# Glucagon vs IV Dextrose



## the_negro_puppy

Hi,

Just a quick question regarding glucagon and IV dextrose.

My service uses glutose gel, IM glucagon and IV glucose 10% to treat hypoglycaemia.

I am learning glucagon for my next assessment.

My question is this:

What cases pt/condition would you use IV glucose over glucagon. Obviously IM glucagon will take longer for effects but with IV glucose you obviously have to gain IV access first. 

Im thinking IV glucose in most cases of unconcncious/ALOC hypo episode as once you have access you can easily give more glucose/other drugs whereas IM is one use. 

Cheers


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## Shishkabob

Malnutrition, alcoholics, people who don't have enough glycogen stores in their livers to let Glucagon be effective.


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## the_negro_puppy

Linuss said:


> Malnutrition, alcoholics, people who don't have enough glycogen stores in their livers to let Glucagon be effective.



Very true.

Which do you guys prefer to go with, if you had a choice between two?

I guess one benefit of IM is that if they are aggresive / aloc due to hypo the cant rip the line out etc.


Is glucagon outdated? Seems iv glucose is the global standard


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## Shishkabob

Glucagon still has it's place (eg beta blocker overdose)

Plus, we can do Glucagon IV, IM and IN via the MADD, so I have a lot more options of when / how to use it than D5/10/25/50.


I suck with IVs lately... therefor Glucagon might see a use sometime soon.


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## Lifeguards For Life

Linuss said:


> Glucagon still has it's place (eg beta blocker overdose)



or a FBAO


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## MrBrown

Young insulin dependant diabetic kids is another time gulcagon might not work.

Can you leave your uncomplicated hypos at home like we can?


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## Shishkabob

MrBrown said:


> Can you leave your *uncomplicated hypos* at home like we can?





???


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## mycrofft

*That's right, feed 'em gumballs and split.*

Hungry, hungry hypos.

Good one-two punch, glucagon then IV gluc. Just keep the neele happy folks from slamming more glucagon when they don't see an upswing in a minute.

Oh, yes, then a PEANUTBUTTER SANDWICH!!


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## Aidey

We can. Well, in reality we can leave nearly anyone at home who insists on being left home, but yes, we can leave hypos at home once they are "fixed". 

Overall, I prefer oral sugar/carbs. It saves the veins, and allows for a more even blood sugar increase, instead of sending them all over the place.  

In the cases were oral glucose isn't appropriate, what I use totally depends on the pt. If the pt is very young,  very old, septic, malnourished etc I stick with IV dextrose. Also, if  the pt is at the gym, or competing in an athletic event, just because  you really have no idea what their glycogen stores look like. Healthy hard-core athletes can deplete their stores under the right situations.


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## MrBrown

If we go to a hypo who has recoverd normally, hasn't done something silly like have a seizure or injured themselves, has access to a complex carbohydrate and somebody to look after them for the next couple hours we can (and often do) leave them at home.


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## BLSBoy

the_negro_puppy said:


> Hi,
> 
> Just a quick question regarding glucagon and IV dextrose.
> 
> My service uses glutose gel, IM glucagon and IV glucose 10% to treat hypoglycaemia.
> 
> I am learning glucagon for my next assessment.
> 
> My question is this:
> 
> What cases pt/condition would you use IV glucose over glucagon. Obviously IM glucagon will take longer for effects but with IV glucose you obviously have to gain IV access first.
> 
> Im thinking IV glucose in most cases of unconcncious/ALOC hypo episode as once you have access you can easily give more glucose/other drugs whereas IM is one use.
> 
> Cheers



great question. 
We use IM Glucagon as a backup, when ya have the day when you can't hit the broad side of a barn with a 24, or the pt left their veins in their other skin. 
Also hit on was the point of Glucagon IVP for Beta Blocker ODs. 
Look into the special considerations for that, as there are a couple.


