Paramedic Pocketbook of Prescription Medications E-Book

Rose Matheson

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 263

Veröffentlichungsjahr: 2024

Beschreibung

Reference pocketbook containing common medications prescribed to patients to facilitate identification and revealing potential interactions, overdose symptoms, and common call outs

Easy to navigate and truly pocket-sized, the Paramedic Pocketbook of Prescription Medications covers common medications and their possible presentations, highlights risk of causing harm, and goes over mechanism of action, use, and potential risks for each.

Key features:

• Concise presentation of a wide range of medications, accessible even to those with a limited pharmacological background
• Brief overview of drug legislation and paramedic practice
• Includes special circumstances in paediatrics, the elderly, and individuals experiencing kidney injury and disease, hepatic failure, pregnancy and breastfeeding, and palliative care
• Highlights which conditions or medications have different prevalence or effects in different ethnic groups

Paramedic Pocketbook of Prescription Medications is an essential guide for emergency services personnel and first responders to carry with them for easy reference and peace of mind.

Leseprobe

Table of Contents

Cover

Table of Contents

Title Page

Copyright Page

Foreword

Acknowledgements

List of Abbreviations

Introduction

‘Have You Recently had a Change in Your Medications?’

References

Drug Legislation and Paramedic Practice

Schedule 19 of the Human Medicines Regulations 2012

Schedule 17 of the Human Medicines Act (Part 3.8)

Patient Group Directives

Associate of Ambulance Chief Executives Protocols

Prescribing

Controlled Drugs

References

Special Circumstances

Paediatrics

The Older Person

Kidney Injury and Disease

Hepatic Failure

Pregnancy and Breastfeeding

Palliative Care and Those at the End of Life

References

Medication Groups

An Example Table

A

References for A

B

References for B

C

References for C

D

References for D

E

References for E

F

References for F

G

References for G

H

References for H

I

References for I

K

References for K

L

References for L

M

References for M

N

References for N

O

Reference for O

P

References for P

Q

Reference for Q

R

References for R

S

References for S

T

References for T

V

Reference for V

W

Reference for W

Z

Brand Names Index

Glossary

End User License Agreement

List of Tables

Drug Legislation and Paramedic Practice

Table 1 Controlled Drug Schedules

Special Circumstances

Table 1 Classification of Paediatric Patient’s Based on Age [2]

Table 2 Estimated Glomerular Filtration Rates and Kidney Disease Classificat...

Table 3 Prehospital Medication and the Pregnant or Breastfeeding Person

List of Illustrations

Introduction

Figure 1 Ambulance call‐outs due to medicines can be grouped into different ...

Special Circumstances

Figure 1 The special circumstances surrounding medications and paediatric pa...

Figure 2 There are several considerations regarding medicines and the older ...

Figure 3 ‘Sick Day Rules’ are a useful piece of safety netting advice to giv...

Figure 4 Examples of Just in Case Medicines as per the Scottish Palliative C...

Guide

Drug Legislation and Paramedic Practice

Special Circumstances

Medication Groups

An Example Table

Cover Page

Table of Contents

Title Page

Copyright Page

Foreword

Acknowledgements

List of Abbreviations

Introduction

Begin Reading

Brand Names Index

Glossary

WILEY END USER LICENSE AGREEMENT

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Paramedic Pocketbook of Prescription Medications

Rose Matheson

Queen Margaret University

Edinburgh, UK

This edition first published 2024© 2024 by John Wiley & Sons Ltd

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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging‐in‐Publication Data applied forPaperback ISBN: 9781394202492

Cover Design: WileyCover Image: © James Thew/Adobe Stock Photos

Foreword

As paramedics, we are entrusted with the immense responsibility of caring for the health and well‐being of those in need. Every day, we face countless challenges, potentially making split‐second decisions that can have long‐lasting effects.

The world of paramedicine continues to evolve at pace, one area that has changed beyond recognition in the last couple of decades is the paramedic’s knowledge of pharmacology; no longer is a protocol approach sufficient. The modern paramedic is expected to understand and navigate the complexities presented by medications and drugs.

