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BMJ 2009; 339 doi: (Published 16 July 2009) Cite this as: BMJ 2009;339:b1978
  1. Ricardo Jorge Paixão José, specialty trainee1,
  2. Haseeb Chaudhary, fifth year medical student2,
  3. Huw Steven Jenkins, consultant in respiratory and general medicine3
  1. 1Department of Medicine, Royal Bolton Hospital, Bolton BL4 0JR
  2. 2School of Medicine, University of Manchester
  3. 3Broomfield Hospital, Chelmsford CM1 7ET

Acute management and use of adrenaline in adults

The incidence of anaphylaxis in the United Kingdom is unknown but estimated to be between 10-20 cases per 100 000 population a year, with half of these iatrogenic.1 About 20 deaths are reported a year and a series of complications and deaths have been reported as a result of the administration of adrenaline (epinephrine).2 Case studies have reported complications after the incorrect administration of adrenaline, including acute myocardial infarction and ventricular tachycardia, even with low dose intravenous adrenaline (0.1mg 1:10 000).34

Confusion exists among junior doctors about the dose and route of administration of adrenaline in anaphylaxis.56 A survey in the United Kingdom found that almost all junior doctors would use adrenaline as the life saving drug of choice but only 16.8% would give it as recommended by the UK Resuscitation Council.5

After it was found that training in resuscitation and intensive care were neglected in UK undergraduate education, the acute care undergraduate teaching initiative was developed in 2005 to improve the care of acutely ill patients. One of the important competencies is to recognise and start treatment for an anaphylactic reaction.7

Box 1: Symptoms and signs of anaphylaxis

  • Erythema

  • Urticaria

  • Angio-oedema

  • Cough

  • Dyspnoea

  • Wheeze

  • Chest tightness

  • Dizziness

  • Collapse

  • Tachycardia

  • Hypotension

  • Shock

  • Nausea and vomiting

  • Cramping

  • Bloating

  • Diarrhoea

What is anaphylaxis?

Anaphylaxis is a type I IgE mediated hypersensitivity reaction to an allergen that leads to degranulation of mast cells and basophils, which release inflammatory mediators (leukotrienes and histamine), leading to the clinical features of anaphylaxis.8 Anaphylactoid reactions are non-IgE mediated reactions but the clinical presentation of the two is indistinguishable and the treatment is the same.8 From a clinical perspective anaphylaxis is a systemic allergic reaction with life threatening features. Life threatening respiratory features are laryngeal oedema and bronchospasm. Life threatening cardiovascular features …

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