EpiPen and diabetes

[EMTtoBE]

Is it something an EMT-I can do or only Paramedic?

 

[usafmedic45]

Is it something an EMT-I can do or only Paramedic?

Depends on the state. In Illinois it was part of the EMT-I protocols. Honestly, it should be an EMT-B skill. I would rather have some dumbass EMT giving glucagon than trying to give oral glucose to someone with marginal protective reflexes.

 

[ajax]

Depends on the state. In Illinois it was part of the EMT-I protocols. Honestly, it should be an EMT-B skill. I would rather have some dumbass EMT giving glucagon than trying to give oral glucose to someone with marginal protective reflexes.

In Mass it is a paramedic skill, and it is low in the protocol for hypoglycemia. D50 is considered a better option because a) it works even if the diabetic is drunk / intoxicated with something else that their liver is busy filtering, or if they have decreased glycogen stores after running a marathon, etc, b) it doesn't cause the same nausea and vomiting that glucagon does, c) it works faster, and d) it doesn't empty the patients last sugar reserves into their bloodstream, which means it doesn't put them at greatly increased risk for more hypoglycemia later.

"If no IV access, administer 1-2 mg glucagon."

Most diabetics will be prescribed a glucagon kit when they are diagnosed - many will not renew the prescription and it will end up out of date. I was told (prior to EMT training) to call 911, give glucagon, and wait. But like I said, glucagon doesn't work for many hypoglycemic episodes. D50 always works (though not always fast enough), unless you screw up your IV.

 

[EMTtoBE]

I live in Vegas and haven't picked up the protocol book yet so wouldn't know lol..and I just started EMT-I class 2 days ago so maybe its something I will learn later on..at least now with the info you guys have been giving I will be one up on the other guys lol thanks

 

[usafmedic45]

it works even if the diabetic is drunk / intoxicated with something else that their liver is busy filtering, or if they have decreased glycogen stores after running a marathon

You do realize that the reason why people who are massively drunk or chronic alcoholics are slow to and/or do not respond to glucagon is the same reason why the marathoners don't right? The "filtering" action of the liver is completely separate from the other functions that are impacted by the administration of glucagon.

 

[usafmedic45]

Most diabetics will be prescribed a glucagon kit when they are diagnosed

Care to provide a source for that bit of information? I would not say most. I've never seen it listed as a standard of care for a run of the mill diabetic, especially those whose primary problem is chronic hyperglycemia managed by diet or oral medications without any history of hypoglycemia.

D50 always works (though not always fast enough), unless you screw up your IV

The only way it does not work fast enough is if you don't have IV/IO access. Care to elaborate how it might not work "fast enough" in the setting where it is administered?

But like I said, glucagon doesn't work for many hypoglycemic episodes.

Actually it's remarkably effective in most. Once again, care to provide a sourcethat provides the rationale for your assumptions?

it doesn't cause the same nausea and vomiting that glucagon does

Having given over a hundred doses of glucagon over the past 15 or so years, including massive doses for patients in refractory heart failure or after calcium channel blocker toxicity, I have seen one patient with nausea and vomiting attributable to the administration of glucagon.

What level of provider are you, just out of curiosity?

 

[MMiz]

I never ran into glucagon kits in the field. It wasn't until I became a public school teacher that I had at least a student or two each year that had the kit.

As a teacher somehow 30 minutes of training qualifies me to inject students with glucagon, insulin, and Epi. Our EMT-Basic protocols said that insulin and glucagon were Paramedic skills, while the Epi pen was a BLS skill.

 

[EMTtoBE]

I never ran into glucagon kits in the field. It wasn't until I became a public school teacher that I had at least a student or two each year that had the kit.

As a teacher somehow 30 minutes of training qualifies me to inject students with glucagon, insulin, and Epi. Our EMT-Basic protocols said that insulin and glucagon were Paramedic skills, while the Epi pen was a BLS skill.

Hahahahaha its funny how the system works

 

[Shishkabob]

because a) it works even if the diabetic is drunk / intoxicated with something else that their liver is busy filtering

Errrrr.....

 

[usafmedic45]

Errrrr.....

Yeah, I pretty much assumed he was not very good with physiology after that point....

