Fillable If checked, give epinephrine immediately if the allergen (Keene Independent School District)

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If checked, give epinephrine immediately if the allergen (Keene Independent School District)

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Name: _________________________________________________________________________ D.O.B.: ____________________
Allergy to: __________________________________________________________________________________________________
Weight: ________________ lbs. Asthma: □ Yes (higher risk for a severe reaction) □ No
PLACE
PICTURE
HERE
1. Antihistamines may be given, if ordered by a
healthcare provider.
2. Stay with the person; alert emergency contacts.
3. Watch closely for changes. If symptoms worsen,
give epinephrine.
PATIENT OR PARENT/GUARDIAN AUTHORIZATION SIGNATURE DATE PHYSICIAN/HCP AUTHORIZATION SIGNATURE DATE
FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 5/2018
1. INJECT EPINEPHRINE IMMEDIATELY.
2. Call 911. Tell emergency dispatcher the person is having
anaphylaxis and may need epinephrine when emergency
responders 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 patient to ER, even if symptoms resolve. Patient should
remain in ER for at least 4 hours because symptoms may return.
HEART
Pale or bluish
skin, faintness,
weak pulse,
dizziness
MOUTH
Significant
swelling of the
tongue or lips
OR A
COMBINATION
of symptoms
from different
body areas.
LUNG
Shortness of
breath, wheezing,
repetitive cough
SKIN
Many hives over
body, widespread
redness
GUT
Repetitive
vomiting, severe
diarrhea
NOSE
Itchy or
runny nose,
sneezing
MOUTH
Itchy mouth
SKIN
A few hives,
mild itch
GUT
Mild
nausea or
discomfort
THROAT
Tight or hoarse
throat, trouble
breathing or
swallowing
OTHER
Feeling
something bad is
about to happen,
anxiety, confusion
Epinephrine Brand or Generic: ________________________________
Epinephrine Dose: □ 0.1 mg IM □ 0.15 mg IM □ 0.3 mg IM
Antihistamine Brand or Generic:
_______________________________
Antihistamine Dose: __________________________________________
Other (e.g., inhaler-bronchodilator if wheezing): __________________
____________________________________________________________
MEDICATIONS/DOSES
SEVERE SYMPTOMS
MILD SYMPTOMS
FOR MILD SYMPTOMS FROM MORE THAN ONE
SYSTEM AREA, GIVE EPINEPHRINE.
FOR MILD SYMPTOMS FROM A SINGLE SYSTEM
AREA, FOLLOW THE DIRECTIONS BELOW:
FOR ANY OF THE FOLLOWING:
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.
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FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 1/2019
EMERGENCY CONTACTS — CALL 911
RESCUE SQUAD: ______________________________________________________________________
DOCTOR:
_________________________________________________ PHONE: ____________________
PARENT/GUARDIAN: ______________________________________ PHONE: ____________________
OTHER EMERGENCY CONTACTS
NAME/RELATIONSHIP: _____________________________________ PHONE: ____________________
NAME/RELATIONSHIP: _____________________________________ PHONE: ____________________
NAME/RELATIONSHIP: _____________________________________ PHONE: ____________________
Treat the person before calling emergency contacts. The first signs of a reaction can be mild, but symptoms can worsen quickly.
ADMINISTRATION AND SAFETY INFORMATION FOR ALL AUTO-INJECTORS:
1. 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.
2. If administering to a young child, hold their leg firmly in place before and during injection to prevent injuries.
3. Epinephrine can be injected through clothing if needed.
4. Call 911 immediately after injection.
OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.):
HOW TO USE AUVI-Q
®
(EPINEPRHINE INJECTION, USP), KALEO
1. Remove Auvi-Q from the outer case.
2. Pull off red safety guard.
3. Place black end of Auvi-Q against the middle of the outer thigh.
4. Press firmly until you hear a click and hiss sound, and hold in place for 2 seconds.
5. Call 911 and get emergency medical help right away.
3
HOW TO USE IMPAX EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF ADRENACLICK
®
), USP
AUTO-INJECTOR, IMPAX LABORATORIES
1. Remove epinephrine auto-injector from its protective carrying case.
2. Pull off both blue end caps: you will now see a red tip.
3. Grasp the auto-injector in your fist with the red tip pointing downward.
4. Put the red tip against the middle of the outer thigh at a 90-degree angle, perpendicular to the thigh.
5. Press down hard and hold firmly against the thigh for approximately 10 seconds.
6. Remove and massage the area for 10 seconds.
7. Call 911 and get emergency medical help right away.
5
HOW TO USE EPIPEN
®
AND EPIPEN JR
®
(EPINEPHRINE) AUTO-INJECTOR AND EPINEPHRINE INJECTION (AUTHORIZED
GENERIC OF EPIPEN®), USP AUTO-INJECTOR, MYLAN AUTO-INJECTOR, MYLAN
1. Remove the EpiPen
®
or EpiPen Jr
®
Auto-Injector from the clear carrier tube.
2. Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward.
3. With your other hand, remove the blue safety release by pulling straight up.
4. Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’.
5. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
6. Remove and massage the injection area for 10 seconds.
7. Call 911 and get emergency medical help right away.
3
4
HOW TO USE TEVA’S GENERIC EPIPEN® (EPINEPHRINE INJECTION, USP) AUTO-INJECTOR, TEVA PHARMACEUTICAL
INDUSTRIES
1. Quickly twist the yellow or green cap off of the auto-injector in the direction of the “twist arrow” to remove it.
2. Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward.
3. With your other hand, pull off the blue safety release.
4. Place the orange tip against the middle of the outer thigh (upper leg) at a right angle (perpendicular) to the thigh.
5. Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’.
6. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
7. Remove and massage the injection area for 10 seconds.
8. Call 911 and get emergency medical help right away.
5
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Completed 31 July 2021

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