Objective: To identify the medications that medical students, interns and casualty medical officers are likely to prescribe when treating an adult patient with anaphylaxis, and to ascertain the dose and route of administration of adrenaline they would use. Design: A questionnaire study survey. Setting: Kasturba medical college hospital, Manipal (Udupi District) and public health centers of Udupi district, Karnataka. Subjects: Data collected from 39 second year medical students, 35 interns and 35 casualty medical officers. Main outcome measure: To determine the percentage of use of adrenaline for the treatment of anaphylaxis in the correct dose, strength and route. Results: Majority (73 .3%) of participants correctly opted to use adrenaline. Only 9 participants have written the correct dose, route and concentration of adrenaline. 41.28% and 66.05% participants preferred to use antihistamines and corticosteroids respectively. Conclusion: This study has shown that confusion exists regarding the correct route of administration and dose of adrenaline to be used when treating anaphylaxis. This confusion applied to medical students, interns and medical officers. Therefore doctors must be made aware of the guidelines to treat anaphylaxis effectively

Adiga, Shalini

Bairy, KL

Nayak, Veena

English

Cognitive Sciences ePrint Archive

Peer Reviewed, Open Access, Free
Published Quarterly
Mangalore, South India
ISSN 0972-5997
Volume 7, Issue 4; Oct-Dec 2008
Treatment of Anaphylaxis in Adults: A Questionnaire Survey
Authors
Shalini Adiga,
Associate Professor, Dept of Pharmacology, Kasturba Medical College, Manipal,
Veena Nayak,
Assistant Professor, Dept of Pharmacology, Kasturba Medical College, Manipal
K.L Bairy
Professor, Dept of Pharmacology, Kasturba Medical College, Manipal
Address For Correspondence
Dr. Shalini Adiga,
Associate Professor,
Dept of Pharmacology,
Kasturba Medical College, Manipal,
Karnataka, INDIA
E-mail: drshali2000@yahoo.co.in
Citation
Adiga S, Nayak V, Bairy KL. Treatment of Anaphylaxis in Adults: A Questionnaire Survey Online J Health 
Allied Scs. 2008;7(4):6
URL
http://www.ojhas.org/issue28/2008-4-6.htm
http://ojhas.org 1
OJHAS Vol 7 Issue 4(6)  Adiga S, Nayak V, Bairy KL. Treatment of Anaphylaxis in Adults: A Questionnaire Survey
 Original Article
Submitted: Nov 20, 2008; Accepted: Jan 15, 2009 Published: Feb 25, 2009
Abstract:
Objective: To identify the medications that medical students, interns and casualty medical officers are likely 
to  prescribe  when  treating  an  adult  patient  with  anaphylaxis,  and  to  ascertain  the  dose  and route  of 
administration  of  adrenaline they would  use.  Design: A questionnaire  study survey.  Setting: Kasturba 
medical college hospital,  Manipal (Udupi District) and public health centers of Udupi district,  Karnataka. 
Subjects: Data  collected  from 39  second year  medical  students,  35  interns  and  35  casualty  medical 
officers.  Main outcome measure: To determine the percentage of use of adrenaline for the treatment of 
anaphylaxis in the correct dose, strength and route.  Results: Majority (73 .3%) of participants correctly 
opted to use adrenaline.  Only 9 participants  have written  the correct  dose,  route and concentration of 
adrenaline.  41.28%  and  66.05%  participants  preferred  to  use  antihistamines  and  corticosteroids 
respectively.  Conclusion: This  study  has  shown  that  confusion  exists  regarding  the  correct  route  of 
administration and dose of  adrenaline to be used when treating anaphylaxis.  This confusion applied to 
medical students, interns and medical officers. Therefore doctors must be made aware of the guidelines to 
treat anaphylaxis effectively.
Key Words: Anaphylaxis, Adrenaline
Introduction:
Anaphylaxis is a life threatening systemic allergic 
condition.  It  is  charecterised  mainly  by 
hypotension,  bronchospasm and angioedema of 
lips  and  mucous  membrane.  Anaphylaxis  is  a 
type  I  reaction  caused by release  of  mediators 
from mast cells and basophils following binding 
