# Hypoglycemia meds



## LucidResq (Mar 26, 2008)

Ok... I'm an EMT-B student, but I understand that paramedics can give oral glucose, D50 and/or glucagon for hypoglycemia.

So for what situations is each drug appropriate? Are they often used in combination? I was reading local paramedic protocols, but they were kind of vague; the indication for glucagon (besides for OD) is "symptomatic hypoglycemia when IV access is unsuccessful (after 2 unsuccessful attempts)." So do paramedics only give glucagon if they can't get access to give D50? 

I'm just curious about this because a while back I was taught to use a glucagon emergency kit for any diabetic who was unconscious due to hypoglycemia as part of a first aid course. It seems like D50 is the preferred method of treatment for hypoglycemia however, is this correct? Are the glucagon kits out there just because it's so easy for a lay person to give an IM injection? 

And are there situations in which oral glucose is the only treatment necessary, or will a paramedic give D50 to most hypoglycemic pts? 

Thanks!


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## TNEMT06 (Mar 27, 2008)

It depends on your scope of practice.  In Tennessee an EMT can establish an IV and adminsiter D50 or glucagon via IM injection.  But if your asking when its best to adminster oral or D50...I would give it orally if the person could follow directions and was making sense  if you can give D50, give it to them if they are unresponsive or not making sense. D50 in my opinion is better than glucagon because you get the patient at a higher BGL quicker.


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## firecoins (Mar 27, 2008)

glucagon is given when you can't get IV access usually.  Sometimes diabetic patients are combatitive and IM is the only way to administer any meds. Glucagon!  Or if the vascualar is giving you a hard time.  Hopefully there is enough sugar in the liver to help bring the patient to a calm conscious state to adminster oral glucose or obtain IV access in the previous case.


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## eggshen (Mar 27, 2008)

Lucid,
I'm pretty sure you are rolling the Metro Area protocols, in reference to hypoglycemia it is to be used only if one is unable to administer IV Dextrose. If you you do happen to give Glucagon I would recommend doing it in the ambulance....on the way to the hospital.

Egg


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## Ridryder911 (Mar 27, 2008)

Glucagon is another alternative to treating hypoglycemia patients. The first treatment of choice of course is if the patient is awake a high carbohydrate/protein snack/meal (pizza/ P & J sandwich, etc.), second oral glucose with allowing it to absorb some in bucosal mucosal membrane (cheek/gum). 

Of course if the patient has decreased level of consciousness (cannot hold or drink per self) an IV of Normal Saline or 5% Dextrose in Water (D5W) may be administered. There is variable ranges of when to treat per glucometer, but the key is the patient assessment. Most services are now not treating if the patient is awake, alert, orientated and the glucose is > 45-50 mg/dl. Some even suggest < 90 mg/dl, again different protocols yet usually in regards to the physical findings. 

There has been heated debate lately on the use of the hypertonicity of Dextrose. Yes, alike any other medication and electrolyte it too has harmful side effects. Many EMS Physicians feel D50W is too high of a concentrate and the risks of a hypertonic solution as well as possible infiltration of an IV. As well as a "rebound" effect of the glucose being low to now high, all within a few seconds. Patients usually complain of chills, headaches, nausea because of this rapid change. 

The new trend is to administer 12.5  grams in lieu of the 25 grams, slowly with fluid administration in between to dilute the concentration level. If the initial glucose reading is extremely low, D50W maybe used or a repeated dosage of D25W maybe given. All glucose and hypertonic solutions should be administered in a larger bore IV 20g>, as well preferred more medial than hand veins. 

Glucagon, again alike other medications is also used for treatment of hypoglycemia. Yes, it can be used as an alternative treatment in lieu of D50W and yes, it can be administered I.M., I.V., and intranasal. It does take longer for the absorption rate than IV glucose. As well, it has other uses such as treatment for overdose of Beta & Calcium channel blockers as well as a smooth muscle relaxer for the treatment of esophageal spasms or esophageal obstruction (foreign body in esophagus). 

Again, it is highly suggested that it be administered I.M. central to the body due to poor circulatory or collapse )as in insulin shock. 

R/r 911


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## Ops Paramedic (Mar 27, 2008)

We have only recently (September 07) recieved Glucogon on ALS protocol.  I have never used it (or had the need to), or haven't studied it 100%, hence i will not comment on it for now, other than saying it is fairly expensive when compaired to Dextrose 50% IV.

With regards to IV dextrose administration, Rid mentioned 12,5g of dextrose, is the way it is going... Our protocol, states that we start of with 10g through a free flowing IV line.  Re-check HGT levels and administer another 10g, up to 60g total, prior to contacting ALS.  I has been like this since i can remember.

I did not see it mentioned in any of the posts, that you can also administer Dextrose via a Naso or Orogastric tube as an alternative.  I don't think it has its place in the every day run of the mill hypoglycemic patient, but keep it in mind non the less.


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## LucidResq (Mar 27, 2008)

eggshen said:


> Lucid,
> I'm pretty sure you are rolling the Metro Area protocols, in reference to hypoglycemia it is to be used only if one is unable to administer IV Dextrose. If you you do happen to give Glucagon I would recommend doing it in the ambulance....on the way to the hospital.
> 
> Egg



Yup that's from Metro protocols. Curious... why do you recommend administering Glucagon en route? 

Thanks for the information everyone


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## Ridryder911 (Mar 27, 2008)

LucidResq said:


> Yup that's from Metro protocols. Curious... why do you recommend administering Glucagon en route?
> 
> Thanks for the information everyone




Why not? It takes about 10-20 minutes for it take action. 

R/r 911


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## LucidResq (Mar 27, 2008)

Ridryder911 said:


> Why not? It takes about 10-20 minutes for it take action.
> 
> R/r 911



I was just wondering if eggshen was placing emphasis on transport because of a specific effect of glucagon that would demand a rapid transport that I'm not aware of... or just because a pt. whose condition warrants the use of glucagon also requires immediate transport (I would assume that an unconscious hypoglycemic pt. that IV access cannot be established on would be a high priority).


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## Ridryder911 (Mar 27, 2008)

I personally would not perform a rapid transport since you know the reason why the patient is unresponsive, and what will a 3 minute increase to the ER prove? 

You made the diagnosis, maintain airway and monitor the hemodynamics, and a smooth, relaxed ride to the ER. Who knows maybe the LOC will increase? 

R/r 911


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## eggshen (Mar 28, 2008)

Thoughts 'round here are do to the depleted glycogen stores after administration and the perceiced need for observation. We are free to leave hypoglycemics at home after Dextrose but are encouraged to transport those receiving Glucagon. Based on that it's easier to do it in the ambulance since Medical Direction prefers they get a ride to the hospital anyhow. 

Egg


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