and how to effectively implement it in the MCI setting.

  View details for DOI 10.7759/cureus.40009

  View details for PubMedID 37425609

  View details for PubMedCentralID PMC10322648

• Emerging Therapies in Anaphylaxis: Alternatives to Intramuscular Administration of Epinephrine CURRENT ALLERGY AND ASTHMA REPORTS Boswell, B., Rudders, S. A., Brown, J. C. 2021; 21 (3): 18

  Abstract

  Anaphylaxis is a severe, life-threatening, systemic allergic reaction that should be recognized and treated promptly. Intramuscular (IM) epinephrine is the first-line treatment for anaphylaxis and there are no absolute contraindications to its use. Despite its established track record of efficacy and safety, physicians and patients face barriers in the recognition and treatment of anaphylaxis, including the maintenance and appropriate use of epinephrine auto-injectors. This has led to investigation into potential alternatives to IM epinephrine administration in anaphylaxis.This review investigates the current standard of care in the treatment of anaphylaxis, barriers to IM epinephrine use, and alternative therapies under investigation for administration in anaphylaxis. Alternative routes under investigation include intranasal, sublingual, inhaled, and needle-free intramuscular administration of epinephrine. There are currently numerous investigational alternatives to IM epinephrine therapy which could hold promise as future effective treatments in the emergent management of anaphylaxis.

  View details for DOI 10.1007/s11882-021-00994-0

  View details for Web of Science ID 000626588000005

  View details for PubMedID 33666759

  View details for PubMedCentralID 3500036