SAMPLE
District letterhead
STANDING ORDERS FOR ANAPHYLAXIS
(LEAs are encouraged to work with a local physician or public health officer to develop standing orders for
anaphylaxis. It is recommended that the standing orders be updated annually)
In the event of anaphylaxis of an individual, an epinephrine auto-injector will be administered by
the school nurse or trained unlicensed personnel according to the following procedure. The
school nurse (or other supervisor of health) is responsible for the training and supervision of
unlicensed personnel.
DEFINITION: Anaphylaxis is a severe allergic reaction which can be life threatening. It may
occur within minutes after a triggering event or up to an hour or more later.
CAUSES: Extreme sensitivity to one or more of the following:
1. Food
4. Latex
2. Insect sting
5. Food-Dependent Exercise-Induced
3. Medication
6. Idiopathic
PHYSICAL FINDINGS:
1. Tingling sensation, itching, or metallic taste in mouth.
2. Hives or generalized flushing, itching, or redness of the skin.
3. Nasal congestion or wheezing (asthma-like symptoms).
4. Swelling of the throat, lips, and tongue, and around the eyes.
5. Feeling of apprehension, agitation, sweating, weakness or shock.
6. Abdominal cramping, nausea, vomiting, or diarrhea.
7. Drop in blood pressure and paleness.
8. Throbbing heart beat/throbbing in ears/dizziness/headache.
9. Throat tightness/change of voice.
10. Difficulty breathing or swallowing
11. Fainting or loss of consciousness
12. Convulsions
ACTION PLAN: (Seconds count, do not delay!)
1. Immediate observation of respiratory condition. If compromised-give epinephrine!
2. Get or direct someone to get epinephrine auto-injector and have them call 911.
3. Select epinephrine auto-injector to administer based on estimated weight of child (if
only one dose available, administer it regardless of weight).
4. Inject epinephrine auto-injector. Pull off cap. Push firmly into upper, outer bare thigh,
through clothing if necessary. Hold for 5-10 seconds.
5. Call EMS (911) if not done so. Have someone call School Nurse, parent, notify
administration.
6. Monitor closely until arrival of paramedics. If symptoms continue or reoccur and
paramedics do not arrive, re-inject 5-15 minutes after initial injection.
7. Start CPR if necessary.
FOLLOW UP:
1. Refer ALL cases to physician.
2. Recommend discussion with physician about avoiding triggers, prescribing
epinephrine auto-injector.
3. Complete district/county and/or medical documentation/forms.
__________________________________________________
(Physician Signature)
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Date