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ASCIA Guidelines - Adrenaline (Epinephrine) Injector Prescription

pdfASCIA Guidelines for adrenaline injector prescription 2024127.88 KB

This document has been developed by ASCIA, the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand. ASCIA information is based on published literature and expert review, is not influenced by commercial organisations and is not intended to replace medical advice. For patient or carer support contact Allergy & Anaphylaxis Australia or Allergy New Zealand

The aim of these guidelines is to outline the appropriate prescription and dose of adrenaline (epinephrine) injectors for use in non-medical settings, for the emergency first aid treatment of potentially life-threatening severe allergic reactions (anaphylaxis). 

These guidelines should be used in conjunction with clinical judgement, with consideration of issues that include training on a new device and preference of device from the patient or their carer.

These guidelines include adrenaline injector devices that are currently available in Australia and New Zealand, and are based on published evidence regarding:

  • Recommended doses of adrenaline injectors to treat severe symptoms, reduce the risk of serious morbidity (e.g. cerebrovascular damage) and prevent fatalities due to anaphylaxis.
  • Epidemiology of allergic reactions triggers that may be difficult to avoid.
  • Risk factors that have been associated with fatal anaphylaxis.

ASCIA Adrenaline Injector Recommendations

Adrenaline rapidly reverses the effects of anaphylaxis and adrenaline injector devices are considered to be first line emergency first aid treatment for anaphylaxis.

Each adrenaline injector device contains a single fixed dose of adrenaline that is administered intramuscularly into the outer mid-thigh, for safe and rapid absorption of adrenaline.

Adrenaline ampoules and syringes are not considered by ASCIA to be suitable for non-medical settings such as schools, children’s education/care centres and workplaces. 

ASCIA recommends the use of adrenaline as the first line treatment for anaphylaxis using either of the following two brands of adrenaline injectors:

  • EpiPen® Jr (150 microgram) and EpiPen® (300 microgram) - TGA approved, available in Australia on the PBS (up to two devices per prescription), and New Zealand (Pharmac listed 2023).
  • Anapen® 500 (500 microgram) - TGA approved and available in Australia on the PBS (up to two devices per prescription).

It is important to specify brand and tick box on PBS prescription to ensure that brand is not substituted. EpiPen® and Anapen® are also available without prescription.

Both EpiPen® and Anapen® devices are widely used in other countries. Most countries have multiple brands of adrenaline injector devices available, and this is important for the following reasons:

  • To ensure continued supply of life saving adrenaline, particularly if one brand has stock shortages.
  • To provide doctors with a choice of dose, who may prefer to prescribe a higher dose (500 microgram device) for people over 50kg .
  • A 500 microgram dose can potentially prevent the need for further doses of adrenaline (which is important due to increasing ambulance delays and many people only carrying one device).
  • To encourage suppliers to provide devices with longer shelf life.
  • To provide choice for consumers to access devices with points of difference to best suit their needs.

It is essential that patients and carers are trained to use the prescribed device (EpiPen® or Anapen®) and provided with an ASCIA Action Plan for Anaphylaxis, including the prescribed device instructions.

ASCIA Adrenaline Injector Dose Recommendations

ASCIA recommends the adrenaline injector doses listed below, based on expert consensus and standard practice by ASCIA members, which vary to the product information. These doses are consistent with the Acute Anaphylaxis Clinical Care Standard for Australia, Australian Prescriber Anaphylaxis Wallchart, Australian Immunisation Handbook and international recommendations from the World Allergy Organisation (WAO), Canada and the UK (refer to weblinks below).

Children 7.5-20kg (aged around one to five years): EpiPen® Jr (150 microgram) 

Children over 20kg and adults: EpiPen® (300 microgram) 