 

[MrBrown]

Yeah, I pretty much assumed he was not very good with physiology after that point....

... but, but, but glycogenesis, gluconeogenesis and glyceroneogenesis are all very large words and easily confused with one another

 

[ajax]

Why might Glucagon injection not work as effectively for treating hypoglycemia while alcohol is in the body?
Answer:
Endogenous glucagon is a pancreatic counterregulatory hormone, which is secreted in response to low blood glucose levels. Its main role is to restore low blood glucose levels by generating a ready supply of glucose. It accomplishes this in two ways. Principally, glucagon stimulates the breakdown of liver glycogen stores, converting them to glucose through a process called glycogenolysis. In addition to mobilizing liver glycogen stores, glucagon stimulates hepatic gluconeogenesis through conversion into glucose of gluconeogenic substrates such as alanine, pyruvate, lactate, and glycerol.
Alcohol can interfere with the process of gluconeogenesis. This occurs during the metabolism of alcohol, in which there is depletion of the supply of pyruvate needed for gluconeogenesis. As a result, alcohol by itself may lead to hypoglycaemia or delay recovery from hypoglycaemia.
It is important to realize that the behaviour-altering effects of alcohol can also complicate hypoglycaemia by clouding the recognition of hypoglycaemia by the patient and his surroundings, as well as by delaying the treatment of hypoglycemia with prompt oral glucose
Updated: January 25, 2006
supplementation. Alcohol consumption may therefore have serious implications in the case of severe hypoglycaemia, in which a person is unable to self-treat. Usually persons are taught to inject exogenous glucagon s.c. or i.m. as an antidote to reverse severe hypoglycaemia. Though alcohol interferes with gluconeogenesis, it may only pose a theoretical concern in the setting of exogenously administered glucagon. This is because of the supraphysiologic blood levels of glucagon achieved following an s.c. or i.m. injection, and alcohol’s lack of effect on the glycogenolytic pathway. It is therefore unlikely that alcohol, on its own, would prevent the reversal of hypoglycaemia following the administration of glucagon.
In the setting of chronic alcoholism, however, liver glycogen stores may become depleted secondary to malnutrition (or a reduced supply of substrate). The efficacy of glucagon, as a treatment for reversing severe hypoglycaemia, may therefore be significantly reduced. This is because both the glucagon-stimulated metabolic processes for generating glucose, namely glycogenolysis and gluconeogenesis, have been compromised, either indirectly or directly. In such a scenario, the preferred treatment for reversal of severe hypoglycaemia would be the administration of intravenous glucose.
In patients with an absent or diminished endogenous glucagon response to low blood glucose (i.e. type 1 diabetes), reversal of severe hypoglycaemia ⎯ particularly when secondary to insulin ⎯ may be more difficult to achieve with exogenous glucagon in the presence of alcohol. In this case, treatment with intravenous glucose may be preferred.
References:
Glucagon product monograph, CPS 2005, Compendium of Pharmaceuticals and Specialities, The Canadian Drug Reference for Health Professionals, Canadian Pharmacists Association.
Griffin, JE, Ojeda, SR., editors. Textbook of Endocrine Physiology (3rd edition). Oxford University Press, 1996.
Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabetes. Diabetes Care 2003; 26: 1902- 1912.
Rasmussen BM, Lotte O, Schmitz O, Hermansen K. Alcohol and glucose counterregulation during acute insulin-induced hypoglycaemia in type 2 diabetes. Metabolism 2001; 50: 451-7.
Bartlett D. Confusion, somnolence, seizures, tachycardia? Question drug-induced hypoglycaemia. Journal of Emergency Nursing 2005; 31: 206-8.
Turner BC, Jenkins E, Kerr D, Sherwin RS, Cavan DA. The effect of evening alcohol consumption on next-morning glucose control in type 1 diabetes. Diabetes Care 2001; 24: 1888-93.

Thanks for making me look deeper into this. I clearly had a layman's explanation, which was unspecific and led me to untrue assumptions.

Care to provide a source for that bit of information? I would not say most. I've never seen it listed as a standard of care for a run of the mill diabetic, especially those whose primary problem is chronic hyperglycemia managed by diet or oral medications without any history of hypoglycemia.