This remarkable book presents a treasure trove of easily accessible content offering a comprehensive guide to common prescription medications for paramedics working in a variety of environments. Within these pages you will find a wealth of information that will enhance your understanding of prescription medications and empower you to make informed decisions in this field. This book is a testament to the author in ensuring that paramedics have access to up to date and relevant information in this critical aspect of our practice.

What truly sets this book apart is its commitment to accessibility. A talented artist, Rose has presented the information in a visually engaging manner, using graphics to enhance comprehension. This practical approach is suited fabulously to the pragmatic people that we paramedics tend to be; each medication is presented in a concise and easily understandable manner, making it accessible even to those with a limited pharmacological background.

I would like to express my deepest gratitude to Rose, for her dedication and expertise in compiling this essential resource. Her commitment to excellence is evident in every page, and her passion for advancing knowledge and understanding of pharmacology shines through.

To my fellow paramedics, I encourage you to embrace this text as a companion on your journey to providing the highest standard of care. May this book serve as a trusted ally in navigating the complex arena of medications.

Kirsty Lowery‐Richardson, Head ofEducation – College of Paramedics

Acknowledgements

Thanks to the team at Wiley for helping me write my first book! Specifically, I would like to thank Tom Marriott at Wiley for initially reaching out to me with his idea for this book and Christabel and Valli for their support during the writing stages. Equally I would like to thank my partner Harry and loyal wire‐haired pointer Marsco for their pastoral support! Thanks to my mum Fiona Matheson for reading through early drafts for spelling errors just as she used to do for my school essays and Maya Walker who also lent me sharp eye! Most importantly, thank you to my students who have helped me get rid of my imposter syndrome (a bit) and to the students who are reading this book to try and learn more to support the people they treat.

List of Abbreviations

5HT – Serotonin

ACE – Angiotensin Converting Enzyme

AF – Atrial Fibrillation

AIDS – Acquired Immune Deficiency Syndrome

AKI – Acute Kidney Injury

BPH – Benign Prostate Hyperplasia

CCB – Calcium Channel Blocker

CK – Creatine Kinase

CKD – Chronic Kidney Disease

CKD‐EPI – Chronic Kidney Disease Epidemiology Collaboration

CNS – Central Nervous System

COPD – Chronic Obstructive Pulmonary Disease

COX – Cyclo‐oxygenase

D2 – Dopamine

DIC – Disseminated Intravascular Coagulation

DMARDs – Disease Modifying Anti‐Rheumatic Drugs

DOAC – Direct Oral Anti‐Coagulant

DPP‐4 – Dipeptidyl Peptidase 4

DRESS – Drug Reaction with Eosinophilia and Systemic Symptoms

DVLA – Driving and Vehicle Licensing Agency

DVT – Deep Vein Thrombosis

ECG – Electrocardiogram

FBC – Full Blood Count

GERD – Gastro‐oesophageal Reflux Disease

GSL – General Sales List

H@H – Hospital at Home

INR – International Normalised Ratio

JIC – Just In Case

LDL – Low Density Lipoproteins

LFT – Liver Function Tests

MHRA – Medicines and Healthcare Products Regulatory Agency

NG – Nasogastric (tube)

NJ – Nasojejunal (tube)

NSAID – Non‐steroidal Anti‐inflammatory Drug

OCD – Obsessive Compulsive Disorder

P – Pharmacy

PC – Palliative Care

PCOS – Polycystic Ovary Syndrome

PE – Pulmonary Embolism

PEG – Percutaneous Endoscopic Gastrostomy (tube)

PGD – Patient Group Directive

POM – Prescription Only Medicine

PPCI – Primary Percutaneous Coronary Intervention

PRN – ‘pro re nata’ (take as required)

QRS – QRS Complex of Electrocardiogram

RAAS – Renin Angiotensin Aldosterone System

RIG – Radiologically inserted gastrostomy (tube)

SCARs – Severe Cutaneous Adverse Reactions

SLE – Systemic Lupus Erythematosus

SNRI – Serotonin and Noradrenaline reuptake inhibitor

STEMI – ST‐Elevation Myocardial Infarction

T2DM – Type 2 Diabetes Mellitus

TIA – Transient Ischaemic Attack

URTI – Upper Respiratory Tract Infection

VT – Ventricular Tachycardia

Introduction

‘Have You Recently had a Change in Your Medications?’