Children and adults over 50kg: Anapen® 500 (500 microgram)* 

*The dose of adrenaline in Anapen 500 is consistent with the intramuscular injection (IMI) dose recommendations for people who weigh more than 50kg in the publications listed below:

https://www.safetyandquality.gov.au/standards/clinical-care-standards/acute-anaphylaxis-clinical-care-standard

https://www.nps.org.au/australian-prescriber/articles/anaphylaxis-emergency-management-for-health-professionals

https://immunisationhandbook.health.gov.au/resources/handbook-tables/doses-of-intramuscular-11000-adrenaline-for-anaphylaxis 

https://www.worldallergyorganizationjournal.org/article/S1939-4551(20)30375-6/fulltext

https://www.resuscitationjournal.com/article/S0300-9572(21)00150-7/fulltext

https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-2-vaccine-safety/page-4-early-vaccine-reactions-including-anaphylaxis.html#shr-pg0

https://onlinelibrary.wiley.com/doi/full/10.1111/cea.14055

Children less than 7.5kg

Adrenaline injectors are not usually recommended for children less than 7.5kg as the risk of fatal anaphylaxis in children this age is very low. While the ‘optimal’ dose of adrenaline is unknown there is a risk that the lower dose adrenaline injector could provide a significant overdose.

ASCIA does not recommend the use of adrenaline ampoules and syringes for children less than 7.5kg as they are inappropriate for non-medical settings, such as childcare centres. Even if ampoules are administered by ‘trained’ non-medical personnel, such as parents, there may be a risk of a serious dosing error.

If there is a concern regarding an infant under 7.5kg requiring adrenaline, they should be referred to a clinical immunology/allergy specialist for assessment. The issues should be discussed with the parents based on a risk assessment. Where it is felt that it is essential for emergency adrenaline to be prescribed for a child less than 7.5kg, the risk of administering a ‘fixed’ overdose via a 150 microgram device is considered to be lower than the risk of a dose error with an adrenaline ampoule and syringe.

ASCIA Adrenaline Injector Prescription Guide

Adrenaline injector prescription is recommended for patients with:
  • History of anaphylaxis - If the patient is considered to be at continuing risk from allergic reactions to identified triggers (confirmed allergen/s) or unidentified triggers (idiopathic anaphylaxis).
  • Food allergy (excluding oral allergy syndrome) and co-existing unstable or moderate to severe, persistent asthma. Rationale: Most food allergy related fatalities occur in those with unstable asthma.
  • Underlying mast cell disorders (e.g. systemic mastocytosis or elevated baseline serum tryptase concentrations) together with any previous systemic allergic reactions to insect stings, including patients undergoing venom immunotherapy.

 

Adrenaline injector prescription is sometimes recommended for patients with a history of a generalised allergic reaction, with one or more of the following additional risk factors:  
  • Age
    • Teenagers and young adults with food allergy. While food allergy is most common in young children aged five years or less, the majority of recorded fatal reactions to foods (~90%) occur in teenagers and young adults. This may in part relate to greater risk taking behaviour in this age group, but may also reflect greater likelihood of accidental exposure to food allergens when eating away from home, or while not under parental supervision.
  • Specific allergic triggers
    • Peanut, tree nuts and seafood. Fatal anaphylaxis may arise from any food, but most fatalities arise from food allergy that persists into adolescence and adult life (e.g. peanut, tree nut, sesame seed and seafood allergies). Allergic reactions to these foods may occur following ingestion of relatively small amounts, and the risk of reaction is unlikely to be reduced by cooking or food processing.
    • Generalised urticaria alone without anaphylaxis following insect stings (e.g. bee, wasp or Jack Jumper ant stings) or following tick bites is not a routine indication for adrenaline autoinjector prescription, but may be considered (in conjunction with allergen specific immunotherapy if available) in selected cases. Decisions regarding immunotherapy will take into consideration factors such as the risk of progression to anaphylaxis (based on follow-up studies), patient age (more likely in adults than children), co-morbidity (significant cardiorespiratory disease) or living or working in remote areas (where access to emergency medical care may be more problematic) or occupational (e.g. bee keeping) or even recreational exposure to stinging insects (e.g. hiking in areas where Jack Jumper ants are endemic).
  • Co-morbid conditions
    • Asthma. Unstable or moderate to severe, persistent asthma increases the risk of respiratory compromise in those allergic to food. Treatment to control asthma symptoms is important in this group (e.g. medication, allergen immunotherapy).
    • Cardiovascular disease (hypertension, ischaemic heart disease or arrhythmia) is associated with a relatively greater risk of fatal anaphylaxis from insect stings.
    • Systemic mastocytosis

This list is not comprehensive and if there is a concern, patients should be referred to a clinical immunology/allergy specialist for assessment.