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## terrible one

Linuss said:


> Glucagon still has it's place (eg beta blocker overdose)




Does anyone actually carry enough of Glucagon to be effective in the event of a Beta-Blocker OD? I've heard it takes a lot more than the 2 or 3mg carried on most units. (being that Glucagon is rather expensive)


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## Smash

terrible one said:


> Does anyone actually carry enough of Glucagon to be effective in the event of a Beta-Blocker OD? I've heard it takes a lot more than the 2 or 3mg carried on most units. (being that Glucagon is rather expensive)



Given that the doses usually recommended are between 1-5mg 5 minutely, I would be surprised! Which is not to say that I wouldn't be using the few units we carry, but I wouldn't be wasting time in scene either


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## Melclin

I suppose traditionally, glucagon was used at the Ambulance officer level because they didn't have IVs. Then when they did, the high command didn't trust them with D50...that was still secret MICA business 

Nowadays, with our fancy IV glucose, glucagon still has a role. 

At the Ambulance paramedic level (Advanced care paramedic in QLD?) we cannot cannulate paeds, so theres that.

For consideration in a pt showing poor response to oral glucose.

Failed IV.

This is a little controversial but some people like to use it in hypoglycaemic seizures, because of the obvious difficulty getting an IV and I think people get the collywobbles about midazolam. I'm of the view that a continuous seizure needs terminating. I'd prefer not to wait around for 10 minutes wondering whether or not the glucagon is working or whether or not it was even a hypo-G seizure in the first place while the patients brain blends itself into a tasty protein shake.


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## Shishkabob

We have it in our protocols specifically for Beta blocker overdose, yet we only carry 2-3mg.


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## mycrofft

*Length of ride versus mg per minute determined by pt weight and meatabolism*

Also, as far as terminating hypoglycemic seizures, need to stop the seizures to allow respiration, but also need to feed the brain. 
I also strongly favor oral gluc fast when there's any chance of hypoglycemia, to prevent it going over the falls in a washbasket.

On glycogen reserves, exactly how badly depleted do you have to be for it to be ineffective, and would a quick shot harm the pt as you porceed to other matters? Are we talking someone who missed a couple meals, or a long distance runner or alky with no body fat?


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## the_negro_puppy

Well I got to see for myself.

The other day got called to a Diabetic patient who had collapsed/been unconscious for a period of time

Pt was GCS 14 sitting/lying on the ground said he felt weak and unable to stand up. IDDM. His initial BSL was 3.2. We started with glucose gel and a honey sandwich, also gained IV access. But after 10 minutes his BSL went down to 2.3. We gave hime 150ml 10% IV glucose which brought it up to 7.7. then 11.0 as we got to hospital. We decided to transport this pt due to his poor initial response and that he did not have a history of Hypos.


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## Dutch-EMT

Glucose 10%?
Why not glucose 50% 20cc i.v.? 
When effect is zero, than again 20cc glucose 50% i.v.
After giving glucose flush with NaCl 0,9% 5cc.
effect within a couple minutes.
In Netherlands all ambulances have glucose 50% in 50cc bottles.


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## BLSBoy

What if you can't get a line?


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## Melclin

Dutch-EMT said:


> Glucose 10%?
> Why not glucose 50% 20cc i.v.?
> When effect is zero, than again 20cc glucose 50% i.v.
> After giving glucose flush with NaCl 0,9% 5cc.
> effect within a couple minutes.
> In Netherlands all ambulances have glucose 50% in 50cc bottles.



We use 10% on everyone now after some research showed it was much better at achieving the desired results without causing large peaks in glucose levels with a concomitant hypo. Much better when we're leaving most of those people at home. Also its safer in terms of tissue necrosis.


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## 8jimi8

Aidey said:


> Overall, I prefer oral sugar/carbs. It saves the veins, and allows for a more even blood sugar increase, instead of sending them all over the place.



Aidey hit on the one point that I wanted to make in this discussion.  Remember that for your noncompliant diabetics....

Dialysis is probably in the cards.  The more scarring of veins (especially since most EMTs always go for the AC) the more at risk they are for having unusable vessels when it comes time for dialysis access.

Don't forget, this is not their first rodeo and most certainly not the last.