with IgE. The term anaphylactoid reaction refers 
to  a  non  IgE  mediated  mast  cell  or  basophil 
activation. The most common trigger factors are 
food  substances  like  peanuts,  milk,  shellfish, 
drugs  like  penicillins,  cephalosporins, 
radiocontrast media or idiopathic.
Adrenaline is the life saving drug for anaphylaxis. 
But, it is also dangerous as it can cause cardiac 
arrhythmias  and  myocardial  ischemia.  Oxygen, 
antihistamines, corticosteroids, nebulised β2-ago-
nists, IV fluids may also be indicated.  (1) Previous 
studies have shown that there exists confusion in 
the  treatment  of  this  emergency  condition.(2-4) 
Hence it is essential that doctors working in the 
emergency department  should  be aware  of  the 
correct drug, route and dose of adrenaline.
Since junior doctors, also can be called upon to 
treat  this  emergency  condition  we  planned  to 
conduct this study in interns working at Kasturba 
Medical College Hospital, Manipal and also in ca-
sualty medical officers ( CMO) working at public 
health centres in Udupi district, who are the first 
medical responders. We also included the medi-
cal students who are being taught on this subject 
during  second year  of  medical  curriculum.  The 
aim of this study was to identify the medications 
that medical students, interns and casualty medi-
cal officers are likely to prescribe when treating 
an adult patient with anaphylaxis,  and to ascer-
tain  the  dose  and  route  of  administration  of 
adrenaline  they would  use.  The  use of  antihis-
tamines and corticosteroids were also studied.
Materials and Methods:
Second  year  medical  students  (n=39),  interns 
(n=35) and casualty medical officers (n=35) were 
asked to answer a questionnaire under supervi-
sion which contained two hypothetical adult cas-
es of  anaphylaxis.  The questionnaire  used in a 
previous study  (2) was modified and used in the 
present study. The identity of the participants was 
not revealed. However, they were asked to fill in 
their  designation.  There  was  no  compulsion  to 
partake  and  subjects  were  informed  that  they 
were participating in a study.
Results:
A total of 109 questionnaires were collected. 80 
(73.3%)  participants  correctly  opted  to  use 
adrenaline.  84.61%  of  second  year  students, 
74.28% of  interns and  60% of  medical  officers 
opted  for  adrenaline.  The  percentage  of 
participants in each group opting for the different 
routes of adrenaline is given in the Table 1. But 
10.3% of students, 25.7% of interns and 40% of 
medical  officers  preferred  hydrocortisone  and 
5.1%  of  students  preferred  salbutamol  inhaler. 
The  percentage  of  participants  in  each  group 
preferring  the  different  concentrations  of 
adrenaline is given in Table 2.  Only 9 students 
have written the correct dose (0.5mg), route (IM) 
and  concentration  (1:1000).  However  13 
participants (8 students, 3 interns and 2 medical 
officers)  did  not  know  the  dose  of  adrenaline 
though  they  knew the  correct  concentration  of 
adrenaline as 1:1000. Two medical officers have 
preferred IV route (1ml) of 1:10000 dilution. One 
and eight  participants  have proposed to  give a 
higher dose of adrenaline in 1:10000 and 1:1000 
dilutions respectively.
Regarding the time for the next dose, 43.11% of 
the participants (14 medical students, 18 interns 
and 15 medical officers) have correctly said that 
the next dose of adrenaline can be given as early 
as 5 minutes. But ten participants did not know 
when to give the second dose and 17 participants 
proposed  not  to  give  a  second  dose  of 
adrenaline. The preferences opted by the individ-
ual groups regarding the time for next dose is giv-
en in Table 3. As an answer to the question re-
garding  second  line  drugs  for  anaphylaxis, 
41.28% and 66.05% participants preferred to use 
antihistamines  and  corticosteroids  respectively. 
The preferences for other second line treatments 
preferred by the participants are given in Table 4. 
