Epinephrine For Anaphylaxis Research Articles

Epinephrine Auto-Injector Versus Drawn Up Epinephrine for Anaphylaxis Management: A Scoping Review*

Anaphylaxis is a life-threatening event. Most clinical symptoms of anaphylaxis can be reversed by prompt intramuscular administration of epinephrine using an auto-injector or epinephrine drawn up in a syringe and delays and errors may be fatal. The aim of this scoping review is to identify and compare errors associated with use of epinephrine drawn up in a syringe versus epinephrine auto-injectors in order to assist hospitals as they choose which approach minimizes risk of adverse events for their patients. PubMed, Embase, CINAHL, Web of Science, and the Cochrane Library were searched using terms agreed to a priori. We reviewed human and simulation studies reporting errors associated with the use of epinephrine in anaphylaxis. There were multiple screening stages with evolving feedback. Each study was independently assessed by two reviewers for eligibility. Data were extracted using an instrument modeled from the Zaza et al instrument and grouped into themes. Three main themes were noted: 1) ergonomics, 2) dosing errors, and 3) errors due to route of administration. Significant knowledge gaps in the operation of epinephrine auto-injectors among healthcare providers, patients, and caregivers were identified. For epinephrine in a syringe, there were more frequent reports of incorrect dosing and erroneous IV administration with associated adverse cardiac events. For the epinephrine auto-injector, unintentional administration to the digit was an error reported on multiple occasions. This scoping review highlights knowledge gaps and a diverse set of errors regardless of the approach to epinephrine preparation during management of anaphylaxis. There are more potentially life-threatening errors reported for epinephrine drawn up in a syringe than with the auto-injectors. The impact of these knowledge gaps and potentially fatal errors on patient outcomes, cost, and quality of care is worthy of further investigation.

Adrenaline overdose in pediatric anaphylaxis: a case report

BackgroundAdrenaline is the standard treatment for anaphylaxis but appropriate administration remains challenging, and iatrogenic overdose is easily overlooked. Despite the established importance of pediatric blood pressure measurement, its use remains inconsistent in clinical practice.Case presentationWe report a case of adrenaline overdose in a 9-year-old white boy with anaphylaxis, where signs of adrenaline overdose were indistinguishable from progressive shock until blood pressure measurement was taken.ConclusionsThe consequences of under-dosing adrenaline in anaphylaxis are well-recognized, but the converse is less so. Blood pressure measurement should be a routine part of pediatric assessment as it is key to differentiating adrenaline overdose from anaphylactic shock.

Autoinjectors Preferred for Intramuscular Epinephrine in Anaphylaxis and Allergic Reactions.

IntroductionEpinephrine is the treatment of choice for anaphylaxis. We surveyed emergency department (ED) healthcare providers regarding two methods of intramuscular (IM) epinephrine administration (autoinjector and manual injection) for the management of anaphylaxis and allergic reactions and identified provider perceptions and preferred method of medication delivery.MethodsThis observational study adhered to survey reporting guidelines. It was performed through a Web-based survey completed by healthcare providers at an academic ED. The primary outcomes were assessment of provider perceptions and identification of the preferred IM epinephrine administration method by ED healthcare providers.ResultsOf 217 ED healthcare providers invited to participate, 172 (79%) completed the survey. Overall, 82% of respondents preferred the autoinjector method of epinephrine administration. Providers rated the autoinjector method more favorably for time required for training, ease of use, convenience, satisfaction with weight-based dosing, risk of dosing errors, and speed of administration (p<0.001 for all comparisons). However, manual injection use was rated more favorably for risk of provider self-injury and patient cost (p<0.001 for both comparisons). Three participants (2%) reported a finger stick injury from an epinephrine autoinjector.ConclusionED healthcare providers preferred the autoinjector method of IM epinephrine administration for the management of anaphylaxis or allergic reactions. Epinephrine autoinjector use may reduce barriers to epinephrine administration for the management of anaphylaxis in the ED.

P041 Availability and use of epinephrine for anaphylaxis in schools: results from the 2014-2015 EpiPen4Schools® survey

P041 Availability and use of epinephrine for anaphylaxis in schools: results from the 2014-2015 EpiPen4Schools® survey

Community Presentations of Anaphylaxis in Tasmania: Who is Administering the Adrenaline?

