ALLERGY ACTION PLAN This child has the following allergies:
Name:
Watch for signs of ANAPHYLAXIS (life-threatening allergic reaction)
Anaphylaxis may occur without skin symptoms: ALWAYS consider anaphylaxis in someone with known food allergy who has SUDDEN BREATHING DIFFICULTY
DOB:
A AIRWAY • Persistent cough • Hoarse voice • Difficulty swallowing • Swollen tongue
Photo
B BREATHING
C CONSCIOUSNESS
• Difficult or noisy breathing
• Persistent dizziness • Pale or floppy • Suddenly sleepy • Collapse/unconscious
• Wheeze or persistent cough
IF ANY ONE (OR MORE) OF THESE SIGNS ABOVE ARE PRESENT:
Mild/moderate reaction: • Swollen lips, face or eyes • Itchy/tingling mouth • Hives or itchy skin rash • Abdominal pain or vomiting • Sudden change in behaviour
1
Lie child flat with legs raised (if breathing is difficult, allow child to sit)
2
Use Adrenaline autoinjector without delay (eg. EpiPen®) (Dose:
3
Dial 999 for ambulance and say ANAPHYLAXIS (“ANA-FIL-AX-IS”)
mg)
*** IF IN DOUBT, GIVE ADRENALINE *** AFTER GIVING ADRENALINE:
Action to take:
•S tay with the child, call for help if necessary • Locate adrenaline autoinjector(s) • Give antihistamine: (If vomited, can repeat dose)
• Phone parent/emergency contact
Emergency contact details:
1. Stay with child until ambulance arrives, do NOT stand child up 2. Commence CPR if there are no signs of life 3. Phone parent/emergency contact 4. If no improvement after 5 minutes, give a further adrenaline dose using a second autoinjectilable device, if available. You can dial 999 from any phone, even if there is no credit left on a mobile. Medical observation in hospital is recommended after anaphylaxis.
How to give EpiPen® PULL OFF BLUE SAFETY CAP and grasp EpiPen. Remember: “blue to sky, orange to the thigh”
1) Name:
2) Name:
Additional instructions: If wheezy, GIVE ADRENALINE FIRST, then asthma reliever (blue puffer) via spacer
Hold leg still and PLACE ORANGE END against mid-outer thigh “with or without clothing”
Parental consent: I hereby authorise school staff to
PUSH DOWN HARD until a click is heard or felt and hold in place for 3 seconds. Remove EpiPen.
administer the medicines listed on this plan, including a ‘spare’ back-up adrenaline autoinjector (AAI) if available, in accordance with Department of Health Guidance on the use of AAIs in schools.
Signed:
Print name:
Date:
For more information about managing anaphylaxis in schools and “spare” back-up adrenaline autoinjectors, visit: sparepensinschools.uk © The British Society for Allergy & Clinical Immunology 6/2018
This is a medical document that can only be completed by the child’s healthcare professional. It must not be altered without their permission. This document provides medical authorisation for schools to administer a ‘spare’ back-up adrenaline autoinjector if needed, as permitted by the Human Medicines (Amendment) Regulations 2017. During travel, adrenaline auto-injector devices must be carried in hand-luggage or on the person, and NOT in the luggage hold. This action plan and authorisation to travel with emergency medications has been prepared by:
Sign & print name: Hospital/Clinic: Date: