Management of Anaphylaxis Form: Drug administration record
Client Name
Age
Date
Clinic Location/Name
Vaccines Received:
Epinephrine (Adrenalin) 1:1000 Aqueous Solution. Administer 0.01mg/kg (maximum 0.5 ml per injection)
intramuscularly (IM). Epinephrine, at the same dose as the initial dose, can be repeated at 5-15 minute
intervals to a maximum of 3 doses. See the dosing guidelines for epinephrine by age and weight (Table 1).
Epinephrine (Adrenalin) Administered
Amount
Time
Site
Route
1st Dose
2nd Dose
3rd Dose
Diphenhydramine (Benadryl®): One dose only after administration of Epinephrine. One dose of
diphenhydramine hydrochloride (e.g., Benadryl®) may be given to relieve itching, flushing, urticaria, and
nasal and eye symptoms. Generally the injectable format is used although oral tablets or liquid elixir may
also be used; the dosing guidelines for diphenhydramine hydrochloride by age (Table 2).
Diphenhydramine hydrochloride Administered
Amount
Time
Site
Route
Dose
Signs and Symptoms (circle pertinent findings):
Skin:
☐Urticaria ☐erythema ☐angioedema ☐generalized itch ☐flushing
Vascular:
☐Hypotension ☐chest discomfort ☐dizziness ☐syncope ☐ headache ☐tachycardia or no pulse
Respiratory:
☐Dyspnea ☐chest tightness ☐wheezing ☐cough ☐stridor
Eyes/nasal:
☐Runny nose ☐red eyes ☐congestion ☐sneezing
Other:
☐Difficulty swallowing ☐abdominal pain ☐nausea ☐vomiting ☐diarrhea ☐diaphoresis ☐apprehension ☐weakness
1
Vital Signs
Respirations (rate/min)
Pulse (rate/min)
Time Recorded
Comments
Followup Emergency Care: (check all that apply)
☐ 911 Contacted
Date:
Time:
☐ Attended by EHS
Date:
Time:
☐ Transfer to Hospital
Date:
Time:
☐ Other:
Date:
Time:
Comments
Recorders Signature
Date
2
Dosing guidelines for epinephrine by age (Canadian Immunization Guide 2013)
Age
0 – 6 months
Weight1
Up to 9 kg (20 pounds)
Dose by injection
0.01 mg/kg body weight
7 - 36 months
9 - 14.5 kg (20-32 lb)
0.1 - 0.2 mg
37 - 59 months
15 - 17.5 kg (33-39 lb)
0.15 - 0.3 mg2
5 - 7 years
18 - 25.5 kg (40-56 lb)
0.2 - 0.3 mg2
8 - 12 years
26 - 45 kg (57-99 lb)
0.3 mg2
13 years and older
0.5 mg3
46 + kg (100 lb or more)
1 Rounded
weight at the 50th percentile for each age range
Maximum dose for children 12 years of age and younger
3 Maximum dose for adolescents
2
Dosing guidelines for diphenhydramine hydrochloride by age (Canadian Immunization Guide
2013)
Age
12-23 months1
Weight
Dose of diphenhydramine hydrochloride
7-12 kg (15-25 lbs)
6.25 - 12.5 mg
2 to 4 years
12-25 kg (25-55 lbs)
12.5 - 25 mg
5 to 11 years
25-45 kg (55-99 lbs)
25 - 50 mg
45 kg + (99 lbs or more)
50 mg
12 years and older
1
Use with caution in children 12 – 23 months due to risk of sedation or paradoxical excitement.
3