Background Anaphylaxis is a significant health concern within the community. The early administration of adrenaline to patients experiencing anaphylaxis has long been recognised as the cornerstone of treatment. Health-care providers, including general practitioners, nurses and paramedics, are well equipped to manage anaphylaxis through the administration of adrenaline. Patients themselves also often have adrenaline auto injectors, allowing early self-management. The objective of this study was to determine the rates of adrenaline administration and identify the administering persons for all anaphylaxis patients presenting to ambulance services in Tasmania from January 1st 2008 until December 31st 2011 by using a retrospective chart review. Methods Ambulance Tasmania electronic case reports (n=226 421) from the period January 1st 2008 to December 31st 2011 were searched for all cases fitting the parameters of anaphylaxis, allergy or allergic reaction. Of these cases, 373 were given a final paramedic diagnosis of anaphylaxis and constituted the primary data for this report. Results Ambulance Tasmania attended 373 patients during the study period that were given a final primary diagnosis of anaphylaxis - of these 59 (15.8%) were excluded, leaving 314 electronic records for analysis. Of the cases identified, 71.7% (n=225) were administered adrenaline according to paramedic records. Adrenaline was administered by a range of health professionals, including general practitioners (n=27), paramedics (n=159), ambulance volunteers (n=4), nurses (n=1) and other health professionals (n=3). Adrenaline was self-administered by 12.4% (n=28) of patients, with an additional 11.6% (n=26) receiving adrenaline from a non-health care worker (layperson). In 10.2% of cases (n=23) adrenaline was administered by more than one provider. Administration of adrenaline prior to paramedic arrival was evident in fewer than 10% of cases treated with adrenaline (n=22). Conclusion The early administration of adrenaline in anaphylaxis is often vital for patient recovery. This study shows that adrenaline is administered by a number of different providers, with early administration accounting for only 9.8% of presentations treated with adrenaline. These findings raise the question, is adrenaline being administered early enough and often enough to improve health outcomes?

Barriers to Treatment with Epinephrine for Anaphylaxis By School Nurses

Barriers to Treatment with Epinephrine for Anaphylaxis By School Nurses

Correct recognition and management of anaphylaxis: not much change over a decade

BackgroundAnaphylaxis is increasing in incidence. This potentially fatal condition requires immediate intramuscular adrenaline as a vital part of early treatment. A 2002 survey of UK Senior House Officers showed a...

Epinephrine in Anaphylaxis: Higher Risk of Cardiovascular Complications and Overdose After Administration of Intravenous Bolus Epinephrine Compared with Intramuscular Epinephrine

Epinephrine is the drug of choice for the management of anaphylaxis, and fatal anaphylaxis is associated with delayed epinephrine administration. Data on adverse cardiovascular (CV) complications and epinephrine overdose are limited. To compare rates of CV adverse events and epinephrine overdoses associated with anaphylaxis management between various routes of epinephrine administration among patients with anaphylaxis in the emergency department. This was an observational cohort study from April 2008 to July 2012. Patients in the emergency department who met diagnostic criteria for anaphylaxis were included. We collected demographics; route of epinephrine administration; trigger; overdose; and adverse CV events, including arrhythmia, cardiac ischemia, stroke, angina, and hypertension. The study cohort included 573 patients, of whom, 301 (57.6%) received at least 1 dose of epinephrine. A total of 362 doses of epinephrine were administered to 301 patients: 67.7% intramuscular (IM) autoinjector, 19.6% IM injection, 8.3% subcutaneous injection, 3.3% intravenous (IV) bolus, and 1.1% IV continuous infusion. There were 8 CV adverse events and 4 overdoses with 8 different patients. All the overdoses occurred when epinephrine was administered IV bolus. Adverse CV events were associated with 3 of 30 doses of IV bolus epinephrine compared with 4 of 316 doses of IM epinephrine (10% vs 1.3%; odds ratio 8.7 [95% CI, 1.8-40.7], P = .006). Similarly, overdose occurred with 4 of 30 doses of IV bolus epinephrine compared with 0 of 316 doses of IM epinephrine (13.3% vs 0%; odds ratio 61.3 [95% CI, 7.5 to infinity], P < .001). The risk of overdose and adverse CV events is significantly higher with IV bolus epinephrine administration. Analysis of the data supports the safety of IM epinephrine and a need for extreme caution and further education about IV bolus epinephrine in anaphylaxis.

