Speed of treatment affects outcome in anaphylaxis

Editor—Sadana et al give undue emphasis to the role of intravenous adrenaline in the treatment of acute anaphylaxis,¹ which detracts from the essential points made by Hughes and Fitzharris in their article on managing anaphylaxis.² The problem is not how to give adrenaline but to ensure that first responders give this life saving drug early, rather than just giving steroids and antihistamines.

An internal audit carried out in this hospital among 28 junior doctors of all specialties who would be called on to treat anaphylaxis in an emergency showed that only 15 (54%) knew how to do so appropriately, by giving adrenaline first and at the correct dose. Asked specifically about giving adrenaline for anaphylaxis of moderate severity, 11 (39%) would give it intravenously, 11 (39%) intramuscularly, and six (21%) subcutaneously.

Of major concern was that six doctors would have used an intravenous adrenaline dilution of 1:1000, and, as if to emphasise this danger, a 23 year old man was admitted under my care recently with ventricular tachycardia after an intravenous injection of 1:1000 adrenaline given for mild anaphylaxis. There is no question over the use of appropriately diluted intravenous adrenaline in life threatening anaphylaxis or during anaesthesia, but these are the minority of cases that are seen,³ and the Resuscitation Council has addressed appropriate treatment with simplicity and clarity.⁴ It is the speed of treatment that affects outcome, and it is more important that our front line staff know the essentials of anaphylaxis treatment rather than hesitate as they try and absorb the finer points of complex flow charts⁵ or await the decision of experienced senior doctors. Initial adrenaline in the quadriceps is better than cardiac arrest after overzealous and incorrect use of intravenous adrenaline—or death with no adrenaline given at all.