128 EDITORIAL Emerg Med J: first published as 10.1136/emj.2003.009639 on 26 February 2004. Downloaded from Anaphylaxis Neurocardiogenic syncope, vasode- ...... pressor or vasovagal syncope, is notable for its variable afferent limb and thresh- old, with triggers ranging from posture, Anaphylaxis gets the adrenaline going pain, fear, and psychological stress to the use of vasodilators, inferior myocar- A F T Brown dial ischaemia (Bezold-Jarisch reflex), and severe haemorrhage. However, the ...... efferent response is uniform with a vagally mediated bradycardia, and para- Andrenaline and now for anaphylactic shock doxical vasodilatation with the con- current interruption of sympathetic naphylaxis today still generates as systemic reactions from 29 patients in vasoconstriction.3 Thus sensory input much excitement, fear, rhetoric, the placebo group, eight were grade IV from arterial baroreceptors as well as Aand ripostes as it must have done or severe according to the grading cardiac mechanoreceptors appear to for Charles Richet and Paul Portier at system developed by Mu˝ller,with fea- modulate the balance of the parasympa- the turn of the 19th century. While they tures of hypotension, collapse, loss of thetic and sympathetic nervous systems. were guests on board Prince Albert of consciousness, incontinence of urine or A neurocardiogenic mechanism was Monaco’s yacht in the Mediterranean, faeces, or cyanosis. Three were grade III further supported by a dramatic they reported on their experiments on reactions manifesting dyspnoea, wheeze response to intravenous atropine dogs rechallenged with Physalia or stridor and two or more of dysphagia, 600 mg in two of Brown’s most parlous extracts, and first coined the phrase dysarthria, hoarseness, weakness, con- patients in virtual cardiac arrest. Rather ‘‘anaphylaxis’’, literally meaning fusion, or a feeling of impending dis- than ascribing this to near terminal ‘‘against protection’’, when some dogs aster, and the remaining 10 had grade II hypoxia, the successful use of atropine unexpectedly died. Since then, anaphy- (three patients) or grade I (seven in these situations to counter vagal tone laxis has come to symbolise one of patients) reactions. There is no question, deserves further study. ’s great clinical bedside chal- this really was significant anaphylaxis Neurocardiogenic syncope may also lenges, demanding rapid recognition being studied, enough to make even the explain Pumphrey’s personal observa- without the benefit of an immediate most torporous ED coming off tions on 214 anaphylactic fatalities, laboratory test, and urgent management a long nightshift galvanise back into where some deaths clearly followed a to avert a potentially fatal outcome action! change in the victim’s posture to a more usually in an otherwise healthy, young Brown’s results highlight some upright position, either sitting or stand- patient. Its evanescent nature has miti- important features about anaphylaxis ing.4 He exhorts us to keep victims of gated against the development of a solid of relevance to us all, some of which are anaphylaxis lying down, even those self scientific database to guide clinicians, already recognised, some merely administering adrenaline, and to sup- and has generated as spiritedly polarised assumed to be true and some would be port or raise their legs to maintain vena views on management as any therapeu- less well known, even surprising. Thus, caval filling at all costs. tic topic. No more so than when the use, all his patients developed cutaneous What Brown did show unequivocally dose, and delivery of adrenaline (epi- features albeit often subtle, such as was the efficacy of intravenous adrena- nephrine) is being argued. erythema, itch or urticaria, which high- line and fluid to successfully treat all his http://emj.bmj.com/ Brown et al in this issue contribute light an essential diagnostic spectrum subjects with anaphylactic shock, with- reliable clinical evidence supporting the that must always be looked for as out the use of any antihistamines or use of carefully titrated intravenous corroborating evidence of the possibility corticosteroids in the acute phase. The adrenaline with volume of anaphylaxis, whether by properly adrenaline was given cautiously at a for treating significant anaphylaxis.1 In undressing the patient in the resusci- dilution of 1:100 000 (that is,10 mg/ml), their case this followed jack jumper ant tation room; or by the anaesthetist starting at 5–15 mg/min to a total dose of (Myrmecia pilosula) sting challenge on 68 peering under the surgical drapes in around 5–20 mg/kg, with more adrena- on September 24, 2021 by guest. Protected copyright. healthy volunteers in Tasmania known theatre, as the patient suddenly loses line being required the more severe the to have a history of hypersensitivity to their blood pressure or develops raised hypotension. This approach gratifyingly this ant. Their original paper in the airway pressures. supports the hereto intuitive (non-evi- Lancet attested to the efficacy of the ant The hypotensive anaphylactic reac- dence based) recommendations of sev- venom immunotherapy they had devel- tions Brown measured in the