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Anaphylaxis Emergency Action Plan

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Anaphylaxis Emergency Action Plan Anaphylaxis Emergency Action Plan Patient Name: ____________________________________________________________ Age: _______________ Allergies: ____________________________________________________________________________________ Asthma Yes (high risk for severe reaction) No Additional health problems besides anaphylaxis: ___________________________________________________ _____________________________________________________________________________________________ Concurrent medications: _______________________________________________________________________ _____________________________________________________________________________________________ Symptoms of Anaphylaxis MOUTH itching, swelling of lips and/or tongue THROAT* itching, tightness/closure, hoarseness SKIN itching, hives, redness, swelling GUT vomiting, diarrhea, cramps LUNG* shortness of breath, cough, wheeze HEART* weak pulse, dizziness, passing out Only a few symptoms may be present. Severity of symptoms can change quickly. *Some symptoms can be life-threatening. ACT FAST! Emergency Action Steps - DO NOT HESITATE TO GIVE EPINEPHRINE! 1. Inject epinephrine in thigh using (check one): Adrenaclick (0.15 mg) Adrenaclick (0.3 mg) Auvi-Q (0.15 mg) Auvi-Q (0.3 mg) EpiPen Jr (0.15 mg) EpiPen (0.3 mg) Epinephrine Injection, USP Auto-injector- authorized generic (0.15 mg) (0.3 mg) Other (0.15 mg) Other (0.3 mg) Specify others: ______________________________________________________________________________ IMPORTANT: ASTHMA INHALERS AND/OR ANTIHISTAMINES CAN’T BE DEPENDED ON IN ANAPHYLAXIS. 2. Call 911 or rescue squad (before calling contact) 3. Emergency contact #1: home__________________ work__________________ cell_________________ Emergency contact #2: home__________________ work__________________ cell_________________ Emergency contact #3: home__________________ work__________________ cell_________________ Comments: ________________________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Doctor’s Signature/Date/Phone Number __________________________________________________________________________________________ Parent’s Signature (for individuals under age 18 yrs)/Date This information is for general purposes and is not intended to replace the advice of a qualified health professional. For more information, visit www.aaaai.org. © 2013 American Academy of Allergy, Asthma & Immunology 7/2013 465 Name: _________________________________________________________________________ D.O.B.: ____________________ PLACE PICTURE Allergy to: __________________________________________________________________________________________________ HERE Weight: ________________ lbs. Asthma: [ ] Yes (higher risk for a severe reaction) [ ] No 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: MILD SYMPTOMS SEVERE SYMPTOMS NOSE MOUTH SKIN GUT LUNG HEART THROAT MOUTH Itchy/runny Itchy mouth A few hives, Mild nausea/ Short of breath, Pale, blue, Tight, hoarse, Significant nose, mild itch discomfort wheezing, faint, weak trouble swelling of the sneezing repetitive cough pulse, dizzy breathing/ tongue and/or lips swallowing FOR MILD SYMPTOMS FROM MORE THAN ONE SYSTEM AREA, GIVE EPINEPHRINE. OR A COMBINATION FOR MILD SYMPTOMS FROM A SINGLE SYSTEM SKIN GUT OTHER of symptoms AREA, FOLLOW THE DIRECTIONS BELOW: from different Many hives over Repetitive Feeling 1. Antihistamines may be given, if ordered by a body areas. body, widespread vomiting, severe something bad is healthcare provider. redness diarrhea about to happen, anxiety, confusion 2. Stay with the person; alert emergency contacts. 3. Watch closely for changes. If symptoms worsen, give epinephrine. 1. INJECT EPINEPHRINE IMMEDIATELY. 