2 Handfuls of Medication in 2 Hours Just to Let Him Talk

Repeated dose of adrenaline in anaphylaxis is limited evidence in clinical setting. Hence, the usage is depending on physician best interest and knowledge. We reported a case of repeated doses of adrenalin was given through nebulizer and intravenous in anaphylaxis. We believed the unusual circumstances of this case was likely to be repeated on some readers' clinical practice and this mode of treatment is an adjunct to consider in such cases especially in Emergency Department (ED). DOI: http://dx.doi.org/10.3329/bjms.v13i2.16100 Bangladesh Journal of Medical Science Vol.13(2) 2014 p.209-211

Legal Briefs

Twins (31 3/7 weeks) were born to a 31-year-old healthy mother with a pregnancy remarkable for an accidental administration of epinephrine at 10 3/7 weeks. The mother was experiencing severe hyperemesis gravidarum for which her physician ordered intravenous (IV) dolasetron mesylate (Anzemet®, sanofi-aventis, Bridgewater, NJ), but the outpatient nurse unintentionally administered epinephrine instead. The nurse gave the mother 1 mL of the 1:1,000 concentration of IV epinephrine. In adults, the dose of epinephrine for anaphylaxis is 1 mL of 1:1,000 solution intramuscularly or subcutaneously, and for cardiac arrest, it is 1 mL of 1:10,000 intravenously. The plaintiff experts pointed out that this mother received a concentration of epinephrine 10-fold higher than that used for cardiac arrest; for the 10-week fetuses, they were likewise exposed to a mega-dose. The mother immediately became pale and dizzy and developed chest pain, shortness of breath, tachycardia, and hypertension. An electrocardiograph showed a subendocardial myocardial infarction. A perinatologist closely observed the twins before and subsequent to this event. The twins were diamniotic monochorionic (DiMo) males as a result of in vitro fertilization (IVF). A week after the epinephrine administration, the mother experienced vaginal bleeding and an ultrasound showed a “possible subchorionic hematoma.” At 14 5/7 weeks’ gestation, 30 days after the epinephrine mishap, discordance was noted in the twin size (121 g and 96 g). The larger twin had polyhydramnios, for which 220 mL of red-brown amniotic fluid was removed. Both bladders were visible. No further amnioreduction was needed for the remainder of the pregnancy. The twin-to-twin transfusion syndrome (TTTS) met the least severe grade of the Quintero grading system (I of V). At 30 4/7 weeks’ gestation, the mother experienced a mild brownish discharge. On external monitoring, regular uterine contractions were occurring. The mother was admitted for IV tocolysis and antenatal steroids, …

Adrenaline auto-injectors for the treatment of anaphylaxis with and without cardiovascular collapse in the community

Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may cause death. Adrenaline (epinephrine) auto-injectors are recommended as the initial, potentially life-saving treatment of choice for anaphylaxis in the community, but they are not universally available and have limitations in their use. To assess the effectiveness of adrenaline (epinephrine) auto-injectors in relieving respiratory, cardiovascular, and other symptoms during episodes of anaphylaxis that occur in the community. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE (Ovid SP) (1950 to January 2012), EMBASE (Ovid SP) (1980 to January 2012 ), CINAHL (EBSCO host) (1982 to January 2012 ), AMED (EBSCO host) (1985 to January 2012 ), LILACS, (BIREME) (1980 to January 2012 ), ISI Web of Science (1950 to January 2012 ). We adapted our search terms for other databases. We also searched websites listing on-going trials: the World Health Organization International Clinical Trials Registry Platform, the UK Clinical Research Network Study Portfolio, and the meta Register of Controlled Trials; and contacted pharmaceutical companies who manufacture adrenaline auto-injectors in an attempt to locate unpublished material. Randomized and quasi-randomized controlled trials comparing auto-injector administration of adrenaline with any control including no intervention, placebo, or other adrenergic agonists were eligible for inclusion. Two authors independently assessed articles for inclusion. None of the 1328 studies that were identified satisfied the inclusion criteria. Based on this review, we cannot make any new recommendations on the effectiveness of adrenaline auto-injectors for the treatment of anaphylaxis. Although randomized, double-blind, placebo-controlled clinical trials of high methodological quality are necessary to define the true extent of benefits from the administration of adrenaline in anaphylaxis via an auto-injector, such trials are unlikely to be performed in individuals experiencing anaphylaxis because of ethical concerns associated with randomization to placebo.There is, however, a need to consider trials in which, for example, auto-injectors of different doses of adrenaline and differing devices are compared in order to provide greater clarity on the dose and device of choice. Such trials would be practically challenging to conduct. In the absence of appropriate trials, we recommend that adrenaline administration by auto-injector should still be regarded as the most effective first-line treatment for the management of anaphylaxis in the community. In countries where auto-injectors are not commonly used, it may be possible to conduct trials to compare administration of adrenaline via auto-injector with adrenaline administered by syringe and ampoule, or comparing the effectiveness of two different types of auto-injector.