most eral authors including this editorial’s oped,2 while this paper reporting on the severe group were characterised by an writer.5 It also supports the perennial same group of patients describes in initial fall in diastolic blood pressure warning of others to always administer detail their management. All received a from systemic vasodilatation, followed adrenaline for significant anaphylaxis sting challenge, and in a randomised, by a drop in systolic pressure too, with with care, suitably diluted, given slowly double blind protocol they received mean arterial pressures ranging from and titrated against response in an either venom immunotherapy or pla- zero (unrecordable) to 55 mm Hg (with adequately monitored patient.6 cebo, followed by resuscitation in a a median at 45 mm Hg). All these The limitations of Brown’s paper are supervised resuscitation area. The ensu- patients were initially tachycardic, but to be aware that certain patients were ing sometimes dramatic reactions were of interest all then developed a relative excluded from the study as mentioned suffered almost exclusively by the pla- bradycardia as hypotension ensued, previously, and that as there were few cebo group, and were to an extent with heart rates from 15–65 per minute life threatening respiratory compli- ameliorated by the study exclusion (median 32). The mechanism of this cations, extrapolating the universal criteria that had eliminated volunteers bradycardia is consistent with neuro- success of intravenous adrenaline with hypertension, heart disease, poorly cardiogenic syncope as suggested by to all forms of severe anaphylaxis, controlled lung disease, ACE inhibitor or Brown, although it is not possible to although highly likely to be efficacious, b blocker therapy, and age less than 17 exclude direct ant venom mediator still effectively remains an eminence or over 65 years. None the less, of the 21 effects on the heart. based recommendation. Likewise, there

www.emjonline.com EDITORIAL 129 Emerg Med J: first published as 10.1136/emj.2003.009639 on 26 February 2004. Downloaded from seemed to be no clear answer as to how specialist until day 4 when the serious, Emerg Med J 2004;21:128–129. much fluid should be being given at the true infective diagnosis was rapidly doi: 10.1136/emj.2003.010652 same time for hypotension, with made. As the authors pointed out, a Correspondence to: A F T Brown, Department Brown’s dose comparatively small at delay in diagnosing orbital cellulitis of , Royal Brisbane one litre of normal saline (with only contributes to a higher rate of serious , Brisbane, QLD 4029, Australia; one patient receiving a total of three complications such as blindness or even [email protected] litres). Also, as Brown mentions, the death from cavernous venous thrombo- Conflicts of interest: none declared. early use of intramuscular adrenaline, sis. A useful table highlighting the particularly prehospital or in the un- differences expected between an infective REFERENCES monitored patient, still warrants direct or allergic presentation of periorbital 1 Brown SGA, Blackman KE, Stenlake V, et al. comparison with intravenous adrenaline swelling is given, and the authors empha- Insect sting anaphylaxis; prospective evaluation of to quantify their relative efficacy com- sise the pivotal role of the CT scan in treatment with intravenous adrenaline and volume resuscitation. Emerg Med J 2004;21:149–54. pared with complication rates. investigating suspected orbital cellulitis. 2 Brown SGA, Wiese MD, Blackman KE, et al. Ant The other paper on suspected allergy Anaphylaxis naturally has a poten- venom immunotherapy: a double-blind, placebo- in this issue is a far more sanguine tially vast differential diagnosis, controlled, crossover trial. Lancet 2003;361:1001–6. reminder that ‘‘all is not gold that although the rapid onset, accompanying 3 Abboud FM. Neurocardiogenic syncope. glitters’’. Goodyear et al describe a case cutaneous features, and direct relation N Engl J Med 1993;328:1117–20. of orbital cellulitis in a 14 year old boy to a potential trigger or particular 4 Pumphrey RSH. Fatal posture in anaphylactic shock. J Allergy Clin Immunol 2003;112:451–2. that was initially diagnosed and treated iatrogenic precipitant suggest the diag- 5 Brown AFT. Therapeutic controversies in the as an allergic reaction on the strength of nosis in most cases. In this instance, the management of acute anaphylaxis. J Accid Emerg unilateral periorbital oedema and a authors did emphasise that unilateral Med 1998;15:89–95. 7 6 Pumphrey RSH. Lessons for management of history of known dog hair allergy. orbital swelling is more likely to be anaphylaxis from a study of fatal reactions. Clin Two days later, despite a high tem- attributable to infection than allergy. I Exp Allergy 2000;30:1144–50. perature of 39.3˚C the condition was agree with this, and unfortunately on 7 Goodyear PWA, Firth AL, Strachan DR, et al. Periorbital swelling: the important distinction still considered to be allergic, delaying this occasion I am unable to blame a dog between allergy and infection. EMJ the final referral to an ophthalmology for this unfortunate boy’s illness! 2004;21:240–2.