This is one of my favourite questions to ask a patient. Mainly in the hope that I can use some pharmacological detective skills to find a medication that is causing their symptoms (Figure 1). Maybe their new blood pressure medication is the reason they are feeling dizzy when they stand up? Maybe their insulin dose is causing them to suffer regular hypoglycaemic events? Has their steroid inhaler caused their oral thrush? Has their lidocaine patch sent them into an arrhythmia?

As paramedics, we have a unique knowledge of medications. We have the medications that we are privileged to provide people in an emergency through Schedule 17 and 19 of the Human Medicines Regulation 2012 and then some more that are mutually agreed to be beneficial and included in guidelines from the JRCALC or as a Patient Group Directive. As the role of the paramedic has developed from primarily a transport service to a mobile medical centre, we have developed into expert generalists in urgent and emergency medicine. The role of the paramedic has been less of an emerging profession but an exploding one with a dramatic change in the demands on the profession over the last few decades.

However, a lot of this learning is done post‐qualification. Education can still be focused on trauma and life‐threatening calls of which the latter is now well expected to make up only 10% of our workload [1]. The other 90% of calls we attend don’t always align to our training. This can leave both new and experienced clinicians to suffer from regular bouts of uncertainty which when repeated can contribute to burnout [2]. The role of the paramedic involves attending more and more people with urgent presentations and chronic disease which has resulted in paramedics needing a more rounded knowledge of prescription medicines despite this not classically being part of the curriculum for paramedics. That is where I am hoping this book comes in useful, as an easy‐to‐use resource to familiarise ambulance clinicians with commonly prescribed medications. The list of medications used includes the top prescribed medications in England [3] but with a greater focus on medications in a primary care setting as these are more commonly encountered by ambulance clinicians in the prehospital environment.

Figure 1 Ambulance call‐outs due to medicines can be grouped into different categories which can hide behind common presentations that we might not consider to be related to a person's medication.

Due to my location and training, this book focuses on UK‐based practice and legislation. However, in the main list, the drug names have been used rather than brand names and many of the uses, side effects and data will still be applicable elsewhere in the world. This pocketbook aims to provide an additional reference for ambulance staff and other non‐prescribers in order to familiarise themselves with commonly prescribed medications. It is not meant to be used as an alternative to the British National Formulary (BNF) or a discussion with a prescriber.

References

1

The Nuffield Trust. Ambulance Response Times [internet]. 2023. The Nuffield Trust: London. [cited 2023 08 29]. Available at:

https://www.nuffieldtrust.org.uk/resource/ambulance‐response‐times

2

Alzahrani, A., Keyworth, C., Wilson, C. and Johnson, J. Causes of stress and poor mental wellbieng among paramedic students in Saudi Arabia and the United Kingdom: a cross‐cultural qualitative study BMC Health Serv Res 2023 5 (23). [cited 2024 03 15]. Available at:

https://doi.org/10.1186/s12913‐023‐09374‐y

3

Audi, S., Burrage, DR., Lonsdale, DO., Pontefract, S. Coleman, JJ., Hitchings, AW. and Baker, EH. The ‘top 100’ drugs and classes in England: an updates ‘starter formulary’ for trainee prescribers Br J Clin Pharm 2018 84 (11) p2562–2571. [cited 2023 06 01]. Available at:

https://doi.org/10.1111/bcp.13709

Drug Legislation and Paramedic Practice

Paramedics are able to administer several medications to patients autonomously, meaning without a discussion with a prescriber, but these medications do not all fall under the same legislation.

