HomeMy WebLinkAboutEmergency Plan Anaphylaxis.pdf(Check the appropriate boxes.)
Peanut Other: ___________________________________________________
Tree nuts Insect stings
Egg Latex
Milk Medication: _____________________________________________
Food:The key to preventing an anaphylactic emergency is absolute avoidance of the
allergen. People with food allergies should not share food or eat unmarked / bulk foods
or products with a “may contain” warning.
Epinephrine Auto-Injector: Expiry Date: __________________ / _______________________
Dosage:EpiPen®Jr 0.15 mg EpiPen®0.30 mg
Twinject™ 0.15 mg Twinject™ 0.30 mg
Location of Auto-Injector(s): ______________________________________________________
Asthmatic: Person is at greater risk. If person is having a reaction and has
difficulty breathing, give epinephrine auto-injector before asthma medication.
Anaphylaxis Emergency Plan: _____________________________________________(name)
This person has a potentially life-threatening allergy (anaphylaxis) to:
A person having an anaphylactic reaction might have ANY of these signs and symptoms:
Skin:hives, swelling, itching, warmth, redness, rash
Respiratory (breathing):wheezing, shortness of breath, throat tightness, cough, hoarse voice, chest pain/tightness, nasal
congestion or hay fever-like symptoms (runny itchy nose and watery eyes, sneezing), trouble swallowing
Gastrointestinal (stomach):nausea, pain/cramps, vomiting, diarrhea
Cardiovascular (heart):pale/blue colour, weak pulse, passing out, dizzy/lightheaded, shock
Other:anxiety, feeling of “impending doom”, headache
Early recognition of symptoms and immediate treatment could save a person’s life.
Act quickly. The first signs of a reaction can be mild, but symptoms can get worse very quickly.
1.Give epinephrine auto-injector (e.g. EpiPen®or TwinjectTM) at the first sign of a reaction occurring in conjunction with a
known or suspected contact with allergen. Give a second dose in 10 to 15 minutes or sooner IF the reaction continues or
worsens. (See second page for instructions.)
2.Call 911. Tell them someone is having a life-threatening allergic reaction. Ask them to send an ambulance immediately.
3.Go to the nearest hospital, even if symptoms are mild or have stopped. Stay in the hospital for an appropriate period
of observation, generally 4 hours, but at the discretion of the ER physician. The reaction could come back.
4.Call contact person.
Emergency Contact Information
Name Relationship Home Phone Work Phone Cell Phone
The undersigned patient, parent, or guardian authorizes any adult to administer epinephrine to the above-named person in the event
of an anaphylactic reaction, as described above. This protocol has been recommended by the patient’s physician.
Patient/Parent/Guardian Signature Date Physician Signature Date
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