  • Limited access to emergency medical care
    • Remote residential locations. In some remote residential locations (e.g. remote rural areas), access to medical care and early administration of adrenaline may not be possible unless an adrenaline autoinjector is provided to the patient or their carers for administration. It is important to distinguish this situation of permanent risk from those at short-lived risk (e.g. bushwalking, school camps).
    • Prolonged travel abroad. Consideration of temporary availability to patients considered at lower risk, who are travelling abroad may also be considered, where language barriers and lesser control over food preparation may increase the risk of accidental exposure and access to medical care may also be limited.

These factors should be considered when deciding whether an adrenaline autoinjector is prescribed, as they are known risk factors for more severe or fatal allergic reactions. 

 

 Adrenaline injector prescription is not normally recommended as follows:
  • Asthma without a history of anaphylaxis or generalised allergic reactions.
  • If known allergen can be successfully avoided (e.g. drug allergy, latex allergy). Under these circumstances the wearing of medical identification jewellery is strongly recommended.
  • Oral allergy syndrome - The likelihood of progression to anaphylaxis is very low.
  • Elevated specific IgE only (positive blood or skin allergy test) without a history of clinical reactivity - A positive allergy test without a history strongly suggestive of allergy is an indication for specialist allergy assessment, which will include assessment of the risk of allergy and anaphylaxis, and sometimes include challenge testing.
  • Family (rather than personal) history of anaphylaxis or allergy - Whilst the risk for allergic disease such as asthma, allergic rhinitis and atopic eczema is in part inherited, there is not a substantial genetic contribution to food, sting or drug allergy risk, and the risk of anaphylaxis is not inherited.
  • Local reactions to insect stings in adults and children - Follow up studies demonstrate that these rarely progress to anaphylaxis.
  • Generalised skin rash (only) to bee or wasp stings in children - Follow up studies of subsequent bee stings in children presenting with local reactions or generalised skin rash (only) show that these children are at a very low risk of experiencing anaphylaxis with subsequent stings.
  • Resolved food allergy - This should be established by a clinical immunology/allergy specialist.
  • Isolated angioedema - The risk of fatal angioedema (unrelated to food or insect sting allergy, hereditary angioedema or use of ACE inhibitor medication) is very low. If there is a concern, patients should be referred to a clinical immunology/allergy specialist for assessment.

To access clinical definitions refer to the ASCIA Guidelines for Acute Management of Anaphylaxis on the ASCIA website www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines

Updated ASCIA Action Plans for Anaphylaxis, e-training courses and other resources which include EpiPen® and Anapen® instructions are available on the ASCIA website www.allergy.org.au/hp/anaphylaxis  

Anaphylaxis Management Plan

An adrenaline injector should only be prescribed within the context of a comprehensive Anaphylaxis Management Plan that includes the following:

1. Referral to a clinical immunology/allergy specialist

Review by a clinical immunology/allergy specialist should occur to:

  • Ascertain if the correct trigger(s) have been identified.
  • Determine whether the allergy persists.
  • Advise on specific management, including suitability for allergen immunotherapy (if available).
  • Advise on co-factors that may increase the risk of more serious reactions (e.g. use of beta blockers, NSAID, exercise, asthma control).

2. Identification of anaphylaxis trigger(s)

This should include a comprehensive history, clinical examination, appropriate use and interpretation of allergy testing and under some circumstances, deliberate challenge to prove or disprove allergy.

3. Education on the avoidance of trigger(s)

This is particularly important with food allergy induced anaphylaxis.

4. Provision of an ASCIA Action Plan for Anaphylaxis (emergency response plan)

This plan includes:

  • Personal details - patient’s photo, name, confirmed allergens and family/emergency contact.
  • Symptoms and signs indicating when to use the adrenaline injector.
  • Instructions on how to use the adrenaline injector.

5. Appropriate follow-up 

Review by a patient’s medical practitioner (normally their GP) approximately 12-18 monthly should occur to:

  • Review any allergic reactions that have occurred since their last review.
  • Examine co-factors (such as poorly controlled or persistent asthma) that may increase the risk of more serious reactions.
  • Prescribe adrenaline injectors. If you do not want brand substitution, it is important to specify brand and tick box on PBS prescription. 
  • Provide re-education on adrenaline injector use (using a trainer device of the prescribed brand) and positioning (e.g. not standing or walking when experiencing anaphylaxis).
  • Renew ASCIA Action Plan for Anaphylaxis - the general version includes instructions for EpiPen® and Anapen®..
  • Provide ASCIA Travel Plan if required.
  • Determine if specialist review is required to ascertain if the allergy persists, new allergies have developed or if more detailed revi4ew is required.