The use of adrenaline autoinjectors by children and teenagers

Although adrenaline is recommended as first line treatment for anaphylaxis, it is often not utilized. There has been a debate about when adrenaline autoinjectors should be prescribed and how many should be dispensed. To see how many adrenaline autoinjectors were used during anaphylactic reactions and to determine why they were not used in situations where they were clinically indicated. Patients were recruited prospectively at 14 paediatric allergy clinics throughout UK. Participants completed a questionnaire covering demographic data, atopic status and details of allergic reactions in the previous year and reasons for using more than one device. A total of 969 patients were recruited of whom 466 (48.1%, 95% CI: 37.9-58.2) had had at least one reaction in the previous year; 245 (25.3%, 95% CI: 16.2-34.4) of these reactions were anaphylaxis. An adrenaline autoinjector was used by 41 (16.7%, 95% CI: 11.7-21.3) participants experiencing anaphylaxis. Thirteen participants received more than one dose of adrenaline, for nine of these a health professional gave at least one. The commonest reasons for using more than one were severe breathing difficulties (40%), lack of improvement with first dose (20%) and miss-firing (13.3%). The commonest reasons for not using adrenaline in anaphylaxis were 'thought adrenaline unnecessary' (54.4%) and 'unsure adrenaline necessary' (19.1%). Many with wheeze did not use their autoinjector. Adrenaline is used by only a minority of patients experiencing anaphylaxis in the community. Thirteen of the 41 patients with anaphylaxis who used their autoinjector needed another dose of adrenaline. Further research is needed to consider how to best encourage the usage of adrenaline when clinically indicated in anaphylaxis.

Assessing the competence of junior doctors to prescribe for children

Objective The National Services Framework for Children states that persons involved in handling medicines for children should be competent to do so. This report describes the development of a process to assess the competence of doctors to prescribe for children while proving educational support. Method A literature search, national guidance, local medication incidents and pharmacists interventions were analysed to determine areas of poor prescribing practices in children. An assessment paper was designed using hospital prescribing documentation to include common scenarios and practices involved in prescribing for children. The assessment paper was piloted and a marking scheme was developed to evaluate both standards of prescribing content and drug calculations. In addition an automatic referral would be made if any prescription was likely to result in patient harm. In addition to the assessment paper the doctors are given a copy of the hospital prescribing standards and the use of the British National Formulary for Children (BNFC) is allowed and recommended. Following marking, where standards are not met the individual and their educational supervisor is contacted with a copy of the completed paper and a feedback form. The feedback form contains the possible remedial options, including discussion with tutor and tutorial with a pharmacist. Doctors meeting standards are offered copies of the completed paper to add to their e-portfolios. Results The following areas of prescribing were targeted for testing on the assessment paper: documentation of allergies; drug dosing according to age in addition to weight or body surface area; selection of the correct dose for indication from the BNFC; selection and calculation of correct intravenous fluids for children; awareness of different strengths of liquid medications for children, including unlicensed medicines; drug calculations involving conversion of ml to mg and ratio strengths. From the pharmacist intervention record specific drugs had a higher trend of poor prescribing, namely paracetamol, co-amoxiclav and aciclovir. These were included in the questions. Return of papers is variable, 56% overall. Of the completed papers three quarters of the doctors achieved a good standard. 19.7% of the papers contained errors which had the potential to cause harm to a patient. These errors included selection of the incorrect strength or route of epinephrine for anaphylaxis, incorrect conversion from ml to mg. Selection of inappropriate intravenous fluids was a common error in doctors that had recently undertaken an adult rotation. Conclusion While the prescribing assessment was introduced to reduce errors, it is becoming more important as an educational tool. It is also evolving to becoming a source of evidence for the doctors of their ability to prescribe in children. The areas of poor prescribing from the assessment mirror the literature but give the opportunity to target the areas for educational intervention for both undergraduate medical students and postgraduate doctors working in paediatrics.

