Treatment Summary Anaphylaxis Emergency Action Plana
NAME: _________________________________________________AGE: ______ ALLERGY TO: ______________________________________________________ Asthma: ☐ Yes (high risk for severe reaction)
☐ No
Other health problems besides anaphylaxis: __________________________________ Concurrent medications, if any: ___________________________________________ ____________________________________________________________________
Wear medical identification jewelry that identifies the anaphylaxis potential and the food allergen triggers.
SYMPTOMS OF ANAPHYLAXIS INCLUDE: > MOUTH – itching, swelling of lips and/or tongue > THROAT†
Only a few symptoms may be present. Severity of symptoms can change quickly. † Some symptoms can be life-threatening! ACT FAST!
> SKIN – itching, hives, redness, swelling > GUT – vomiting, diarrhea, cramps > LUNG† > HEART†
– shortness of breath, cough, wheeze – weak pulse, dizziness, passing out
WHAT TO DO: 1. INJECT EPINEPHRINE IN THIGH using (check one): ☐ EpiPen Jr® ☐ EpiPen®
(0.30 mg) (0.15 mg)
☐ Adrenaclick® ☐ Adrenaclick® ☐ Ana-Guard®
(0.15 mg) ☐ Twinject® (0.30 mg) ☐ Twinject® (0.30 mg)
DO NOT HESITATE TO GIVE EPINEPHRINE! Patients should be allowed to self-carry and self-administer epinephrine.
Other medication/dose/route: _____________________________________________ IMPORTANT: Asthma inhalers and/or antihistamines cannot be depended on in anaphylaxis! 2. CALL 911 or RESCUE SQUAD (before calling contacts)!
3. EMERGENCY CONTACTS #1: Name: _______________________ home ________ work ________ cell ________ #2: Name: _______________________ home ________ work ________ cell ________ #3: Name: _______________________ home ________ work ________ cell ________
COMMENTS: _______________________________________________________
____________________________________________________________________ Parent's Signature (for individuals under age 18 yrs)
____________________________________________________________________ Doctor's Signature
Date Date
a Adapted from J Allergy Clin Immunol 1998;102:173-176 and J Allergy Clin Immunol 2006;117:367-377. 10
(0.15 mg) (0.30 mg)
– itching, tightness/closure, hoarseness