© ASCIA 2024

Content and weblinks updated July 2024

For more information go to www.allergy.org.au/hp/anaphylaxis

To support allergy and immunology research go to www.allergyimmunology.org.au/donate

ASCIA Travel Plan and Checklist for people at risk of anaphylaxis

The ASCIA travel plan and checklist have been developed to assist people at risk of anaphylaxis, who need to carry adrenaline (epinephrine) injectors (EpiPen® or Anapen®) when travelling.

The travel plan should be used in conjunction with a red ASCIA Action Plan for Anaphylaxis and both plans need to be completed by a doctor or nurse practitioner.

pdfASCIA Travel Plan Anaphylaxis 2023184.47 KB

pdfASCIA PC Checklist Anaphylaxis Travel 2024135.08 KB

ASCIA Checklist - TravelASCIA PC Checklist Anaphylaxis Travel 2024 

This document has been developed by ASCIA, the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand. ASCIA information is based on published literature and expert review, is not influenced by commercial organisations and is not intended to replace medical advice.        

For patient or carer support contact Allergy & Anaphylaxis Australia or Allergy New Zealand.

Plan ahead

You may need to request the following from your doctor or nurse practitioner:

  • Prescriptions to cover your trip.
  • Letter about medications you need to take.
  • Special vaccinations.
  • Updated ASCIA Action Plan for Anaphylaxis and ASCIA Travel Plan if you are carrying an adrenaline (epinephrine) injector (EpiPen® or Anapen®). You may wish to photograph these onto your mobile phone together with your prescriptions.
  • Medical report for your travel insurance policy, if required.

Medication

  • Take enough for your trip, and some spare in case you get delayed, lose it or need a higher dose.
  • Make sure medicines have not expired or will not expire whilst you are travelling.
  • If you have been prescribed adrenaline injectors, you should always carry these with you, including when travelling. You should check if it is possible to replace the adrenaline injectors if they are used.
  • Take medication in original packaging. This reduces the risk of having problems with security and customs when leaving Australia or New Zealand as there are regulations about exporting government subsidised medicines. There may also be problems with security and customs when entering other countries.
  • Carry essential medicines in your hand luggage. Adrenaline injectors should not be packed into checked-in luggage or in overhead lockers. They must be easily accessible at all times.

Vaccination

  • Respiratory infections can trigger asthma so it is advised to consider influenza and other available vaccination. If egg allergic, the influenza vaccine can usually be given safely. For more information go to the ASCIA website www.allergy.org.au/patients/food-allergy/egg-allergy-flu-vaccine.
  • If you need other egg-containing vaccines, you will need specialist advice.

Travel Plan for Anaphylaxis

  • Download an ASCIA Travel Plan for people at risk of anaphylaxis (severe allergic reaction) from the ASCIA website wwww.allergy.org.au/hp/ascia-plans-action-and-treatment#r3 and have it completed by your doctor or nurse practitioner. This helps if you are carrying adrenaline injectors in hand luggage and through security and customs.

Notify travel agent and airline/s about food allergy

  • Contact the airline/s to determine their food allergy policies well in advance of travel and before you book tickets.
  • Tell your travel agent and airline/s about your food allergy in advance.

Insurance

  • Have adequate travel insurance.
  • Ensure the policy covers your medical condition. Special approval may be required.
  • Check if there are any special conditions, such as a medical certificate or an additional fee to cover anaphylaxis.

Hospital and other medical facilities

  • At your travel destination/s determine the location and contact details of emergency facilities and have these details available in case they are needed.
  • Ensure that you have a way of contacting emergency services, such as your mobile phone.

Accommodation

  • For food allergy, consider self-catering accommodation, which gives you the option of safely preparing food for yourself.
  • When booking, enquire about relevant inhalant allergen risk (such as pets) if you have significant asthma or allergic rhinitis (hay fever) symptoms.
  • Speak with your doctor if you often become unwell when away from home. Some people have medications increased or commenced for the time of the travel.

