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JLCE-R2, Emergency Anaphylactic Shock Procedures

File:  JLCE-R2

Emergency Anaphylactic Shock Procedures

To provide guidelines and standing orders for licensed nursing staff to treat anaphylactic shock following exposure to a causative agent.


1.Signs and symptoms of anaphylaxis include:

a.Appearance of hives on face and upper chest within seconds after exposure to allergen.
b.Diffuse erythema and the feeling of warmth with or without exposure to allergen.
c.Respiratory difficulty.
d.Severe abdominal cramping with associated gastrointestinal or genital-urethral symptoms.
e. Vascular collapse/circulatory failure and accompanying symptoms.

2.Bee stings, food, chemicals, or medications can cause an anaphylactic reaction.

3.The school nurse shall not provide first dose of any parenteral drug. When a parenteral medication is given, the nurses must observe patient for at least 20 minutes after any parenteral drug administration.  

4.Advise patients with bee sting sensitivities to maintain EpiPen in the health room or, if old enough, to carry one with them.

5.Advise students with drug sensitivities to wear alert tags.

6.Administer EpiPen cautiously to any student who is pregnant or to those with cardiovascular disease, hypertension, diabetes, hyperthyroidism, or psychosis.  Adrenaline is contraindicated in narrow angle glaucoma, organic brain syndrome, and in cardiac insufficiency.

7.Please be advised that use of the EpiPen must occur promptly.  Failure to administer the EpiPen in a timely manner has been the most common cause of fatality in individuals with an anaphylactic reaction.


1.Follow Universal Precautions.

2.Evaluate student’s symptoms rapidly, obtaining pertinent vital signs as soon as possible.

3.Administer Epinephrine Hydrochloride, following EpiPen protocol.

4.Arrange for immediate emergency care and transportation.  Direct another person to contact 911 and continue monitoring and direct care.

5.Notify parents/guardian and complete the Epi-Pen administration forms for DPH.

1.  The EpiPen is activated per instructions in the EpiPen container.  Instructions may vary according to manufacturer.  Instructions generally include:

a.Remove the gray safety cap.

b.Apply EpiPen to skin (positioning described in instructions).

c.Hold EpiPen in place for several seconds to insure that entire dose is administered.

d.The EpiPen is designed to release a specified amount of Epinephrine Hydrochloride, to provide treatment for anaphylaxis.

e.EpiPen releases 0.3mg. Of Epinephrine solution, and is indicated for patients who weigh more than 66 pounds.

f.EpiPen Junior releases 0.15mg. Of Epinephrine solution, and is indicated for patients who weigh less than 66 pounds.

g.EpiPen should not be used for females who may be pregnant, children with any heart disease, or children who weigh less than 30 pounds.

h.Health Services in each school should have at least one EpiPen available.  The Elementary Schools should have at least one EpiPen Junior, and Middle and High Schools should have one EpiPen.  Elm Street School should have both the EpiPen and the EpiPen Junior.

i.If use of the EpiPen is necessary, 911 must be called to transport the patient to the emergency room for further evaluation.

After Care:

1.Document in the student’s health record:

a.Incident and contributing factors (i.e. bee sting, medication given, food,etc..).

b.Treatment provided, including medications administered, dose, time, route, and site.  Also note time that parents/guardians were notified.

c.Patient’s response to treatment.

d.Identity and location of emergency facility.

e. Condition of patient at time of transport.

[Adopted: November 2004]
[Reviewed: January 2006]
[Revised: October 2015

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