EPA – (Emergency Plan of Action)

or Anaphylaxis/Severe Allergic Reaction Management

For Classroom teachers, bus driver and other support staff

Student Name: ____________________ School: ________________ Grade/Teacher: ________________

Parent Name: _________________________ Phone Number(s): _________________________________
ALLERGEN(S): _________________________________________ Student carries Epi-Pen ___Yes ___No

*Remain calm & reassure the child Student

Immediate action is required *Follow instructions below Picture
when the student exhibits any (Refer to back for instructions for
of the following signs of Epi-Pen)
distress. *Contact Parents & School Nurse.
Never leave child unattended *Monitor closely until arrival of
paramedics
*Start CPR if necessary

FOR ANY OF THE FOLLOWING:

MILD SYMPTOMS
SEVERE SYMPTOMS

NOSE MOUTH SKIN GUT

Mild
LUNG HEART THROAT MOUTH
Itchy/runny Itchy A few Significant
Short of breath Pale, blue, Tight, hoarse,
nose, mouth hives, mild nausea/
wheezing, faint, weak trouble swelling of
Sneezing itch discomfort
repetitive cough pulse, dizzy breathing or the tongue
swallowing or lips

For MILD SYMPTOMS,

follow the directions below: OR A
COMBINATION
SKIN GUT OTHER of symptoms
1. Give antihistamines, if written permission from Many hives over Repetitive
Feeling something from different
parent. bad is about to
body, widespread vomiting, body areas.
2. Stay with the person; alert emergency contacts. severe happen, anxiety,
redness confusion
3. Watch closely for changes. If symptoms worsen, diarrhea
give epinephrine.
1. INJECT EPINEPHRINE IMMEDIATELY
2. CALL 911. Tell them the child is having anaphylaxis
MEDICATIONS/DOSES and may need epinephrine when they arrive
 Consider giving additional medications following
(check all that apply) epinephrine:
Antihistamine: Benadryl  o Antihistamine
o Inhaler (bronchodilator) if wheezing
Antihistamine Dose: 12.5mg  25mg  50mg   Lay the person flat, raise legs and keep warm. If
Epinephrine Brand: Epi-Pen  Auvi-Q  breathing is difficult or they are vomiting, let them sit
up or lie on their side.
Epinephrine Dose: 0.15mg IM  0.3 mg IM   If symptoms do not improve, or symptoms return,
Inhaler/Bronchodilator (if wheezing) more doses of epinephrine can be given about 5
minutes or more after the last dose.
Inhaler Type: Ventolin  ProAir   Alert emergency contacts
Inhaler Dose: 1 puffs  2 puffs  Transport them to the ER even if symptoms resolve.
Person should remain in ER for at least 4 hours
Other:_____________________________________
because symptoms may return.
_
 How to Use Epi-Pens

EPIPEN (EPINEPHRINE) AUTO-INJECTOR DIRECTIONS

1. Remove the EpiPen Auto-Injector from the plastic carrying case.
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.
5. Remove and massage the area for 10 seconds.

AUVI-Q (EPINEPHRINE INJECTION, USP) DIRECTIONS

1. Remove the outer case of Auvi-Q. This will automatically active
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 DIRECTIONS
1. Remove the outer case.
2. Remove grey caps labeled “1” and “2”.
3. Place red rounded tip against mid-outer thigh.
4. Press down hard until needle penetrates.
5. Hold for 10 seconds. Remove from thigh.

OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.):

______________________________________ _________________
Parent/Guardian Authorization for EPA DATE