When boarding (airline or ship)

  • Notify ship or airline attendants when you board about your allergies and indicate the location of your ASCIA Action Plan and adrenaline injector (if prescribed).
  • If an allergic reaction occurs while travelling, follow your ASCIA Action Plan and notify travel attendants so they can assist if needed.
  • You may also wish to notify passengers around you, particularly to reduce the likelihood that food may be offered to young children with food allergy.
  • Consider taking your own supply of food, bearing in mind restrictions on liquids for international flights. This is particularly important when considering the bottle size of antihistamine liquid or baby formula.
  • Consider wiping down tables and armrests to remove possible residual food allergens (contact can sometimes trigger mild allergic symptoms).
  • While fumes or dust from inhaled food allergen might cause allergic rhinitis (hay fever) or mild asthma symptoms, the risks of severe allergic reactions is very low unless the food is actually eaten.
  • Some airlines offer “exclusion zones” (not serving allergenic food within a few rows of the allergic person). While this can be requested, availability cannot be guaranteed. Since the effectiveness of ‘exclusion zones’ has not yet been researched, it is unknown whether this is an effective strategy to reduce the risk of allergen exposure.
  • Keep emergency medication with you in hand luggage. If you are travelling with adrenaline injectors, keep these with you or under the seat in front of you and NOT in the overhead locker. You need to be able to access your adrenaline injectors with your seatbelt fastened.

Language cards

  • If travelling to non-English speaking countries and eating out, consider purchasing foreign language travel cards that warn about your allergy to show to food service staff. 

© ASCIA 2024

Content updated March 2024

For more information go to www.allergy.org.au/patients/about-allergy 

To support allergy and immunology research go to www.allergyimmunology.org.au/donate 

ASCIA First Aid Plan for Anaphylaxis

ASCIA First Aid Plan Anaphylaxis General 2023 - ReadSpeaker will audio describe text and images shown in main panel. Anaphylaxis is the most severe type of allergic reaction and should always be treated as a medical emergency. Anaphylaxis requires immediate treatment with adrenaline (epinephrine), which is injected into the outer mid-thigh muscle. If treatment with adrenaline is delayed, this can result in fatal anaphylaxis. 

pdfASCIA First Aid Plan Anaphylaxis General 2023

MILD TO MODERATE ALLERGIC REACTIONS

SIGNS

  • Swelling of lips, face, eyes
  • Hives or welts
  • Tingling mouth
  • Abdominal pain, vomiting - these are signs of anaphylaxis for insect allergy

ACTIONS

  • Stay with person, call for help
  • Locate adrenaline injector
  • Phone family/emergency contact
  • Insect allergy - flick out sting if visible
  • Tick allergy - seek medical help or freeze tick and allow to drop off
Mild to moderate allergic reactions may not always occur before anaphylaxis
SIGNS OF ANAPHYLAXIS (SEVERE ALLERGIC REACTIONS)

Watch for ANY ONE of the following signs:

  • Difficult or noisy breathing
  • Swelling of tongue
  • Swelling or tightness in throat
  • Wheeze or persistent cough
  • Difficulty talking or hoarse voice
  • Persistent dizziness or collapse
  • Pale and floppy (young children)
ACTIONS FOR ANAPHYLAXIS 
1 LAY PERSON FLAT - do NOT allow them to stand or walk
• If unconscious or pregnant, place in recovery position - on left side if pregnant       
• If breathing is difficult allow them to sit with legs outstretched
• Hold young children flat, not upright
 
LAY PERSON FLAT do NOT allow them to stand or walkIf unconscious or pregnant place in recovery position, on left side if pregnantIf breathing is difficult allow them to sit with legs outstretchedHold young children flat not uprightDo NOT allow the person to stand or walk
  

2 GIVE ADRENALINE INJECTOR

3 Phone ambulance - 000 (AU) or 111 (NZ)

4 Phone family/emergency contact

5 Further adrenaline may be given if no response after 5 minutes

6 Transfer person to hospital for at least 4 hours of observation

IF IN DOUBT GIVE ADRENALINE INJECTOR
Commence CPR at any time if person is unresponsive and not breathing normally

ALWAYS give adrenaline injector FIRST, if someone has SEVERE AND SUDDEN BREATHING DIFFICULTY (including wheeze, persistent cough or hoarse voice), even if there are no skin symptoms. THEN SEEK MEDICAL HELP. 
 
