Download/Print Copy of Food Allergy & Anaphylaxis Emergency Care Plan
Food Allergy & Anaphylaxis Emergency Care Plan
Download/Print Copy of Food Allergy & Anaphylaxis Emergency Care Plan
- Name
- DOB
- Allergic to
- Weight (lbs)
- Asthma
- Yes (Higher risk for severe reaction)
- No
Note: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. USE EPINEPHRINE.
Extremely reactive to the following allergens:
Therefore:
- If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms.
- If checked, give epinephrine immediately if the allergen was DEFINITELY eaten, even if no symptoms are apparent.
For Any Of The Following: Severe Symptoms
- Lung
- Shortness of breath, wheezing, repetitive cough.
- Heart
- Pale or bluish skin, faintness, weak pulse, dizziness.
- Throat
- Tight or hoarse throat, trouble breathing or swallowing.
- Mouth
- Significant swelling of the tongue 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.
- Inject Epinephrine Immediately.
- Call 911. Tell emergency dispatcher the person is having anaphylaxis and may need epinephrine when emergency responders arrive.
- Consider giving additional medication 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 ca be given about 5 minutes or more after the last dose.
- Alert emergency contacts.
- Transport patient to ER, even if symptoms resolve. Patient should remain in ER for at least 4 hours because symptoms may return.
- Consider giving additional medication following epinephrine:
Mild Symptoms
- Nose
- Itchy or runny nose, sneezing.
- Mouth
- Itchy mouth.
- Skin
- A few hives, mild itch.
- Gut
- Mild nausea or 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.
Medication/Doses
- Epinephrine Brand or Generic
- Epinephrine Dose:
- 0.1mg IM
- 0.15mg IM
- 0.3mg IM
- Antihistamine Brand or Generic
- Antihistamine Dose
- Other (e.g., Inhaler-bronchodilator if wheezing)
- Patient or Parent/Guardian Authorization Signature
- Date
- Physician/HCP Authorization Signature
- Date
HOW TO USE AUVI-Q® (EPINEPHRINE INJECTION, USP), KALEO
- Remove Auvi-Q from the outer case. Pull off red safety guard.
- Place black end of Auvi-Q against the middle of the outer thigh.
- Press firmly until you hear a click and hiss sound, and hold in place for 2 seconds.
- Call 911 and get emergency medical help right away.
HOW TO USE IMPAX EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF ADRENACLICK®), USP AUTO-INJECTOR, AMNEAL PHARMACEUTICALS
- Remove epinephrine auto-injector from its protective carrying case.
- Pull off both blue end caps: you will now see a red tip. Grasp the auto-injector in your fist with the red tip pointing downward.
- Put the red tip against the middle of the outer thigh at a 90-degree angle, perpendicular to the thigh. Press down hard and hold firmly against the thigh for approximately 10 seconds.
- Remove and massage the area for 10 seconds. Call 911 and get emergency medical help right away.
HOW TO USE EPIPEN®, EPIPEN JR® (EPINEPHRINE) AUTO-INJECTOR AND EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF EPIPEN®), USP AUTO-INJECTOR, MYLAN AUTO-INJECTOR, MYLAN
- Remove the EpiPen® or EpiPen Jr® Auto-Injector from the clear carrier tube.
- Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. With your other hand, remove the blue safety release by pulling straight up.
- Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
- Remove and massage the injection area for 10 seconds. Call 911 and get emergency medical help right away.
HOW TO USE TEVA’S GENERIC EPIPEN® (EPINEPHRINE INJECTION, USP) AUTO-INJECTOR, TEVA PHARMACEUTICAL INDUSTRIES
- Quickly twist the yellow or green cap off of the auto-injector in the direction of the “twist arrow” to remove it.
- Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. With your other hand, pull off the blue safety release.
- Place the orange tip against the middle of the outer thigh at a right angle to the thigh.
- Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
- Remove and massage the injection area for 10 seconds. Call 911 and get emergency medical help right away.
HOW TO USE SYMJEPI™ (EPINEPHRINE INJECTION, USP)
- When ready to inject, pull off cap to expose needle. Do not put finger on top of the device.
- Hold SYMJEPI by finger grips only and slowly insert the needle into the thigh. SYMJEPI can be injected through clothing if necessary.
- After needle is in thigh, push the plunger all the way down until it clicks and hold for 2 seconds.
- Remove the syringe and massage the injection area for 10 seconds. Call 911 and get emergency medical help right away.
- Once the injection has been administered, using one hand with fingers behind the needle slide safety guard over needle.
ADMINISTRATION AND SAFETY INFORMATION FOR ALL AUTO-INJECTORS:
- Do not put your thumb, fingers or hand over the tip of the auto-injector or inject into any body part other than mid-outer thigh. In case of accidental injection, go immediately to the nearest emergency room.
- If administering to a young child, hold their leg firmly in place before and during injection to prevent injuries.
- Epinephrine can be injected through clothing if needed.
- Call 911 immediately after injection.
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 worsen quickly.
Emergency Contacts - call 911
- Rescue Squad
- Doctor
- Phone
- Parent/Guardian
- Phone
Other Emergency Contacts
- Name/Relationship
- Phone
- Name/Relationship
- Phone
- Name/Relationship
- Phone