Schedule 19 of the Human Medicines Regulations 2012

These are medications that anyone can administer in an emergency [1]. This is why anyone can give an EpiPen® to someone suffering from suspected anaphylaxis and there is increasing training in ‘Take Home Naloxone’ for opiate overdoses. Medications under this legislation include:

Adrenaline 1:1000 up to 1 mg for intramuscular use in anaphylaxis

Atropine sulphate and obidoxime chloride injection

Atropine sulphate and pralidoxime chloride injection

Atropine sulphate injection

Atropine sulphate, pralidoxime mesylate and avizafone injection

Chlorphenamine injection

Dicobalt edetate injection

Glucagon injection

Glucose injection

Hydrocortisone injection

Naloxone hydrochloride

Pralidoxime chloride injection

Pralidoxime mesylate injection

Promethazine hydrochloride injection

Snake venom antiserum

Sodium nitrate injection

Sodium thiosulphate injection

Sterile pralidoxime

Note that the only indication here is for anaphylaxis and there is no clear guidance on when other medications should be indicated. Regulation 214 [2] may also be quoted in reference to paramedics which suggests prescription‐only medications can only be administered parenterally in the presence of an ‘appropriate practitioner’ of whom paramedics are not identified. However, Regulation 238 states that Regulation 214 should be disregarded in the instance of Schedule 19 medicines in order to save a life in an emergency. Therefore, these medications can still be given by anyone; however, the indication for giving them is not clear.

Schedule 17 of the Human Medicines Act (Part 3.8)

These prescription medications can be given by paramedics for the ‘necessary’ treatment of sick people [2]. This schedule covers different professions that have their own exemptions to allow them to provide certain prescription medications. These may be referred to as ‘exemption medications’. Not all medications we use are covered by this legislation and some of the medications here have fallen out of favour (e.g. streptokinase). Some medications are listed but not indicated for the use that they are now mainly given – for example, heparin is only stated to be used as a flush and not as part of cardiac thrombolysis. Again, there are no indications stated for all these medications.

These medications include:

Adrenaline acid tartrate

Adrenaline hydrochloride

Amiodarone

Anhydrous glucose

Benzylpenicillin

Compound sodium lactate (Hartmann’s Solution)

Diazepam 5 mg/ml

Ergometrine 500 mcg

Ergometrine maleate 500 mcg and oxytocin 5 units (Syntometrine

®

)

Furosemide

Glucose

Heparin sodium (only to flush a cannula)

Lidocaine hydrochloride

Metoclopramide

Morphine sulphate

Nalbuphine hydrochloride

Naloxone hydrochloride

Ondansetron

Paracetamol

Reteplase

Sodium chloride

Streptokinase

Succinylated modified fluid gelatin

Tenecteplase

Patient Group Directives

Patient Group Directives (PGDs) are legislation that allows for a certain group of health care professionals to administer a specific medication to a specific patient group [3]. An example is heparin; ambulance services create a PGD to allow paramedics to administer heparin to people expecting Primary Percutaneous Coronary Intervention (PPCI) treatment or thrombolysis. Different ambulance services will have different medications available as PGDs and this can include a ‘new’ medication for paramedics such as codeine for moderate pain or a medication we use but in a different form or route, e.g. nebulised adrenaline for croup. What is important to understand is that these medications can only be given for the presentations mentioned on the PGD and if you change employment to another ambulance service or trust you cannot give this medication unless it is also a PGD in your new service.

Associate of Ambulance Chief Executives Protocols

The Joint Royal College Ambulance Liaison Committee (JRCALC) list medications that ambulance services and trusts have generally agreed will benefit people if paramedics are able to administer them. These medications are more colloquially known as ‘JRCALC medicines’. This includes medications such as clopidogrel. Individual ambulance trusts may have their own specific guidelines for these medications through PGD, or they will follow JRCALC guidance.

Prescribing

Some paramedics will choose to do additional training to gain their Non‐Medical Prescribing qualification at Bachelors or Masters level. This allows them to prescribe medications from the BNF and they will be listed as an independent or supplementary prescriber on the Health and Care Professions Council (HCPC). However, at the time of writing, paramedic prescribers are only able to prescribe a limited list of controlled drugs [4].

Controlled Drugs

Since I’ve mentioned it, let’s talk about controlled drugs.

Paramedics can autonomously administer a selection of what are known as ‘controlled’ medications such as morphine sulphate and benzodiazepines through various forms of legislation. The Misuse of Drugs Act 1971 [5] places drugs in different ‘classes’ which are organised on a scale based on the potential harm when misused and includes both prescription drugs and illicit drugs.

Class A

– Includes cocaine, heroin, LSD, MDMA, morphine, methadone.