Adrenaline injectors doses are:
• 150 mcg for children 7.5-20kg
• 300 mcg for children over 20kg and adults
• 300 mcg or 500 mcg for children and adults over 50kg
Instructions are on device labels.

 

If adrenaline is accidentally injected, phone your local poisons information centre. Continue to follow this plan for the person with the allergic reaction.

© ASCIA 2023

This document has been developed for use as a poster, or to be stored with general use adrenaline injectors. 

Adrenline injector instructions are available on the ASCIA website as follows: 

https://www.allergy.org.au/hp/anaphylaxis/how-to-give-epipen

https://www.allergy.org.au/hp/anaphylaxis/how-to-give-anapen

https://www.allergy.org.au/hp/anaphylaxis/how-to-give-injector

ASCIA First Aid Plan for Anaphylaxis Pictorial

ASCIA First Aid Plan for Anaphylaxis Pictorial

pdfASCIA First Aid Plan Anaphylaxis Pictorial A3 Poster 2023

Anaphylaxis is the most severe type of allergic reaction and should always be treated as a medical emergency. Anaphylaxis requires immediate treatment with adrenaline (epinephrine), which is injected into the outer mid-thigh muscle. If treatment with adrenaline is delayed, this can result in fatal anaphylaxis.

MILD TO MODERATE ALLERGIC REACTIONS

SIGNS
  • Swelling of lips, face, eyes
  • Hives or welts
  • Tingling mouth
  • Abdominal pain vomiting these are signs of anaphylaxis for insect allergy

ACTIONS

  • Stay with person, call for help
  • Locate adrenaline injector
  • Phone family/emergency contact
  • Insect allergy - flick out sting if visible
  • Tick allergy - seek medical help or freeze tick and allow to drop off
Mild to moderate allergic reactions may not always occur before anaphylaxis

ANAPHYLAXIS (SEVERE ALLERGIC REACTIONS)

WATCH FOR ANY ONE OF THE FOLLOWING SIGNS

  • Difficult or noisy breathing
  • Swelling of tongue
  • Swelling or tightness in throat
  • Wheeze or persistent cough
  • Difficulty talking or hoarse voice
  • Persistent dizziness or collapse
  • Pale and floppy (young children)
  • Abdominal pain, vomiting - these are signs of ANAPHYLAXIS for insect allergy

ACTIONS

1. LAY PERSON FLAT - do NOT allow them to stand or walk
• If unconscious or pregnant, place in recovery position - on left side if pregnant       
• If breathing is difficult allow them to sit with legs outstretched
• Hold young children flat, not upright
 
LAY PERSON FLAT do NOT allow them to stand or walkIf unconscious or pregnant place in recovery position, on left side if pregnantIf breathing is difficult allow them to sit with legs outstretchedHold young children flat not uprightDo NOT allow the person to stand or walk
  

2. GIVE ADRENALINE INJECTOR as shown on the device label

Give adrenaline injector as shown on device label to person lying downgive adrenaline injector as shown on device label to person sittinggive adrenaline injector as shown on device label for self lying downgive adrenaline injector as shown on device label for self sittinggive adrenaline injector as shown on device label for baby

3. Phone ambulance - 000 (AU) or 111 (NZ)

4. Phone family/emergency contact

Phone ambulance - 000 (AU) or one one one (NZ) Phone family/emergency contact

5. Further adrenaline may be given if no response after 5 minutes

Further adrenaline may be given if no response after 5 minutes

6. Transfer person to hospital for at least 4 hours of observation

Transfer person to hospital for at least 4 hours of observation

IF IN DOUBT GIVE ADRENALINE INJECTOR
Commence CPR at any time if person is unresponsive and not breathing normally

Commence CPR at any time if person is unresponsive

Adrenaline injectors doses are:

  • 150 mcg for children 7.5 to 20 kg
  • 300 mcg for children over 20 kg and adults
  • 300 mcg or 500 mcg for children and adults over 50 kg
Instructions are on device labels.

ALWAYS give adrenaline injector FIRST, if someone has SEVERE AND SUDDEN BREATHING DIFFICULTY (including wheeze, persistent cough or hoarse voice), even if there are no skin symptoms. THEN SEEK MEDICAL HELP. 

If adrenaline is accidentally injected, phone your local poisons information centre. Continue to follow this plan for the person with the allergic reaction.

