Emergency Response Sheets

Samples for wording:

If Child Name has a seizure lasting more than five minutes, or if she is having seizures non-stop, one after the other with no breaks in between:

Give her an Ativan pill inside her cheek
Watch so that it doesn’t fall out
It helps to rub it around inside her cheek so it stays in place and dissolves quickly

Call 911 – eight year old girl with history of seizures. Currently in status,
has been administered 2 mg Ativan, Health Card #123456789

Call a parent
Tell them that the ambulance has been called
Mom Name good phone numbers
Dad Name good phone numbers

Current medications are 750 mg stiripentol bid (available through AAA Pharmacy), 0.875 mg clonazepam bid (pms brand), 300 mg topiramate bid (2 x 100 mg + 4 x 25 mg, both sns brand), 3 mg warfarin nightly (apo brand), micronor (0.35 mg norethindrone) nightly (usual pharmacy is BBB pharmacy)
(also one Tums extra strength bid, one 1000 IU Vitamin D pm, one multi-vitamin am)

Do NOT give her dilantin (phenytoin), tegretol (carbamazepine, carbatrol), lamictal (lamotrigine, oxcarbazepine), vigabatrin. Tolerates Nasal Midazolam

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