# When is it the right time to give Glucagon?



## kashton (Jan 6, 2008)

You have a 33 year old male unresponsive to verbal, pale and diaphoretic... sitting up against the back of his couch. His wife tells you he became confused 20 minutes ago and has been getting worse since. She states that he is a diabetic and hasn't eaten since early this morning, it is now 3 in the afternoon. He is starting to moan and looks in a great deal of distress. You put him on O2 NRB 15 lpm, D-stick of LO, get him on a POx, monitor, get him on your stretcher and into the back of the ambulance. You and your partner are trying to get a line but are having a very difficult time. After two tries your partner gives Glucagon deep IM and tries a third time to get a line. Finally, after three tries, you are able to initiate a saline drip and give 25 grams of D50W. 

This was a real call we had when I was doing my clinicals as a basic.

My question is, when is the right time to give Glucagon? Only when you are having problems getting a line? The reason I ask is because it takes 10-15 minutes for Glucagon to kick in and getting a line can take up valuable time where the Glucagon could have already started to work. Should you give Glucagon when it looks like you may have trouble getting a line started? 

Please give your thoughts or even better, personal experience. Thanks!

Kevin


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## MasterIntubator (Jan 6, 2008)

You pretty much have it!  That is a justified and logical way of doing it.  First line is D50... but, if you can't get a line - you can give D50 rectally... but who the heck wants to do that??? I don't wanna do that again. 

Glucagon given when your IV attempts are failing is a good time, their brain will need it, and will use it before you will see the effects.


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## paccookie (Jan 6, 2008)

Our protocol is to go for the IV first so you can give D50.  If that isn't working after 2 attempts, give glucagon and then keep trying for an IV while the glucagon is working.  We also have the option of rectal D50, but very very few people have ever tried it...


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## medic001918 (Jan 6, 2008)

I only give D50 when I feel that I've exhausted my opportunity for an IV.  Glucagon is slow acting, but it's also a hormone that releases the bodies own natural stores.  In a patient that might have recurrent episodes of hypoglycemia, it can cause a problem since it will leave them without a reserve.

Shane
NREMT-P


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## MSDeltaFlt (Jan 6, 2008)

A lot of times your pt's peripheral veins might clamp down when sugar is low.  If there are no AC's, or any vein available, I might try tilting the pt's head to one side and going for the neck.  EJ's are usually the last to clamp down.  Depending on the pt, I might not have that option, then I have no problem giving Glucagon.

I think of it as BGL (your body's energy reserve) is not unlike your car's motor oil.  It's not wise to let your car run out of oil.  Tends to lock things up... permanently.

Plus I had Med Control jump my @ss once for not attempting an EJ.  Hope this helps.


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## triemal04 (Jan 6, 2008)

MSDeltaFlt said:


> A lot of times your pt's peripheral veins might clamp down when sugar is low.  If there are no AC's, or any vein available, I might try tilting the pt's head to one side and going for the neck.  EJ's are usually the last to clamp down.  Depending on the pt, I might not have that option, then I have no problem giving Glucagon.
> 
> I think of it as BGL (your body's energy reserve) is not unlike your car's motor oil.  It's not wise to let your car run out of oil.  Tends to lock things up... permanently.
> 
> Plus I had Med Control jump my @ss once for not attempting an EJ.  Hope this helps.


That's probably the most important part right there.  

Far as glucagon goes, if you can't give oral glucose and can't get a line and the pt needs it, your options are pretty limited.

But as far as getting a line goes...I've seen way way WAY to many people get focused on the AC as the only place a line can go.  And far to many who refuse to look anywhere that is not between the AC and the fingertips.  There are plenty of peripheral veins out there for access.  If your usual spot isn't available, start looking elsewhere...the neck...legs...feet...shoulders...upper arms...scalp...anywhere you think one might be.


