Food Allergy and Anaphylaxis Emergency Care Plan

Name:

Date of Birth:

Allergy to:

Weight:

Asthma:

Yes

(higher risk for a severe reaction)

NOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. USE EPINEPHRINE.

Extremely reactive to the following foods:

THEREFORE:

If checked, give epinephrine immediately for ANY symptoms if the allergen was likely eaten.

If checked, give epinephrine immediately if the allergen was definitely eaten, even if no symptoms are noted.

FOR ANY OF THE FOLLOWING:

SEVERE SYMPTOMS

LUNG - Short of breath, wheezing, repetitive cough
HEART - Pale, blue, faint, weak pulse, dizzy
THROAT - Tight, hoarse, trouble breathing/ swallowing
MOUTH - Significant swelling of the tongue and/or lips
SKIN - Many hives over body, widespread redness
GUT - Repetitive vomiting, severe diarrhea
OTHER - Feeling something bad is about to happen, anxiety, confusion
OR A COMBINATION of symptoms from different body areas.

1. INJECT EPINEPHRINE IMMEDIATELY.
2. Call 911. Tell them the child is having anaphylaxis and may
need epinephrine when they arrive.

• Consider giving additional medications following epinephrine:
» Antihistamine
» Inhaler (bronchodilator) if wheezing
Lay the person flat, raise legs and keep warm. If breathing is difficult or they are vomiting, let them sit up or lie on their side.
• If symptoms do not improve, or symptoms return, more doses of epinephrine can be given about 5 minutes or more after the last dose.
• Alert emergency contacts.
• Transport them to the ER even if symptoms resolve. A person should remain in the ER for at least 4 hours because symptoms may return.

MILD SYMPTOMS

NOSE - Itchy/runny nose, sneezing
MOUTH - Itchy mouth
SKIN - A few hives, mild itch
GUT - Mild nausea/ discomfort

FOR MILD SYMPTOMS FROM MORE THAN ONE SYSTEM AREA, GIVE EPINEPHRINE.

FOR MILD SYMPTOMS FROM A SINGLE SYSTEM AREA, FOLLOW THE DIRECTIONS BELOW:

Antihistamines may be given, if ordered by a healthcare provider.
Stay with the person; alert emergency contacts.
Watch closely for changes. If symptoms worsen, give epinephrine.

MEDICATIONS/DOSES

Epinephrine Brand:

Epinephrine Dose:

0.15 mg IM 0.3 mg IM

Antihistamine Brand or Generic:

Antihistamine Dose:

Other (e.g., inhaler-bronchodilator if wheezing):

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

PARENT/GUARDIAN AUTHORIZATION SIGNATURE:

DATE:

PHYSICIAN/HCP AUTHORIZATION SIGNATURE:

DATE:

EPIPEN® (EPINEPHRINE) AUTO-INJECTOR DIRECTIONS

Remove the EpiPen Auto-Injector from the plastic carrying case.
Pull off the blue safety release cap.
Swing and firmly push orange tip against mid-outer thigh.
Hold for approximately 10 seconds.
Remove and massage the area for 10 seconds

AUVI-Q™ (EPINEPHRINE INJECTION, USP) DIRECTIONS

Remove the outer case of Auvi-Q. This will automatically activate the voice instructions.
Pull off red safety guard.
Place black end against mid-outer thigh.
Press firmly and hold for 5 seconds.
Remove from thigh.

ADRENACLICK®/ADRENACLICK® GENERIC DIRECTIONS

Remove the outer case.
Remove grey caps labeled “1” and “2”.
Place red rounded tip against mid-outer thigh.
Press down hard until needle penetrates.
Hold for 10 seconds. Remove from thigh.

OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.):

Treat the person before calling emergency contacts. The first signs of a reaction can be mild, but symptoms can get worse quickly.

EMERGENCY CONTACTS — CALL 911

RESCUE SQUAD:

DOCTOR:

PHONE:

PARENT/GUARDIAN:

PHONE:

OTHER EMERGENCY CONTACTS

NAME/RELATIONSHIP:

PHONE:

NAME/RELATIONSHIP:

PHONE:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

PARENT/GUARDIAN AUTHORIZATION SIGNATURE:

DATE:

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