• anaphylaxis
• anaphylactic shock
• adrenaline
• epinephrine
• neurocardiogenic syncope

Anaphylaxis today still generates as much excitement, fear, rhetoric, and ripostes as it must have done for Charles Richet and Paul Portier at the turn of the 19th century. While they were guests on board Prince Albert of Monaco’s yacht in the Mediterranean, they reported on their experiments on dogs rechallenged with Physalia extracts, and first coined the phrase “anaphylaxis”, literally meaning “against protection”, when some dogs unexpectedly died. Since then, anaphylaxis has come to symbolise one of medicine’s great clinical bedside challenges, demanding rapid recognition without the benefit of an immediate laboratory test, and urgent management to avert a potentially fatal outcome usually in an otherwise healthy, young patient. Its evanescent nature has mitigated against the development of a solid scientific database to guide clinicians, and has generated as spiritedly polarised views on management as any therapeutic topic. No more so than when the use, dose, and delivery of adrenaline (epinephrine) is being argued.

Brown et al in this issue contribute reliable clinical evidence supporting the use of carefully titrated intravenous adrenaline with volume resuscitation for treating significant anaphylaxis.¹ In their case this followed jack jumper ant (Myrmecia pilosula) sting challenge on 68 healthy volunteers in Tasmania known to have a history of hypersensitivity to this ant. Their original paper in the Lancet attested to the efficacy of the ant venom immunotherapy they had developed,² while this paper reporting on the same group of patients describes in detail their management. All received a sting challenge, and in a randomised, double blind protocol they received either venom immunotherapy or placebo, followed …