2. Call 911. Tell them the child is having anaphylaxis and may need epinephrine when they arrive. MEDICATIONS/DOSES • Consider giving additional medications following epinephrine: Epinephrine Brand: __________________________________________ » Antihistamine » Inhaler (bronchodilator) if wheezing Epinephrine Dose: [ ] 0.15 mg IM [ ] 0.3 mg IM • 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. Antihistamine Brand or Generic: _______________________________ • If symptoms do not improve, or symptoms return, more doses of Antihistamine Dose: __________________________________________ epinephrine can be given about 5 minutes or more after the last dose. • Alert emergency contacts. Other (e.g., inhaler-bronchodilator if wheezing): __________________ • Transport them to ER even if symptoms resolve. Person should remain in ER for at least 4 hours because symptoms may return. ____________________________________________________________ PARENT/GUARDIAN AUTHORIZATION SIGNATURE DATE PHYSICIAN/HCP AUTHORIZATION SIGNATURE DATE FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (WWW.FOODALLERGY.ORG) 5/2014 467 EPIPEN® (EPINEPHRINE) AUTO-INJECTOR DIRECTIONS 1. Remove the EpiPen Auto-Injector from the plastic carrying case. 2 2. Pull off the blue safety release cap. 3. Swing and firmly push orange tip against mid-outer thigh. 4. Hold for approximately 10 seconds. 4 5. Remove and massage the area for 10 seconds. TM AUVI-Q (EPINEPHRINE INJECTION, USP) DIRECTIONS 2 3 1. Remove the outer case of Auvi-Q. This will automatically activate the voice instructions. 2. Pull off red safety guard. 3. Place black end against mid-outer thigh. 4. Press firmly and hold for 5 seconds. 5. Remove from thigh. ADRENACLICK®/ADRENACLICK® GENERIC DIRECTIONS 1. Remove the outer case. 2 3 2. Remove grey caps labeled “1” and “2”. 2 3. Place red rounded tip against mid-outer thigh. 4. Press down hard until needle penetrates. 1 5. 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 OTHER EMERGENCY CONTACTS NAME/RELATIONSHIP: __________________________________________________________________ RESCUE SQUAD: ______________________________________________________________________ PHONE: ______________________________________________________________________________ DOCTOR: _________________________________________________ PHONE: ____________________ NAME/RELATIONSHIP: __________________________________________________________________ PARENT/GUARDIAN: ______________________________________ PHONE: ____________________ PHONE: _______________________________________________________________________________ PARENT/GUARDIAN AUTHORIZATION SIGNATURE DATE FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (WWW.FOODALLERGY.ORG) 5/2014 468 SAMPLE ASTHMA ACTION PLAN Name Asthma Action Plan, DOB for Children 0–5 Years Record # Health Care Provider’s Name Health Care Provider’s Phone Number Completed by Date Long-Term Control Medicines Other Instructions (Use every day to stay healthy) How Much To Take How Often (such as spacers/masks, nebulizers _____ times per day EVERY DAY _____ times per day EVERY DAY _____ times per day EVERY DAY Quick-Relief Medicines How Much To Take How Often Other Instructions NOTE: If this medicine is needed often Give ONLY as needed ( _____ per week), call physician Child is WELL and has no asthma symptoms, Prevent asthma symptoms every day even during active play • Give the above long-term control medicines every day • Avoid things that make the child’s asthma worse Avoid tobacco smoke, ask people to smoke outside GREEN ZONE Child is NOT WELL and has asthma symptoms that CAUTION: Take action by continuing to give regular asthma medicines may incude: every day AND: • Coughing Give • Wheezing • Runny nose or other cold symptoms (include dose and frequency) • Breathing harder or faster If the Child is not in the Green Zone and still has symptoms after 1 hour: • Awakening due to coughing or difficulty breating Give • Playing less than usual • (include dose and frequency) • Give YELLOW ZONE Other symptoms that could indicate that your child is having trouble breathing may include: difficulty feeding (grunting (include dose and frequency) sounds, poor sucking), changes in sleep patterns, cranky and Call tired, decreased appetite Child FEELS AWFUL warning signs may incude: MEDICAL ALERT! Get help! • Child’s wheeze, cough or difficult breathing continues Take the child to the hospital or call 9-1-1 immediately! or worsens, even after giving yellow zone medicines Give more • Child’s breathing is so hard that he/she is having trouble walking/talking/eating/playing (include dose and frequency) until you get help • Child is drowsy or less alert than normal Give more (include dose and frequency) until you get help RED ZONE DANGER! Get help immediately! Call 9-1-1 if: • The child’s skin is sucked in around neck and ribs or • Lips and/or fingernails are grey or blue, or • Child doesn't respond to you. Source: http://www.calasthma.org/uploads/resources/actionplanpdf.pdf.
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