Editor,—We have read with grave concern the project team's recommendations for the medical treatment of anaphylaxis¹ and believe very strongly that the advice against using intravenous adrenaline (epinephrine) is potentially very dangerous. We also find the omission of reference to guidelines for the management of anaphylaxis in the accident and emergency (A&E) department published in the same journal² as very regrettable if deliberate, or puzzling if the project team had no knowledge of their existence.

The project team's guidelines have also failed to emphasise the relevance of grading the severity of anaphylaxis and that its treatment should be directed to the severity of the attack encountered.

We agree that the project team's guidelines should be used by the inexperienced and invariably pre-hospital responders. We also agree that the subcutaneous route is unreliable and should be abandoned. However, to suggest that A&E seniors or supervised trainees and well supported juniors lack clinical credibility to administer high dilution intravenous epinephrine carefully titrated against response in the fully monitored patient in the resuscitation room is insulting to the specialty of A&E. It also shows that in spite of having A&E representation the project team fails to understand fundamental principles of …