© ASCIA 2023

This pictorial poster has been developed in response to requests for a more visual version of the ASCIA First Aid Plan for Anaphylaxis, which can also assist people with limited reading ability. The plan is best viewed when printed as an A3 poster which can be displayed in schools, children’s education/care (CEC) services and other community settings. It includes infographics showing:

  • Signs of mild, moderate and severe allergic reactions (anaphylaxis); and
  • Actions for anaphylaxis.

Development of this poster was supported by ASCIA and the NSW Anaphylaxis Education Program (NSWAEP), as part of the Sydney Children's Hospitals Network (SCHN).

ASCIA Action Plans for First Aid - Quick links

Read more …ASCIA First Aid Plan for Anaphylaxis Pictorial

ASCIA Action Plans and First Aid Plans for Anaphylaxis old 2020

The ASCIA Action Plan for Anaphylaxis is an emergency response plan for severe allergic reactions (anaphylaxis). Current ASCIA Action Plans are the General and EpiPen 2021 versions, and the 2022 Anapen version. However, prior versions (2021, 2020 and 2018) are still valid for use in 2022 and 2023. 

ASCIA Action Plans do not expire, and therefore the plan is still valid beyond the recommended review date, which is a guide for patients to see their doctor. For more information about ASCIA Action Plans go to www.allergy.org.au/hp/anaphylaxis/action-plans-for-allergic-reactions-faq

ASCIA Action Plans are medical documents that are completed and signed by the treating doctor or nurse practitioner. A signature is sufficient, ASCIA Action Plans do NOT need to be stamped. To insert a digital photograph and signature, first save as a PDF after typing patient details into the text fields. Alternatively a physical photograph can be glued to the plan and the doctor can use a wet or digital signature.

ASCIA Action Plan for Anaphylaxis (RED) for use with EpiPen® adrenaline autoinjectors 2021
ASCIA Action Plan for Anaphylaxis (RED) 2021 EpiPen® 

This plan is provided to people with allergies who have been prescribed EpiPen® adrenaline autoinjectors. 

This plan is not for allergic rhinitis (hay fever) due to pollen, dust mite, animals or other inhaled allergens.

pdfASCIA Action Plan Anaphylaxis EpiPen Red 2021
ASCIA Action Plan for Anaphylaxis (RED) for use with Anapen adrenaline autoinjectors 2021
ASCIA Action Plan for Anaphylaxis (RED) 2022 Anapen®

This plan is provided to people with allergies who have been prescribed Anapen® adrenaline autoinjectors. The TGA has approved Anapen® to be held in place for 3 seconds (reduced from 10 seconds) since September 2022. 

This plan is not for allergic rhinitis (hay fever) due to pollen, dust mite, animals or other inhaled allergens.

pdfASCIA Action Plan Anaphylaxis Anapen Red 2022
ASCIA Action Plan for Anaphylaxis (RED) for use with adrenaline autoinjectors 2021
ASCIA Action Plan for Anaphylaxis (RED) 2021 General version with QR code 

This plan is provided to people with allergies who have been prescribed any brand of adrenaline injector.  This plan should be printed with the 'ASCIA How to give Adrenaline Injectors' document on the reverse side (see below).

This plan is not for allergic rhinitis (hay fever) due to pollen, dust mite, animals or other inhaled allergens.

pdfASCIA Action Plan Anaphylaxis General Red 2021
How to give adrenaline injectors (Anapen® and EpiPen®)
ASCIA How to give Adrenaline Injectors 2022

This document can be used as a poster, and should be printed on the reverse side of the general versions of the 'ASCIA Action Plan for Anaphylaxis' (see above) and 'ASCIA First Aid Plan for Anaphylaxis' (see below). 

pdfASCIA PCC How to give Adrenaline Injectors 2022
ASCIA Action Plan for Allergic Reactions (GREEN)
ASCIA Action Plan for Drug (Medication) Allergy (GREEN) 2021

This plan is provided to people with drug (medication) allergies who are not usually prescribed an adrenaline injector, because accidental exposure to drugs can mostly be avoided. They are usually recommended to wear medical identification, to avoid exposure to drugs used in medical procedures. 

pdfASCIA Action Plan Drug Allergy 2021
ASCIA Action Plan Allergic Reactions Green 2021
ASCIA Action Plan for Allergic Reactions (GREEN) 2021

This plan is provided to people with allergies who have not been prescribed an adrenaline injector. 