Again, I should be more specific. I actually know very little about type two diabetes. I know a hell of a lot about type one, and forget that there are so many people with type two diabetes. My source is conversations with people with type one, which is a relatively large but self selected sample.

The only way it does not work fast enough is if you don't have IV/IO access. Care to elaborate how it might not work "fast enough" in the setting where it is administered?

When you're friends are also drunk and don't call until you're already having arrhythmia because they don't realize anything is wrong. Not the problem of D50, just the same on scene timing problem that is possible with all medications.

Actually it's remarkably effective in most. Once again, care to provide a sourcethat provides the rationale for your assumptions?

My assumptions come from my admittedly imperfect knowledge of alcohol and counter regulatory hormone function, and sitting through lots of lectures that make drinking sound like a sure road to severe, untreatable hypoglycemia.

Having given over a hundred doses of glucagon over the past 15 or so years, including massive doses for patients in refractory heart failure or after calcium channel blocker toxicity, I have seen one patient with nausea and vomiting attributable to the administration of glucagon.

That's really interesting. Every time I have had a conversation with anyone who has had to use their glucagon kit for severe hypoglycemia they have told me they were nauseated, but at least they were alive. It's not a huge sample size, but probably 20 people. It's interesting that that hasn't been your experience.

What level of provider are you, just out of curiosity?

I am a new basic, and want to be a medic. I am also a type 1 diabetic. I have put a lot of energy into learning about physiology of type 1 from medical journals. Like I said earlier, I have next to no knowledge about type 2, which affects 90% of people with diabetes. I should have made that clear originally.

 

[usafmedic45]

When you're friends are also drunk and don't call until you're already having arrhythmia because they don't realize anything is wrong. Not the problem of D50, just the same on scene timing problem that is possible with all medications.

Then that is a problem with your friends, not with D50 and even with a glucagon kit there if they are too blind drunk to realize a problem, how are they going to do anything about it? It's like blaming the airbags when one of your drunk friends crashes into a bridge abuttment. Just another friendly suggestion, if you're hanging around with people like that, you need to find different friends and as a diabetic you certainly do not need to be drinking to excess. If you're the DD and someone notices you down, chances are good they are going to realize it's not because you're passed out drunk.

sitting through lots of lectures that make drinking sound like a sure road to severe, untreatable hypoglycemia.

Well, if you become a chronic, malnourished alcoholic, it complicates the treatment of hypoglycemia. It makes glucagon less effective and occasionally ineffective because of a lack of glycogen stores to pull from. The result is simply that one has to give D50 and some thiamine. In a couple of severe cases, I've had to put in IO lines or a central line (when I was in the military) to be able to accomplish this.

Now, if you're prone to hypoglycemia it's not smart to be drinking in the first place but it's not going to produce an intractable hypoglycemic episode simply because you occasionally have a few beers.

That's really interesting. Every time I have had a conversation with anyone who has had to use their glucagon kit for severe hypoglycemia they have told me they were nauseated, but at least they were alive. It's not a huge sample size, but probably 20 people. It's interesting that that hasn't been your experience.

A lot of people (myself included) become nauseous simply from the fear associated with needles. I've never seen a spike in nausea or vomiting associated with glucagon more than some of the other drugs I have given, although it does make sense since it has some effects on the contractions of various parts of the GI tract. I've noticed a much greater frequency of nausea with narcotics and bronchodilators like albuterol.

I am a new basic, and want to be a medic. I am also a type 1 diabetic. I have put a lot of energy into learning about physiology of type 1 from medical journals. Like I said earlier, I have next to no knowledge about type 2, which affects 90% of people with diabetes. I should have made that clear originally.

Can I suggest you complete the following classes before going to medic school?
-Anatomy and Physiology I and II
-Pathophysiology
-Any specialized pathophysiology courses (cardiac, etc) that you can find
-General Chemistry I and II
-Organic Chemistry I and II
-Biochemistry
-Epidemiology
-Statistics
They may not seem absolutely necessary, but they will really help you if you realize that understanding the "why" of what we do is as important, if not more so, than understanding the "what", "when" and "how".