Epinephrine and its use in anaphylaxis: current issues

Epinephrine is a life-saving medication in the treatment of anaphylaxis, in which it has multiple beneficial pharmacologic effects. Here, we examine the evidence base for its primary role in the treatment of anaphylaxis episodes in community settings. We review the practical pharmacology of epinephrine in anaphylaxis, its intrinsic limitations, and the pros and cons of different routes of administration. We provide a new perspective on the adverse effects of epinephrine, including its cardiac effects. We describe the evidence base for the use of epinephrine in anaphylaxis. We discuss the role of epinephrine auto-injectors for treatment of anaphylaxis in community settings, including identification of patients who need an auto-injector prescription, current use of auto-injectors, and advances in auto-injector design. We list reasons why physicians fail to prescribe epinephrine auto-injectors for patients with anaphylaxis, and reasons why patients fail to self-inject epinephrine in anaphylaxis. We emphasize the primary role of epinephrine in the context of emergency preparedness for anaphylaxis in the community. Epinephrine is the medication of choice in the first-aid treatment of anaphylaxis in the community. For ethical reasons, it is not possible to conduct randomized, placebo-controlled trials of epinephrine in anaphylaxis; however, continued efforts are needed towards improving the evidence base for epinephrine injection in this potentially fatal disease.

Pharmacologic treatment of anaphylaxis: can the evidence base be strengthened?

To evaluate the evidence base for the pharmacologic treatment of anaphylaxis. In this review, we focus on four classes of medications (the alpha/beta-agonist epinephrine (adrenaline), H1-antihistamines, H2-antihistamines, and glucocorticoids) that are used in healthcare settings for the initial treatment of anaphylaxis. Epinephrine and many H1-antihistamines and glucocorticoids were introduced before the era of randomized controlled trials and before the era of evidence-based medicine. In anaphylaxis, no randomized controlled trials that are free from methodological problems and meet current standards have been performed with these medications, or with H2-antihistamines. The evidence base for epinephrine injection is stronger than the evidence base for use of other medications in anaphylaxis. Guidelines unanimously recommend prompt injection of epinephrine as the life-saving first-line medication in anaphylaxis; however, they differ in their recommendations for H1-antihistamines, H2-antihistamines, and glucocorticoids. Epinephrine is the only medication that is universally available for anaphylaxis treatment in healthcare settings worldwide. Paradoxically, it is underused in anaphylaxis treatment. For ethical reasons, there should never be a placebo-controlled trial of epinephrine in anaphylaxis. We discuss why the possibility of conducting randomized placebo-controlled trials with H1-antihistamines, H2-antihistamines, and particularly with glucocorticoids in anaphylaxis should be considered in order to improve the evidence base for treatment and guide clinical decision-making. We also describe the precautions that will be needed if randomized controlled trials are conducted in anaphylaxis.

Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock.

Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may cause death. Adrenaline is recommended as the initial treatment of choice for anaphylaxis. To assess the benefits and harms of adrenaline (epinephrine) in the treatment of anaphylaxis. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to March 2007), EMBASE (1966 to March 2007), CINAHL (1982 to March 2007), BIOSIS (to March 2007), ISI Web of Knowledge (to March 2007) and LILACS (to March 2007). We also searched websites listing ongoing trials: http://clinicaltrials.gov/, http://www.controlledtrials.com and http://www.actr.org.au/; and contacted pharmaceutical companies and international experts in anaphylaxis in an attempt to locate unpublished material. Randomized and quasi-randomized controlled trials comparing adrenaline with no intervention, placebo or other adrenergic agonists were eligible for inclusion. Two authors independently assessed articles for inclusion. We found no studies that satisfied the inclusion criteria. Based on this review, we are unable to make any new recommendations on the use of adrenaline for the treatment of anaphylaxis. Although there is a need for randomized, double-blind, placebo-controlled clinical trials of high methodological quality in order to define the true extent of benefits from the administration of adrenaline in anaphylaxis, such trials are unlikely to be performed in individuals with anaphylaxis. Indeed, they might be unethical because prompt treatment with adrenaline is deemed to be critically important for survival in anaphylaxis. Also, such studies would be difficult to conduct because anaphylactic episodes usually occur without warning, often in a non-medical setting, and differ in severity both among individuals and from one episode to another in the same individual. Consequently, obtaining baseline measurements and frequent timed measurements might be difficult, or impossible, to obtain. In the absence of appropriate trials, we recommend, albeit on the basis of less than optimal evidence, that adrenaline administration by intramuscular (i.m.) injection should still be regarded as first-line treatment for the management of anaphylaxis.

Anti-snake venom: use and adverse reaction in a snake bite study clinic in Bangladesh

Snakebites can present local or systemic envenomation, while neurotoxicity and respiratory paralysis are the main cause of death. The mainstay of management is anti-snake venom (ASV), which is highly effective, but liable to cause severe adverse reactions including anaphylaxis. The types of adverse reaction to polyvalent anti-snake venom have not been previously studied in Bangladesh. In this prospective observational study carried out between 1999 and 2001, in the Snake Bite Study Clinic of Chittagong Medical College Hospital, 35 neurotoxic-snake-bite patients who had received polyvalent anti-snake venom were included while the ones sensitized to different antitoxins and suffering from atopy were excluded. The common neurotoxic features were ptosis (100%), external ophthalmoplegia (94.2%), dysphagia (77.1%), dysphonia (68.5%) and broken neck sign (80%). The percentage of anti-snake venom reaction cases was 88.57%; pyrogenic reaction was 80.64%; and anaphylaxis was 64.51%. The common features of anaphylaxis were urticaria (80%); vomiting and wheezing (40%); and angioedema (10%). The anti-snake venom reaction was treated mainly with adrenaline for anaphylaxis and paracetamol suppository in pyrogenic reactions. The average recovery time was 4.5 hours. Due to the danger of reactions the anti-snake venom should not be withheld from a snakebite victim when indicated and appropriate guidelines should be followed for its administration.

Second symposium on the definition and management of anaphylaxis: Summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium

There is no universal agreement on the definition of anaphylaxis or the criteria for diagnosis. In July 2005, the National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network convened a second meeting on anaphylaxis, which included representatives from 16 different organizations or government bodies, including representatives from North America, Europe, and Australia, to continue working toward a universally accepted definition of anaphylaxis, establish clinical criteria that would accurately identify cases of anaphylaxis with high precision, further review the evidence on the most appropriate management of anaphylaxis, and outline the research needs in this area.

Appropriate use of epinephrine in anaphylaxis

We are submitting a case-based presentation illustrating medical errors in the use of epinephrine for the treatment of anaphylaxis. Readers will learn from mistakes made by other emergency caregivers in treating anaphylaxis. The article will specifically review the recommended use of epinephrine in the management of anaphylaxis. Four patients are presented who were seen in consultation by our outpatient allergy service. In all 4 cases, the history was suggestive of an episode of anaphylaxis in which emergency care providers mismanaged treatment. In 2 cases, the patients required ICU care after improperly receiving intravenous epinephrine. In the remaining 2 cases, epinephrine use was either omitted or significantly delayed in its administration. Our presentation includes a review of consensus statements regarding the treatment of anaphylaxis with particular regard to the use of epinephrine. We hope that this information will help prevent similar errors from harming other patients.

Treatment of acute anaphylaxis

Surviving the journey is a good prognostic indicator EDITOR,--Malcolm Fisher's article on acute anaphylaxis was prompted by an anecdote concerning a doctor's panic when his young daughter developed an acute allergic reaction.1 The father ended up “ranting and raving” in the emergency department because his daughter had not received adrenaline immediately. Fisher uses this scenario to underline the need for the rapid administration of adrenaline in anaphylaxis. Nevertheless, he freely admits that, with the protean …