This plan is not for allergic rhinitis (hay fever) due to pollen, dust mite, animals or other inhaled allergens.

pdfASCIA Action Plan Allergic Reactions Green 2021

An ASCIA Action Plan for Anaphylaxis for use with adrenaline autoinjectors on airlines is available upon request. This plan is should be stored with adrenaline autoinjectors in emergency medical kits on airlines. 

ASCIA First Aid Plans for Anaphylaxis (ORANGE)

Note: These have replaced the general versions of ASCIA Action Plans for Anaphylaxis (ORANGE).

ASCIA First Aid Plans for Anaphylaxis (ORANGE) for use with EpiPen® adrenaline autoinjectors 2021
ASCIA First Aid Plan for Anaphylaxis (ORANGE) 2021 EpiPen®   

This plan can be used as a poster or stored with general use EpiPen® adrenaline autoinjectors.

pdfASCIA First Aid Anaphylaxis EpiPen Orange 2021
ASCIA First Aid Anaphylaxis Orange Anapen 2022 
ASCIA First Aid Plan for Anaphylaxis (ORANGE) 2022 Anapen®   

This plan can be used as a poster or stored with general use Anapen® adrenaline autoinjectors. The TGA has approved Anapen® to be held in place for 3 seconds (reduced from 10 seconds) since September 2022. 

pdfASCIA First Aid Anaphylaxis Anapen Orange 2022
ASCIA First Aid Plans for Anaphylaxis (ORANGE) for use with any brand of adrenaline autoinjectors 2021
ASCIA First Aid Plan for Anaphylaxis (ORANGE) 2021 General version

This plan can be used as a poster or stored with any brand of general use adrenaline injectors. 

pdfASCIA First Aid Anaphylaxis General Orange 2021
ASCIA First Aid Plan for Anaphylaxis ORANGE 2021 Pictorial Poster
ASCIA First Aid Plan for Anaphylaxis (ORANGE) 2021 Pictorial Poster 

The plan is best viewed when printed as an A3 poster.

pdfASCIA First Aid Anaphylaxis Pictorial Orange 2021 poster

For translated versions of ASCIA First Aid for Anaphylaxis go to www.allergy.org.au/hp/anaphylaxis#ta5

For further information about ASCIA Action Plans and other anaphylaxis resources go to www.allergy.org.au/anaphylaxis   

Important information:

  1. ASCIA Action Plans were first developed in 2003 to standardise the recognition of signs and symptoms of anaphylaxis and provide easy to follow steps for the emergency treatment of allergic reactions, including anaphylaxis. They continue to be used as the standard action plans throughout Australia and New Zealand. The content is regularly reviewed by experts and updated as required. 
  2. ASCIA Action Plans do not expire, and therefore the plan is still valid beyond the review date, which is a guide for patients to see their doctor. Ideally, ASCIA Action Plans should be reviewed when patients are reassessed by their doctor or nurse practitioner, and each time they obtain a new adrenaline injector prescription, which is approximately every 12 to 18 months. If there are no changes in diagnosis or management the medical information on the ASCIA Action Plan may not need to be updated. However, if the patient is a child, the photo should be updated each time, so they can be easily identified.
  3. ASCIA Action Plans for Anaphylaxis can be used for people with food, insect, tick and drug allergies, or any other allergy that can result in a severe allergic reaction (anaphylaxis).  The plans are not for allergic rhinitis (hay fever) due to pollen, dust mite, animals or other inhaled allergens.
  4. Adrenaline injectors contain a single, fixed dose of adrenaline and are designed to be used by anyone (medical training is not required), or the patient themselves, if they are not too unwell or too young.
  5. It is generally recommended that people who have an adrenaline injector should also wear a medical identification/emergency response emblem, or other medical identification.
  6. ASCIA Action Plans should be used as part of a comprehensive anaphylaxis management plan that includes:
- Age appropriate education of people with allergies and their peers or colleagues. 
- Training in the recognition and management of allergic reactions.
- Development of strategies to reduce the risk of accidental exposure
- An ASCIA Action Plan to be used as an emergency response plan for when exposure to allergens occurs. 

Content updated March 2023

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