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## Dutch-EMT

Melclin said:


> Also its safer in terms of tissue necrosis.



With that i fully agree! It's a disaster for a vein.
Ofcourse we use glucagon as well... 

When leaving a patiënt at home, always the GP will be called to see his patiënt and deal with the care after the ambulance-care


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## Sam Adams

Lifeguards For Life said:


> or a FBAO



I've heard rumor of glucagon being used for esophageal spasm, never heard of this one....


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## CAOX3

Sam Adams said:


> I've heard rumor of glucagon being used for esophageal spasm, never heard of this one....



It can be used as smooth muscle relaxant in a FBAO.  I have seen it used once in the field years ago, it was unsuccessful and was eventually removed by endoscopy.


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## GothamEMS

One of the funniest calls we had, was a pt whose BGL was low, a known diabetic, don't remember the exact number, but she was alert, oriented, and functioning, just a bit woosie. It was Easter morning, and low and behold what do I see sitting on the counter in an Easter basket, YUP, a Cadbury cream egg! It worked awesome, LOL!


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## rhan101277

I couldn't get an IV last night on a diabetic pt. tried 3x and then resorted to IM glucagon.  Pt had a CBG of 51 but was conversing, slow to respond and somewhat confused.  Ten minutes after administration CBG increased to 78.

I had another one that I did get an IV on and they got a AMP of D50 and then a D5W drip TKO.


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## usafmedic45

MrBrown said:


> Young insulin dependant diabetic kids is another time gulcagon might not work.
> 
> Can you leave your uncomplicated hypos at home like we can?


We could.  Completing the protocol ("Witness the patient eating something containing protein and complex carbohydrates") was how I got to meet one of the last surviving WWI veterans in the US.


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## the_negro_puppy

Got trained on Glucose 10% today and was told that if oral glucose cannot be given then we should then go IV access and glucose 10%. Glucagon only to be given if difficulty in obtaining access and giving 10%


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## clibb

If they person is unable to swallow I'll use Dextrose instead of Glucagon.


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## reaper

clibb said:


> If they person is unable to swallow I'll use Dextrose instead of Glucagon.



I think you are thinking of Glucose!


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## rhan101277

clibb said:


> If they person is unable to swallow I'll use Dextrose instead of Glucagon.



I hope you mean IV, if you give D50 IM then you are going to cause some major necrosis.

I could not obtain IV and I was not comfortable giving him oral glucose due to his LOC, so IM glucagon.


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## usafmedic45

> I think you are thinking of Glucose!



No, if they _can't _swallow it's either IV dextrose or IM glucagon.


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## mc400

Oral glucose and food for the patient able to swallow, Glugagon for Hard sticks, siezing patients, etc. IV dextrose for the patient that gets a quick IV. I usually give the D50 really slow and sometimes start with 12.5mg and work slowly. 

We treat and release hypo patients when it is appropriate.


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## usafmedic45

> Glugagon for Hard sticks, siezing patients, etc



Personally, I always thought starting out with the glucagon (unless you had a reason to suspect it would not work) was a good way to get the patient conscious so you could give oral glucose and save the headache of trying to start an IV.  Then again, for most of my prehospital career, I had a very practical medical director who saw that as a valid argument.


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## mc400

We usually will have at least 2 medics on scene but normally 3. We have 2als/2bls engines and 1/1 rescue ambos. So we usually have enough hands to have 1 look for a good vein, another get the glucagon ready. I think it is a good idea to use it first. We are looking into the IN route since we are getting protocol for IN narcan and versed. 

Also it was discussed above, I am all for stopping the siezure as soon as possible instead of waiting and hoping that glucagon works. We have versed on hand for that as well.


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## Bieber

I'm a new paramedic and amazingly I've never once pushed dextrose IV.  We carry both but our protocol states to hold on the glucagon unless we can't get an IV.  In the case of a hypoglycemic seizure, however, I could see where going with glucagon first might be more feasible.


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## MrBrown

Glucagon should be considered first then IV glucose second if glucagon does not work or should be considered first if glucagon is unlikely to work.