The  participants  were  ignorant  of  any  existing 
guidelines for the management of anaphylaxis.
http://ojhas.org 2
OJHAS Vol 7 Issue 4(6)  Adiga S, Nayak V, Bairy KL. Treatment of Anaphylaxis in Adults: A Questionnaire Survey
Table 1: Percentage of participants opting for different routes of adrenaline 
Group 
number Group
Adrenaline
All 
routes/doses
Adrenaline 
IM
Adrenaline 1:1000
IM - correct dose Adrenaline IV
Adrenaline 
SC
1 Medical students (39) 33 (84.61%) 20 (51.3%) 9 (45%) 11 (28.2%) 2 (5.1%)
2 Interns (35) 26( 74.28%) 9 (25.7%) 0 (0%) 11 ( 31.4%) 6 (17.1%)
3 CMO (35) 21 (60%) 1 (2.9%) 0(0%) 7 ( 20%) 13 (37.1%)
4 Total (109) 80 (73.3%) 30 (27.5%) 9 ( 9%) 29 (26.6%) 21 (19.3%)
Table 2: Percentage of participants opting for different dilutions of adrenaline
Group 1:100 1:1000 1:10000 1:100000 1:200000 Don’t know
Medical students 1(2.56%) 24(61.5%) 6(15.4%) - 1(2.56%) 7(19.4%)
Interns - 8(22.85%) 20(57.14%) 3(8.57%) 1(2.85%) 3 (8.57%)
CMO - 10(28.57%) 18(51.42%) 1(2.85%) - 6(17.14%)
Table 3: Timing opted for the second dose of adrenaline by the participants
Group Don’t 
know
1min 5min 15min Any other No second 
dose 
Medical students 6 (15.38%) 1(2.56%) 14 (35.89%) 10(25.64%) 0 (0%) 8 (20.51%)
Interns 2(5.71%) 7(20%) 18(51.42%) 7(20%) 0 1(2.85%)
CMO 2(5.71%) 8(22.85%) 15(42.85%) 1(2.85%) 1(2.85%) 8(22.85%)
Table 4: Second line treatments preferred by the participants
Group NSAIDS Diuretics IV fluids Oxygen Nebulisation 
Medical students 2 2 3 0 0
Interns 0 2 0 0 0
CMO 0 1 7 3 3
Total 2(1.8%) 5(4.6%) 10(9.2%) 3(2.8%) 3(2.8%)
Discussion:
The main aim of  this  study was  to  identify the 
medications that doctors would administer when 
treating an adult patient with anaphylaxis and to 
ascertain the routes and doses of adrenaline that 
they  would  use.  The  first  problem  describes  a 
patient  with  anaphylaxis  for  which  73.3%  of 
participants in this study stated that  they would 
give adrenaline as their first line of treatment. The 
other 26.7% would give either IV hydrocortisone, 
or  nebulised  salbutamol.  Although  these  are 
useful in the treatment of anaphylaxis, adrenaline 
is the life saving drug in anaphylaxis as it acts on 
α, β1, β2,  all of which are required to reverse the 
pathophysiologic  processes  of  anaphylaxis. (5) 
This  study  has  shown  that  confusion  exists 
regarding the correct route of administration and 
dose  of  adrenaline  to  be  used  when  treating 
anaphylaxis.  This  confusion  applied  to  medical 
students,  interns  and  medical  officers.  In  this 
study, 26.6% and 19.3% of participants chose to 
give  adrenaline  by  IV  route  and  subcutaneous 
routes respectively. The absorption of adrenaline 
is  unpredictable  when  given  by  subcutaneous 
route  as  the  blood  flow  to  the  skin  would  be 
decreased in anaphylactic shock. . Adrenaline by 
IM route should be used as first line treatment in 
the  majority  of  situations  to  treat  anaphylaxis. 
Injection in the anterolateral aspect of thigh may 
lead to more predictable and rapid absorption of 
adrenaline. (6)  Previous studies have shown that 
plasma levels  are  higher  when  given  by 
intramuscular  route  than  when  given  by 
subcutaneous  route  and  also  it  avoids  the 
potentially  lethal  effects  of  large  IV  bolus 
injections.  In  some  patients  with  impaired 
cardiovascular  function,  intravenous  injection  of 
epinephrine may be required. Adrenaline should 
be given intravenously only during cardiac arrest 
or to profoundly hypotensive patients who have 
failed  to  respond  to  multiple  injections  of 
epinephrine  and  IV  fluid  replacement. 
Intravenous  adrenaline  should  be  administered 
by experienced clinicians and requires constant 
monitoring. (7)
This study has shown that many doctors are un-
aware  of  the correct  dose of  adrenaline to use 
when treating anaphylaxis. In response to Ques-
tion 2, only 9 medical students (9% of all partici-
pants) who chose the IM route, and 2 medical of-
