2013 Day Camp Individual Anaphylaxis Emergency Plan

YMCA Day Camps Anaphylaxis Emergency PlanThis child has a potential life-threatening allergy (anaphylaxis)______________________________ (Child’s Name)Circle Allergen(s) to avoidPeanutsTree NutsPeas (green, yellow, chick peas)EggMilkInsect Stings:___________________Medication: ___________________Other: _______________________EpiPen Expiry Date: ______________________________________Dosage: EpiPen Jr 0.1mg EpiPen 0.30 mg Twinject 0.15mg Twinject 0.30 mgLocation of EpiPen: In red fanny pack worn by a staff member when camper is in attendance, locked in the medication box whennot in attendance.Monitoring and Avoidance StrategiesA person having an anaphylactic reaction might have ANY of these signs & symptoms:. Skin: hives, swelling, itching, warmth, redness, rash. Respiratory (breathing): wheezing, shortness of breath, throat tightness, cough, hoarse voice, chest pain/tightness, nasalCongestion or hay-fever-like symptoms (runny itchy nose &watery eyes, sneezing, trouble swallowing. Gastrointestinal (stomach): nausea, pain/cramps, vomiting, diarrhea. Cardiovascular (heart): pale/blue colour, weak pulse, passing out, dizzy/light-headed, shock. Other: anxiety, headache, feeling of “impending doom”Early recognition of symptoms & immediate treatment could save a child’s life.Act quickly. The first signs of a reaction can be mild, but symptoms can rapidly worsen:1) Follow “Emergency Action Plan” on page 2 at the first sign of a reaction occurring in conjunction with a known orsuspected contact with allergen. If the” Emergency Action Plan” ask that an over the counter medication be given first, staff mustadminister the Epi Pen after if symptom worsens, or additional symptoms occur. .2) After an Epi Pen is given Call 911: Tell them a child is having a life-threatening allergic reaction – use the work “anaphylactic”.Request an ambulance immediately. Ask which hospital the ambulance will be going to.3) Call emergency contact, and inform them you have administered the EpiPen4) Escort child in ambulance with this plan, and the used Epipen injector, remain with the child until parent arrives1

YMCA Day Camps Anaphylaxis Emergency PlanChild’s Name: ________________________________Anaphylaxis Emergency PlanEmergency Contact InformationName Relationship Home Number Work Number Cell NumberEmergency Action Plan: (To be filled in by parent)Camp Staff Roles and Responsibilities:Review the allergy list to identify the children with anaphylactic allergies and their triggersAttend training on the administering of an EPI-pen for each childReview Anaphylaxis Procedures and Anaphylaxis Individual Emergency Plan prior to providing care for thechildren, annually or as information changes.Staff will ensure that Monitoring Avoidance Strategies is adhered toStaff will attend a training on Emergency ReadinessStaff will ensure the EPI-pen is accessible at all times, placed in a red labeled fanny pack and carried by the staffthat is with that child or otherwise indicated on the Anaphylaxis Individual Emergency PlanWill understand and be an advocate for the child by fostering awareness of anaphylaxis, its avoidance andtreatmentParent AgreementI _____________________________acknowledge my participation in the development of the preceding AnaphylaxisEmergency Plan. I give consent for the staff of YMCA Day Camps to execute the responsibilities as outlined withinthe plan. Adhere to _______________________________ Anaphylaxis Emergency PlanIn the event of an emergency, I authorize the Day Camp staff to administer the designated medication and obtainmedical Staff assistance. will check to ensure that they have the required medication with them while the child ispresent.Parent Signature: Administer __________________________________medication and/or instructions as set out in the child’s Date_________________________Individual Pan andEmergency Procedures Staff is to remain calm Staff will be debriefed2 Written report to be filled out by staff dealing with emergency Serious Occurrence to be filed