Why go for a more invasive procedure than required and as soon as you stick a drip into somebody they must be transported, so why not give them some glucagon and leave em at home?


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## skivail

I beleive Glucagon is also a little harder on the body and does not last as long.  Especially in seniors.


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## Aidey

MrBrown said:


> Glucagon should be considered first then IV glucose second if glucagon does not work or should be considered first if glucagon is unlikely to work.
> 
> Why go for a more invasive procedure than required and as soon as you stick a drip into somebody they must be transported, so why not give them some glucagon and leave em at home?




We don't have to transport people just because we gave them IV dextrose, they are allowed to refuse if they meet certain criteria.


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## clibb

rhan101277 said:


> I hope you mean IV, if you give D50 IM then you are going to cause some major necrosis.
> 
> I could not obtain IV and I was not comfortable giving him oral glucose due to his LOC, so IM glucagon.



I'm an EMT-B, can't give IM so thinking IV.


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## MasterIntubator

There was a small study for rectal glucose, and the absorption rate was amazing, and better than oral and almost neck and neck with IV doses.  I think it fell out of favor.... but it was interesting.

:-/


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## usafmedic45

Not quite sure where you are getting that from.  Can you send me the specifics on that particular study?  The rectal route was one of our options for administration of glucose under the "its better than nothing if you don't have immediate access to ALS and oral glucose is not an option".  However, it fell out of favor because there were several studies which should poor absorption especially when the rectum was not completely devoid of feces.  

Aman J, Wranne L. Treatment of hypoglycemia in diabetes: failure of absorption of glucose through rectal mucosa. Acta Paediatr Scand. 1984 Jul;73(4):560-1. No abstract available. 

Attvall S, Lager I, Smith U.  Rectal glucose administration cannot be used to treat hypoglycemia.  Diabetes Care. 1985 Jul-Aug;8(4):412-3

There have been similar reports for diazepam and for rectal glucagon (see Parker DR, Braatvedt GD, Bargiota A, Newrick PG, Brown S, Gamble G, Corrall RJ.  Glucagon is absorbed from the rectum but does not hasten recovery from hypoglycaemia in patients with type 1 diabetes. Br J Clin Pharmacol. 2008 Jul;66(1):43-9. Epub 2008 May 27.

I'm only aware of one positive study for the use of rectal dextrose in hypoglycemia and it was a pilot study in rats:  
McGee D, Chen A, de Garavilla L.  Dextrose is absorbed by rectum in hypoglycemic rats. J Emerg Med. 2003 Apr;24(3):253-7.



> I beleive Glucagon is also a little harder on the body and does not last as long. Especially in seniors.



It's not particularly long lasting but then again neither is D50 (or a lot of the drugs we use).  As for "harder on the body", I don't really think that is much of a concern for the most part since hypoglycemia is pretty brutal in and of itself.  Short of hypoxia, it's one of the faster ways to kill or gork someone by derailing of their basic bodily functions.


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## Akulahawk

Personally, I prefer the D50. You'll never see me shove it in fast. One, it's pretty thick stuff... two, give it slowly and it'll have a chance to become a bit more diluted so it won't be like syrup coursing through someone's veins... 

If I could give 25mg Dextrose in a D10 concentration... that would certainly keep tissue necrosis possibilities down to a minimum if it extravasates. Unfortunately, we didn't carry 250mL bags... so I just did D50 slow IVP. Works pretty well, actually.


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## JPINFV

MrBrown said:


> Glucagon should be considered first then IV glucose second if glucagon does not work or should be considered first if glucagon is unlikely to work.
> 
> Why go for a more invasive procedure than required and as soon as you stick a drip into somebody they must be transported, so why not give them some glucagon and leave em at home?



I think that sticking a needle into a muscle and sticking a needle inside a tube into a vein is pretty much equal in the invasiveness part. 

Also, why would anyone have to transport just because they started an IV? D/Cing an IV isn't exactly rocket surgery. 

Also, why go for Glucagon OR D50 over D10 or D25 in a simple diabetic? Lower concentrations of dextrose don't overshoot as much AND, unlike Glucagon, doesn't destroy any reserves the patient has.