ficers (1.83% of total) opting for the IV route actu-
ally knew the correct dose.
Surprisingly, 13 participants did not know the cor-
rect dose of adrenaline though they knew the cor-
rect  concentration  of  adrenaline  and  9  partici-
pants have written higher dose of adrenaline. 8 
participants have asserted that the second dose 
of adrenaline cannot be given. However 40% to 
70% of patients with severe anaphylaxis will  re-
http://ojhas.org 3
OJHAS Vol 7 Issue 4(6)  Adiga S, Nayak V, Bairy KL. Treatment of Anaphylaxis in Adults: A Questionnaire Survey
quire  more  than  one  dose  of  adrenaline.  The 
dose of adrenaline can be repeated every 5-15 
minutes. (6) The findings of this study highlight the 
need to educate clinical staff  regarding the cor-
rect dose, route and concentration of adrenaline 
to be used in anaphylaxis.
Antihistamines (H1- and H2-receptor antagonists) 
such as diphenhydramine (25–50 mg orally, intra-
muscularly,  or  intravenously  every  4–6  hours) 
and ranitidine (150 mg orally every 12 hours or 
50 mg intramuscularly or intravenously every 6–8 
hours) may be useful adjuvant therapies for alle-
viating the cutaneous manifestations of  urticaria 
or angioedema and pruritus and for the gastroin-
testinal  and uterine smooth muscle spasms. In-
halation of selective adrenergic agonists such as 
albuterol,  and  intravenous  administration  of 
aminophylline (0.5 mg/kg/h IV with 6 mg/kg load-
ing dose over 30 minutes) for bronchospasm and 
corticosteroids  may reduce  prolonged reactions 
or relapses. [6] In this study most of  the partici-
pants preferred to use corticosteroids and antihis-
tamines as second line drugs.  Very few partici-
pants have preferred to use oxygen, salbutamol 
nebulisation  and  IV  fluids.  Diuretics  and  nons-
teroidal  anti-inflammatory drugs have no role in 
the treatment of anaphylaxis.
Conclusion:
This  survey  reflects  the  knowledge  of  students 
and doctors who may be called upon to treat pa-
tients with anaphylaxis. The lifetime risk of ana-
phylaxis is presumed to be 1% to 3% per individ-
ual  with  mortality  rate  of  1  %. (7) Therefore,  all 
doctors should be able to diagnose anaphylaxis 
and  treat  it  effectively.  There  are  resuscitation 
guidelines  put  forward  by  various  countries  for 
the management of anaphylaxis that are found to 
be almost similar.(3-4) The same needs to be im-
plemented by our doctors for an effective treat-
ment of anaphylaxis
Acknowledgments:
Our sincere acknowledgments are due to all the 
participants of the study.
References:
1. Marshall  SE,  Immunological  factors  in 
medicine. In: Boom NA, Colledge NR, Walker 
BR,  Hunter  JAA.  Davidson’s  principles  and 
practice of medicine. 20th ed, New York: Else-
vier Health Sciences 2006; p 465-478. 
Suzy  T,  Jill  R,  Treatment  of  anaphylaxis  in 
adults:  results  of  a  survey  of  doctors  at 
Dunedin  Hospital,  New  Zealand.  The  New 
Zealand Medical journal. 2007;120:1252-1258. 
2. Gompels LL, Bethune C, Johnston SL, Gom-
pels  MM.  Proposed  use  of  adrenaline 
(epinephrine) in anaphylaxis and related con-
ditions: a study of senior house officers start-
ing accident and emergency posts.  Postgrad 
Med J 2002;78:416–418. 
3. Ricardo J, Gerald JC. Survey of  the use of 
epinephrine  (adrenaline)  for  anaphylaxis  by 
junior hospital doctors. Postgrad Med J 2007; 
83:610-611. 
4. Hoffman  BB.  Adrenoceptor-activating  and 
other  sympathomimetic  drugs,  In:  Katzung 
BG, Basic and clinical pharmacology.10th edi-
tion,  Singapore:  McGraw-Hill  companies; 
2007.p137. 
5. Kishiyama JL, Adelman DC. Allergic and im-
munologic  disorders,  In:  McPhee  SJ,  Pa-
padakis MA, Tierney LM. Current medical di-
agnosis  and  treatment  . 47th edition,  New 
York: McGraw-Hill companies; 2008.p691
6. Oswalt  ML,  Kemp  SF.  Anaphylaxis:  Office 
management and prevention.  Immunol Aller-
gy Clin N Am 2007;27:177-91.
http://ojhas.org 4
OJHAS Vol 7 Issue 4(6)  Adiga S, Nayak V, Bairy KL. Treatment of Anaphylaxis in Adults: A Questionnaire Survey