Class B

– Includes oral amphetamines, cannabis, codeine, dihydrocodeine, ketamine and barbiturates.

Class C –

Includes buprenorphine, benzodiazepines, tramadol, zopiclone, androgenic and anabolic steroids, gabapentin, pregabalin and most recently nitrous oxide.

The Misuse of Drugs (Safe Custody) regulations 1973 is related to the safe storage of controlled drugs and the Misuse of Drugs Regulations 2001 discusses who can provide controlled drugs and the requirements for supply, prescribing and record keeping (Table 1). This is where the terminology of having different ‘schedules’ of controlled medications comes in. This is why morphine and midazolam need to be double locked in a safe whereas diazepam does not.

This legislation originates from attempts to prevent misuse of drugs to cause harm. The knowledge behind drug misuse is evolving and a greater understanding of life experiences that contributes to drug use is becoming clearer. There is greater appreciation that drug use and addiction is a coping mechanism for early childhood trauma which can be supported through appropriate rehabilitation. Legislation is yet to reflect this; however, there is growing acceptance within the medicine and psychology fields that to tackle drug misuse legislation needs to be supportive not punitive [6].

Table 1 Controlled Drug Schedules

SCHEDULE

EXAMPLES

REQUIREMENTS

PREHOSPITAL EXAMPLES

Schedule 1

Hallucinogenic drugs, ecstasy‐like drugs, opium, cannabis

Home office licence required for production, possession+supply. Controlled drugs register kept with pharmacy details.

NONE

Schedule 2

Opiates, stimulants, cocaine, ketamine, medicinal cannabis products

Controlled drugs register to be kept detailing administration of supply. Must be stored in a locked safe.

Morphine sulphate (IV preparation) Ketamine

Schedule 3

Most barbituates, gabapentin, pregabalin, midazolam, temazepam

Some groups must be stored in a locked safe. Retention of invoices for 2 years

Midazolam

Schedule 4

other benzodiazepines, Z‐drug, anabolic + androgenic steroids

Retention of invoices for 2 years

Diazepam

Schedule 5

Codeine phosphate, oral preparations of morphine

Retention of invoices for 2 years

Codeine, oramorph

®

References

1

United Kingdom. The Humans Medicines Regulation 2012 No 1916 Schedule 19

2

United Kingdom. The Human Medicines Regulation 2012 no 1916 Schedule 17 Part 3.8

3

Medicines and Healthcare Products Regulatory Authority. Patient Group Directions: who can use them [internet] 2017 [cited 2024 03 18]. Available at:

https://www.gov.uk/government/publications/patient‐group‐directions‐pgds/patient‐group‐directions‐who‐can‐use‐them

4

England, Wales and Scotland. The Misuse of Drugs Regulations 2023 No. 1345

5

United Kingdom, The Misuse of Drugs Act 1971 c.38

6

Maté, G. and Maté, D. The Myth of Normal. Vermillion: London, 2022, p213–234

Special Circumstances

Paediatrics

Figure 1 The special circumstances surrounding medications and paediatric patients.

There are special circumstances surrounding medications and paediatric patients due to their unique stages of development (Figure 1). Dose and route considerations are important and several medications are unlicensed which leaves scope for adverse effects.

Not Small Adults

The phrase ‘children are not small adults’ is especially applicable to pharmacology. Paediatrics vary from adults not only in their size but also their organ maturity which can affect the pharmacokinetics and pharmacodynamics of a drug in the body.

Paediatrics is also not a single group, there are several stages of development that can alter aspects of pharmacology as we go through childhood. Anecdotally, defining different groups within paediatrics is a grey area in paramedic practice and we are not often sure of the boundaries. Often, we only consider there to be neonates and paediatrics in relation to resuscitation guidelines. However, when it comes to medication, these groups can be subdivided and furthermore there is still considerable overlap in rates of metabolism, physical and mental development (Table 1). For example, did you know that the dose of adrenaline in cardiac arrest is greater in a newborn than a one month old?1

Adverse Reactions

Reporting of adverse reactions to medications in paediatric patients from practice is vital. Not only for duty of candour and authenticity as a professional but also because most clinical trials for developing medications and randomised controlled trials for testing effects do not routinely involve paediatric populations. Understandably, this would not be easy to gain ethical approval for. This means that many drugs are considered ‘off‐label’ or ‘unlicensed’ in paediatrics as they have not been fully tested on these patient groups. This means that many medications have not actually been tested for the same level of safety for paediatrics which can put both the prescriber and the child at risk. Many of the known side effects of medications on paediatric populations are because of people reporting adverse effects after using the medicine.