War in the department. Later I reflected in ...... my journal on the impact of the plethora of personal tributes in the tabloids to our soldiers killed in action. Personal view: a day in the life of an Dealing with death regularly in A&E, I considered, was often by dissociation emergency physician at war and reliance on the fact that there is little opportunity to form any substan- T J Hodgetts tial relationship with a patient or their

family. But I could not mentally http://emj.bmj.com/ ...... dismiss those soldiers on whom I had pronounced death and placed in our The reality of emergency medicine in the war arena temporary mortuary (a refrigerated ISO container, or ‘‘reefer’’, known as the would not regard myself as super- ceased (an event that would wake even Grim Reefer) and whose images stitious, but 13 April 2003 was not the heaviest sleeper, and cover the tent repeatedly appeared in print. what I would call a lucky day. It was in gunpowder). Since 2001 I had spent five months in I on September 24, 2021 by guest. Protected copyright. the 22nd day of the ground war in Iraq The day had started inspiringly at the deserts of Oman, Afghanistan, and and I was the officer in command of the 0700 hours with a medley of marching Kuwait where the weather could change of 34 Field music from the attached military band in an instant, and today was to be a Hospital. Seventeen days previously this practising outside A&E, poignantly striking example. Imperceptibly to those had moved into Iraq in support of the interspersed with the Last Post from a working in the dim artificial light inside 1st (UK) Armoured Division and had cornet player raised on a flat bed truck the green tented hospital complex a begun treating battle casualties on 27 against a sky darkened by oil pit fires. storm had rapidly closed in and was March. Unusually the hospital was co- An hour later the first routine of the day heralded by a ‘‘dust devil’’ (a euphe- located far forward with the infantry was the heads of department attending mism for a small tornado). This pro- and armour units on a disused military the Commanding Officer’s briefing ceeded with divine direction through airfield close to the city of Al Basrah. By (‘‘Orders Group’’). Serious business in the senior officers’ accommodation this time in the war the explosions hand, the Regimental Sergeant Major tents, most of which were unoccupied, around the perimeter had become less had stated that the stethescope was not miraculously sparing the near capacity frequent, and the hostile incoming an article of uniform, and was not to be 200 bed hospital. A young female soldier mortar and artillery fire had stopped. worn around a doctor’s neck outside in the shower tent was witnessed to Challenger II tanks of the Scots Dragoon clinical areas. Predictably this was to be lifted and transported spinning in Guards and 2 Royal Tank Regiment precipitate a flurry of fluorescent and canvas, Dorothy-like, some 50 metres could no longer be seen racing across improvised striped tubes worn defiantly sustaining serious chest on the desert and engaging targets; and the by the senior clinicians. In turn I briefed landing. My own tent was forcibly nightly firework display of tracer from A&E clinical staff with the latest intelli- moved, pulling free the securing bolts heavy artillery lobbing rounds across gence and assigned daily tasks, then drilled in the runway, with the contents our accommodation tents had also flicked through the week old newspapers churned in an action akin to a giant

www.emjonline.com 130 COMMENTARY Emerg Med J: first published as 10.1136/emj.2003.009639 on 26 February 2004. Downloaded from washing machine. The same evening manifested in a novel and severe form fragments from playing with a land- mother nature gave a second impressive among the hospital’s 76 staff. Forty per mine. A 14 year old Iraqi girl with 60% demonstration, this time of sheet light- cent of the staff were ill and a further burns. A 3 year old Iraqi boy with a ning: two soldiers on the airbase were 20% quarantined, with five cases of compound tibia fracture after a road struck, and one died of his wounds. meningitis (two requiring ventilation, accident. A 12 year old Iraqi girl with In the build up to war I had been and one with DIC). This was particularly 20% burns from two weeks ago and deployed with the first medical elements clear in my own mind as I had been the septic shock. And a prisoner of war with to establish the A&E department in 22 emergency physician and had required appendicitis. Field Hospital in Kuwait. Attendance to take the additional roles of consultant So what? Nothing you could not cope here had peaked at 80 per day, which ITU, consultant general medicine, and with in your own practice. But what if although a fraction of a standard NHS junior doctor for the whole hospital the nearest CT scanner and neurosur- department’s activity the manning was because of staff shortages. It is conve- geon is in another country? Would your only one consultant and one SHO. nient to point the finger at ‘‘poor general surgeons perform burr holes or a Furthermore, the clinical routine was hygiene’’ in both instances, but this craniotomy on clinical grounds alone? regularly interrupted by ballistic missile