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## usafmedic45

JPINFV said:


> I think that sticking a needle into a muscle and sticking a needle inside a tube into a vein is pretty much equal in the invasiveness part.
> 
> Also, why would anyone have to transport just because they started an IV? D/Cing an IV isn't exactly rocket surgery.
> 
> Also, why go for Glucagon OR D50 over D10 or D25 in a simple diabetic? Lower concentrations of dextrose don't overshoot as much AND, unlike Glucagon, doesn't destroy any reserves the patient has.


You do have a very good point about the reserves issue.


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## the_negro_puppy

MrBrown said:


> Glucagon should be considered first then IV glucose second if glucagon does not work or should be considered first if glucagon is unlikely to work.
> 
> Why go for a more invasive procedure than required and as soon as you stick a drip into somebody they must be transported, so why not give them some glucagon and leave em at home?



I understand the logic but our protocols state:


"Glucose 10% is the preferred treatment for hypoglycaemia patients unable to take oral glucose. This is due to its rapid onset and ability to restore blood glucose concentration to normal values"

The reference provided with this was:

Collier, A, Steedman, D, Patrick A, et al. 'Comparison of intravenous glucagon and dextrose in treatment of severe hypoglycaemia in an accident and emergency department'. Diabetes Care 1987;10: 712-5

One of our instructors justified this by stating that when he uses 10% glucose for a hypo, he know its going to work and quickly (1-3 mins onset) however this is not the same with glucagon due to depletes glycogen stores and other factors (4-7 minute onset)

Our dosages are 150ml followed by 100ml boluses while BGL < 4.0mmol

no max dose

Paediatric 2.5ml per kg


Also we do not have to transport once IV has been put in- we are permitted to remove IV and apply dressing/band-aid etc to site.


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## 18G

Our protocols state to give 1 amp of D50 for hypoglycemia. I personally push it and wait for pt. response... usually pt. responds great and can stop at half an amp. I agree with not overshooting the BG level. The goal should be to return the pt. to being euglycemic with a substantial high carb meal to maintain that level versus making the pt. hyperglycemic. 

I didn't see it mentioned anywhere here but there is also a role for glucagon in treating anaphylaxis that is refractory to epinephrine.


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## Melclin

Thankfully we don't have any of that "If an IV has been started, they must be sick enough to go to hospital" crap. 

Protocol aside, I don't know that I like the idea of chosing one drug over another based on the the idea that it means you can leave them at home. 

Glucagon can take a long time to work, if it works at all. During which time they continue to be hypoglycaemic. I would be uncomfortable spending all that time buggerising around glucagon when there is a better option sitting right next to it in my drug bag. 

The IV=transport thing really needs addressing. Is it an actual policy that you would get in trouble for breaking, or is it just part of the culture?


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## MrBrown

Our guidelines state any significant intervention requires transport- defined as a medicine or IV fuid except where exceptions exist for hypos, seizures, palliative care and where the AOs believe transport is not required.

Now in practice Brown has never given anybody IV glucose and left them at home, and removing an IV is not rocket science.  However its a grey area that Brown should follow up.


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## MasterIntubator

usafmedic45 said:


> Not quite sure where you are getting that from.
> 
> Round table discussion back in the early 90's with a bunch of medical nerds and an article in hand in the pediatric ICU ward
> 
> Can you send me the specifics on that particular study?
> Nope....  but I am sure somewhere out in google-land, its out there.



You have already done some homework.... and I have not. Has not greatly interested me lately about it... it was just an interesting thought I had back in my head of potentially tried and failed things related to the topic.
I do appreciate the update, because I really never looked further into it.  We kinda sat around the table back then and leaned back saying, "Not me... ""


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## rhan101277

Melclin said:


> Thankfully we don't have any of that "If an IV has been started, they must be sick enough to go to hospital" crap.
> 
> Protocol aside, I don't know that I like the idea of chosing one drug over another based on the the idea that it means you can leave them at home.
> 
> Glucagon can take a long time to work, if it works at all. During which time they continue to be hypoglycaemic. I would be uncomfortable spending all that time buggerising around glucagon when there is a better option sitting right next to it in my drug bag.
> 
> The IV=transport thing really needs addressing. Is it an actual policy that you would get in trouble for breaking, or is it just part of the culture?