Table 1 Classification of Paediatric Patient’s Based on Age [2]

TERM

AGE RANGE

CONSIDERATIONS

Pre‐term Newborn

Delivery < 37 weeks

There is still considerable variation in this category as a baby delivered at 25 weeks can differ in development from a baby delivered at 30 weeks. Expected birth weight is also a factor as low birth weight may align to a more prematurely developed infant.

Term Newborn

Delivery > 37 weeks

Infant

0 – 28 days

There is high body surface area to weight ratio at this stage. Small volumes can account for a large portion of the overall blood volume. The blood‐brain barrier is not fully formed. Hepatic and renal clearance is immature leading to an increased suspectability to toxic effects.

Infant ‐ Toddler

28 days – 25 months

Hepatic + renal clearance continue to develop. Clearance of drugs can be quicker than in adults so doses may be higher than adult doses. The blood‐brain barrier is fully formed at 4 months.

Children

2 – 11 years

Again drug clearance can exceed adult values so doses may still be high. There are several growth and cognitive milestones during this phase which may be affected by medications. Consider that onset of puberty can vary and may occur in the later stages of this age group.

Addescents

12 – 18 years

Consideration is required for medications or conditions that interfere with sex hormones at these ages. Pregnancy, alcohol and drug use can be genuine considerations. Individuals start to take ownership of their own health decisions. Variable degrees of emotional maturity.

We have already seen that children are not just small adults and can have different levels of organ maturity which may mean that the action of a drug or metabolite may differ to that of an adult. Aspirin is a well‐known example where, given to a person under 16 can cause Reye’s Syndrome2 where the components of aspirin damage mitochondria in children but not adults. Clinical presentations of disease can also differ between adults and children – croup is an example where a viral upper respiratory infection can be fatal in children but a mere annoyance in an adult.

Due to the important growth milestones throughout childhood, it is not certain how some medications might affect different stages of development.

Medications may not be available in formulations that allow for specific dosing for paediatrics. Continuing with croup, consider the use of dispersible tablet formulations of dexamethasone compared to the solution. It is much easier to give the exact dosing using the solution, but this is not always made available by ambulance trusts.

Dose and Route are Important

Children should be involved in discussions regarding their medications where possible to improve agency over their own health. Paediatric dosing can be complex when trying to balance an increased metabolic rate with a small blood volume which can result in increased daily dosing. It is important to consider the regime for drug dosing and to avoid midday doses in younger children who might be at school and away from a caregiver to provide or supervise administration.

Generally, the oral route is preferred by most children with solutions being the easiest and most palatable. It can be common practice to disguise the taste of medicines using food – this is known as covert administration and if a person has capacity, they still must provide consent to being given the medication even if it is disguised. Caregivers must check that the medication absorption will not be hindered by being given with food. In children, this can also result in developing an aversion to certain foodstuffs as they are associated with medication.

Invasive parenteral routes such as intramuscular and intravenous administration should be avoided where possible. However, some drugs and clinical scenarios will necessitate the use of these routes especially in the prehospital environment. It is worth remembering that these procedures can be traumatic for both child and caregiver (as well as the clinician!) and there are some things we can try to help improve the overall experience:

Try to avoid doing the procedure in a child’s ‘safe space’ so as to not tarnish an area of sanctuary.

If a topical anaesthetic is available for pre‐cannulation, then this should be utilised.

Explain what you are doing in appropriate terms for the child and caregiver. Where possible explain each piece of equipment and perhaps practice on a cuddly toy or trusted adult (where appropriate!).

Do not always assume a child will have a fear of needles. Some children may be accustomed or even interested in injections. Judge your response based on the child and react accordingly – assuming fear may just encourage a fear response.