group of viruses is notorious for its high What if your burns services are also in warnings for incoming SCUDs, or chem- attack rate among institutions, includ- another country: can you really spare an ical attack alarms (one second on, one ing NHS . Traditional cases of anaesthetist for the inter-hospital trans- second off a vehicle horn). So reactive dysentery (salmonellosis, shigellosis, fer, as it may take a day for them to was the system that a reversing lorry amoebiasis) were very rare compared return? How will you manage the could have the whole camp masked up with historical precedents in war patients in A&E when your two surgical in seconds (the same ripple effect was because of improvements in field teams are occupied; there are no surgi- memorably produced by some chump hygiene and perhaps, as the Professor cal reinforcements? How will you running in his respirator to increase his of Military Medicine observed, this was improvise if your paediatric resuscita- cardiovascular workout). At two hours simply nature expanding to fill a tion equipment is ‘‘limited’’? And what notice I had been transferred to 34 Field vacuum. This experience was translated if your intensive care unit is full? These Hospital as it moved into Iraq to into a process of assessing infectious were a day’s worth of challenges. establish itself as the main medical disease patients separately from con- So few words cannot do justice to the effort to receive battle casualties. I had ventional patients. A 14 bay assess- intensity of this experience, of frustra- crossed the border at night in the back ment tent was placed adjacent to A&E tions balanced with fulfillment and of a battlefield with one of and infectious patients streamed to spiced with a little anxiety. Nothing my registrars, having been ‘‘sanitised’’ this area for assessment by staff with has yet been said of the effort required of all personal effects. We were to join appropriate protective equipment. The to simply sustain yourself in a desert the main body of personnel at the broader concern was for recognising and environment, without climate control, airbase. In satirical contrast with the separating those patients showing the washing out of a mess tin, and eating convoys of armoured vehicles, they had first symptoms of biological warfare packet meals (termed Meals Ready to Eat, moved forward on a blue coach bearing (particularly those highly contagious or less charitably Meals Rejected by the inscription ‘‘Happy Journey’’.A conditions such as smallpox and pneu- Everyone). The personal challenge to small department was established in monic plague). Distant from us our NHS anticipate and manage the requirements 24 hours to support a 25 bed rapidly colleagues had the real and present of equipment, people, and procedures to deployable hospital. Over the next week threat of controlling the global SARS provide the emergency medicine service http://emj.bmj.com/ the 200 bed hospital was built alongside, crisis, no doubt working through similar across three field hospitals and within using the necessary engineering exper- thought processes. the medical regiment was enormous, is tise to supply running water, improved With domestic normality at 34 Field not one I would have missed, and was sanitation, and power. The department’s Hospital rapidly restored after the morn- only achievable with the quality and manning was then boosted to three ing’s storm, focus was drawn to the resourcefulness of my staff. It is quite consultants, four specialist registrars, clinical activity. It was lunchtime when amazing, I thought as I lay on my and four SHOs, with two of the con- we had an influx of critical patients over sleeping bag under the mosquito net sultants resident at any time during 90 minutes. A soldier with an acute that night of 13 April listening to the on September 24, 2021 by guest. Protected copyright. peak activity. Attendance rose to 140 per onset dilated cardiomyopathy and fast tanks trundling behind the protective day during war fighting, but with far atrial fibrillation. Two escaping prison- berm (a wall of sand), the wind and fewer minor presentations. ers of war with gunshot wounds, one rain, and the indiscernible crackle of the Experience in Oman in 2001, with damage to a popliteal artery and a tannoy, how quickly you can adapt to Afghanistan in 2002, and again in Iraq shattered tibia, the other with multiple the most bizarre circumstances. And in 2003 has confirmed that a substantial limb wounds. A 15 year old Iraqi boy almost regard them as normal. proportion of a field hospital’s work will unconscious with a closed head injury Emerg Med J 2004;21:129–130. be soldiers incapacitated by an enteric after a road accident. An 18 month old doi: 10.1136/emj.2003.009639 virus. Particularly important lessons Iraqi girl who had fallen into a burning Correspondence to: Colonel T J Hodgetts, Royal were learned by 34 Field Hospital at pit of oil sustaining facial and limb Centre for Defence Medicine, K Block, Selly Bagram airbase in Afghanistan when burns. A 7 year old Iraqi girl with an Oak Hospital, Birmingham B29 6JD, UK; an outbreak of Norwalk-like virus amputation of the hand and abdominal [email protected]

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