1. APPENDIX C
  2. ANAPHYLAXIS EMERGENCY PLAN OF CARE
      1. This person has a potentially life-threatening allergy (anaphylaxis) to:


    altAPPENDIX C


     

     

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    ANAPHYLAXIS EMERGENCY PLAN OF CARE


     

     

     

    ANAPHYLAXIS EMERGENCY PLAN OF CARE:_______________________________ (Student Name)

     

     





    This person has a potentially life-threatening allergy (anaphylaxis) to:

     

     


     

    STUDENT PHOTO

     


    (Check the appropriate boxes)

    □ Food(s):__________________________________________

    □ Insect stings

    □ Other: ____________________________________________

     

    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®    □ 0.15 mg    □ 0.30 mg

       

    Location of Auto-Injector(s): ____________________________________________________________

     

    □   Previous anaphylactic reaction: Person is at greater risk.

    □   Asthmatic:  Person is at greater risk. If person is having a reaction and has difficulty breathing, give  epinephrine auto-injector before asthma medication.


     

     

    A person having an anaphylactic reaction might have ANY of these signs and symptoms:

     

     


    ·   Skin system: hives, swelling, itching, warmth, redness

    ·   Respiratory system (breathing): coughing, sneezing, shortness of breath, chest pain/tightness, throat tightness, hoarse voice, nasal congestion or hay fever-like symptoms (runny, itchy nose and watery eyes, sneezing), trouble swallowing

    ·   Gastrointestinal system (stomach): nausea, pain/cramps, vomiting, diarrhea

    ·   Cardiovascular system (heart): pale/blue colour, weak pulse, passing out, dizzy/lightheaded, shock

    ·   Other: anxiety, feeling of “impending doom”, headache, uterine cramps, metallic taste

    ·   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®) at the first sign of a known or suspected anaphylactic reaction. (See attached instruction sheet.) Note the time the epinephrine auto-injector was administered.

    2.  Call 9-1-1 or local emergency medical services, tell them someone is having a life-threatening allergic reaction.

    3.  Give a second dose of epinephrine in 5 to 15 minutes IF the reaction continues or worsens.

    4.  Go to the nearest hospital immediately (ideally by ambulance), even if symptoms are mild or have stopped. The reaction could worsen or come back, even after proper treatment. Stay in the hospital for an appropriate period of observation as decided by the emergency department physician (generally about 4 hours).

    5.  Call emergency contact person (e.g. parent, guardian).


     
    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.


     


    This information is being collected pursuant to the provisions of the Municipal Freedom of Information and Protection of Privacy Act and under the Authority of The Education Act, c. 129, s. 60 and will be used for the purposes of the Emergency Allergic Reaction Form and Obtaining Consent for Intervention during an Emergency Allergic Reaction. Questions about this collection should be directed to the Superintendent of Education at the Niagara Catholic District School Board, 427 Rice Road, Welland, Ontario L3C 7C1 Telephone 905-735-0240.


     


    In accordance with the Municipal Freedom of Information and Protection of Privacy Act, I give consent for the pertinent medical information concerning my child to be released as required. I have read and reviewed Appendix A : Division of Responsibilities regarding Anaphylaxis, Policy No. 302.1.

     


     

    Patient/Parent/Guardian Signature _______________________________    Date___________________   

     

     

    Physician Signature ________________________________________    Date___________________

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