Yeah but I could not obtain IV access.  So I used glucagon and it did work after about 10 minutes.  Pt was still conversing just confused.


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## Aidey

rhan101277 said:


> I couldn't get an IV last night on a diabetic pt. tried 3x and then resorted to IM glucagon.  Pt had a CBG of 51 but was *conversing, slow to respond and somewhat confused.*  Ten minutes after administration CBG increased to 78.
> 
> I had another one that I did get an IV on and they got a AMP of D50 and then a D5W drip TKO.





rhan101277 said:


> Yeah but I could not obtain IV access.  So I used glucagon and it did work after about 10 minutes.  *Pt was still conversing just confused.*



Why didn't you use oral glucose?


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## rhan101277

Aidey said:


> Why didn't you use oral glucose?



He would converse and be confused and then not respond and then back to responding so I did not give it.


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## Sam Adams

18G said:


> I didn't see it mentioned anywhere here but there is also a role for glucagon in treating anaphylaxis that is refractory to epinephrine.



Are you referring to those pt's on BB's? I've asked a few people about it and all I got in response was blank stares and blinking...


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## NomadicMedic

Glucagon for refractory anaphylaxis used to be in the Thurston County Washington protocols, but I believe it was just removed (along with beta blockers) in the last revision. 

Interesting article about the alternative uses of glucagon here: http://paramedicine101.blogspot.com/2010/02/common-and-uncommon-usages-of-glucagon.html


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## clibb

rhan101277 said:


> Yeah but I could not obtain IV access.  So I used glucagon and it did work after about 10 minutes.  Pt was still conversing just confused.



Just confused? So he could still swallow and you decide to start an IV with a BGL of 51... Neglect is my opinion.


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## reaper

clibb said:


> Just confused? So he could still swallow and you decide to start an IV with a BGL of 51... Neglect is my opinion.



How in anyway is this even close to neglect?

He was the medic on scene. If he felt the Pt was not alert enough to protect airway, then he did exactly what needed to be done. He could have spent 10 minutes looking for an IV, while the brain cells cooked. No, he choose to give him Glucagon right away, so it could take effect. 

That is thinking far enough ahead, to help the Pt.


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## Aidey

I wouldn't call it neglect, but if a patient can talk, they can swallow.


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## JPINFV

Aidey said:


> I wouldn't call it neglect, but if a patient can talk, they can swallow.



[not.sure.if.serious.jpg]

I have 1 word for you, just one word. Dysphagia.


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## usafmedic45

JPINFV said:


> [not.sure.if.serious.jpg]
> 
> I have 1 word for you, just one word. Dysphagia.


Damn it JP. Why do you have to post before I do... LOL


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## the_negro_puppy

Aidey said:


> I wouldn't call it neglect, but if a patient can talk, they can swallow.



Its not as black and white as this



What about someone who is GCS 9 E2V3M4 making inappropriate verbal/speech


Would you give them oral glucose still?


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## MedicOut

*Cost*

Not that cost ever changes how we treat.....but did you guys know that a single vial of glucagon costs around $65.00?

I am the medication guru at my service so I know all the costs of this stuff. 

Crazy, huh?

We have a brittle diabetic who has no veins and he has this window of lethargic behavior just before he gets really combative. He usually gets glucagon. Big dude, well-nourished, skin like leather up to his armpits. As soon as he is alert enough, I feed him a peanut butter sandwich. 

Oral glucose is surprisingly expensive as well!


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## phildo

Have his family keep cake icing in a tube at hand.  Cheap, effective.  Tastes better than the oral glucose (have you ever tried it?)


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## MedicOut

Oh yes, I've definitely done the icing trick. In this particular case, that will involve the family actually giving  a c$%p about the patient.


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