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## kashton (Jan 6, 2008)

Good advice, much appreciated


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## MasterIntubator (Jan 6, 2008)

Young Jedi, keep in mind..... that diabetics are prone to infection and loosing appendages.  A normal persons simple phlebitis is a diabetics worst nightmare.  Good clean technique is paramount.  When we drop the pt off at the ED, their journey just starts, you may never know what happens until one day you pick them up and they are missing that arm. 

phood for thought


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## MasterIntubator (Jan 6, 2008)

Tried to delete this repeat... ohh well.


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## Anomalous (Jan 7, 2008)

You didn't really specify, but just because they are unresponsive to verbal doesn't mean they can't take oral glucose.  If you explain to them what you are going to do and then place the tube to their lips they may be alert enough to swallow.  If they TRY to swallow you are good to go.  Depending on their condition, you may be able to take a small amount and rub it on the inside of their gums or under their tongue.  Again, depending on their condition.


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## kashton (Jan 7, 2008)

With the way he was acting, oral glucose wasn't an option. He was moaning and swinging his head around with his eyes closed and wouldn't respond to anything we were asking.


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## byun01 (Jan 10, 2008)

*Glucagon*

Glucagon has a lot of effects on the body.  It pretty much has the opposite effect of insulin.  Glucagon has both glycogenolysis and gluconeogensis properties.  This means that not only will it break down your glycogen stores to create glucose, it will take protein and eventually create glucose with it.  Note that glycogen stores are the body's initial way of storing glucose.  Assuming the patient does not have an enzyme disorder for glycogenolysis, glucagon is from what we know a safe drug to provide to a patient.  In agreement with the others, if you can't get an IV after one or two tries or you see that the patient will be a very difficult IV stick, you should prepare the glucagon.  The longer the patient goes on without glucose, the more brain damage can occur.


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## bonedog (Jan 11, 2008)

MSDeltaFlt said:


> A lot of times your pt's peripheral veins might clamp down when sugar is low.  If there are no AC's, or any vein available, I might try tilting the pt's head to one side and going for the neck.  EJ's are usually the last to clamp down. QUOTE]
> 
> You can always us an IO if IV is unattainable, especially important if transport time is excessive....


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## MSDeltaFlt (Jan 11, 2008)

Very true, and I have them on my bird.  However, I was speaking from a gound medic's point of view in state and service that does not have adult IO's.

When I land, and can't get a line, I'll drill them in a heart beat.


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## Anomalous (Jan 11, 2008)

triemal04 said:


> Far as glucagon goes, if you can't give oral glucose and can't get a line and the pt needs it, your options are pretty limited.



How about IN ??  As of Jan 1 our B's can give glucagon IN.


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## Ridryder911 (Jan 11, 2008)

True, I have to admit I forget about intranasal routes (maybe it is something my mother keeps telling me about not sticking something in my nose)... 
"..._Intranasal glucagon offers an alternative by generating a rapid rise in blood glucose-not as fast as intramuscular glucagon, but faster than oral glucose"..._...



_Pontiroli AE, Calderara A, Pajetta E, et al. Intranasal glucagon as remedy for hypoglycemia. Studies in healthy subjects and Type 1 diabetic patients. Diabetes Care 12 (9): 604-608, Oct 1989._

R/r 911


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## bonedog (Jan 12, 2008)

MSDelta fit, I would love to drill em', however have to settle for a Pyng, which works well also. Lucky so far, only used the Pyng in an arrest situ, too obese to find a jug.... even the manubrium was a stretch, worked though.


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## mikie (Feb 16, 2008)

Anomalous said:


> How about IN ??  As of Jan 1 our B's can give glucagon IN.



Basics here in Peoria can give IM glucagon


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## firecoins (Feb 16, 2008)

mikie333 said:


> Basics here in Peoria can give IM glucagon



I don't want to give anything sharp to some of the basics I work with.

MasterIntubator is really close to my first screen name, it remarkable.  :angry:


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## jaron (Mar 9, 2008)

*Something to remember*

If your pt is an alcoholic and/or has some type of hepatic pathology they my not have any glucose stores in there liver, therefore Glucagon is not going to work.

Just something to keep in mind.

Stay Safe,
Jaron F.


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