Why is the severe anaphylaxis patient actually unstable, and how do you treat it? This was a fascinating discussion with Dr Ryan Smith about his group’s study on dogs with severe anaphylaxis that did not receive early epinephrine as part of their management. We cover those 49 cases, basic physiology, hepatic rupture and the protocol that Dr Smith and his team use. That protocol is available as supporting information to the study itself here: Canine Anaphylaxis Patients Receiving Late Epinephrine or No Epinephrine: 49 Cases (2019–2023) https://onlinelibrary.wiley.com/doi/10.1111/vec.70102 Other articles also mentioned: Evaluation of hemostatic derangements associated with canine anaphylaxis and the relationship to syndrome severity https://onlinelibrary.wiley.com/doi/10.1111/vec.13345 Acute hepatic rupture causing hemoperitoneum in a dog with anaphylaxis https://onlinelibrary.wiley.com/doi/10.1002/vms3.1391 Clinical characteristics of two-hundred thirty-two dogs (2006-2018) treated for suspected anaphylaxis in Perth, Western Australia https://onlinelibrary.wiley.com/doi/10.1111/avj.13114