Adrenoceptor-activating and other sympathomimetic drugs, In: Katzung BG, Basic and clinical pharmacology.10th edition, Singapore: McGraw-Hill companies;

Allergic and immunologic disorders, In: McPhee SJ, Papadakis MA, Tierney LM. Current medical diagnosis and treatment . 47th edition,

Anaphylaxis: Office management and prevention. Immunol Allergy Clin N Am 2007;27:177-91. http://ojhas.org 4

Immunological factors in medicine. In:

Proposed use of adrenaline (epinephrine) in anaphylaxis and related conditions: a study of senior house officers starting accident and emergency posts.

Survey of the use of epinephrine (adrenaline) for anaphylaxis by junior hospital doctors. Postgrad Med J

Treatment of Anaphylaxis in Adults: A Questionnaire Survey

CogPrints Cognitive Sciences Eprint Archive

Objective: To identify the medications that medical students, interns and casualty medical officers are likely to prescribe when treating an adult patient with anaphylaxis, and to ascertain the dose and route of administration of adrenaline they would use. Design: A questionnaire study survey. Setting: Kasturba medical college hospital, Manipal (Udupi District) and public health centers of Udupi district, Karnataka. Subjects: Data collected from 39 second year medical students, 35 interns and 35 casualty medical officers. Main outcome measure: To determine the percentage of use of adrenaline for the treatment of anaphylaxis in the correct dose, strength and route. Results: Majority (73 .3%) of participants correctly opted to use adrenaline. Only 9 participants have written the correct dose, route and concentration of adrenaline. 41.28% and 66.05% participants preferred to use antihistamines and corticosteroids respectively. Conclusion: This study has shown that confusion exists regarding the correct route of administration and dose of adrenaline to be used when treating anaphylaxis. This confusion applied to medical students, interns and medical officers. Therefore doctors must be made aware of the guidelines to treat anaphylaxis effectivel

Shalini Adiga

Veena Nayak

K.L Bairy

Directory of Open Access Journals

http://doaj.org/search?source=%7B%22query%22%3A%7B%22bool%22%3A%7B%22must%22%3A%5B%7B%22term%22%3A%7B%22id%22%3A%2265c761103ad542c792f916baf7d7f735%22%7D%7D%5D%7D%7D%7D

Treatment of Anaphylaxis in Adults: A Questionnaire Survey

Abstract

Similar works

Full text

Available Versions

Cognitive Sciences ePrint Archive

CogPrints Cognitive Sciences Eprint Archive

Directory of Open Access Journals