Glucagon

glucagon

I rank Glucagon 17 out of the 33 drugs we carry.

We primarily use Glucagon for hypoglycemia when we cannot get an IV and the patient isn’t alert enough to drink juice. I did not use Glucagon at all last year. I gave D50 19 times. My secret EMS pride has always been my IV skills. I like to think of myself as a Zen master of IVs. And so I know I am hexing myself when I write this — I know somewhere out there right now a diabetic with no veins is slipping into unconciousness, and I will be summoned to perform, and then empty catheter wrappers all around me, I will despair to the heavens that I have lost my IV karma and at last reach into my kit for the Glucagon. For all the IVs I have gotten, I have been humbled as well.

Sure Glucagon is great to have when you have an unresponsive diabetic and you can’t get a vein, but you do have options. You can choose between the tube of glucose in the rectum or the EZ-IO. One is painful for me when the 350 pound diabetic wakes up and wonders why his butt is sticky, the other is painful for me watching the patiient writhe in pain while I push the D50 into his leg bone. I have never availed myself of either option and hope never to have to. Fortunately I don’t have to really take Glucagon off my truck and should have it always available.

There are some drawbacks to Glucagon. It doesn’t always work. Glucagon converts the liver glycogen to glucose, but if the person doesn’t have any glycogen stores, then there is nothing to convert and so no revival. If a diabetic has a hypoglycemic episode on Monday and is given Glucagon, and they have another hypoglycemic episode on Tuesday, it is quite likely that the Glucagon won’t work on Tuesday like it did on Monday because the Monday dose used up the stores and they haven’t had time to rebuild back sufficiently.

Also, Glucagon doesn’t work right away like D50. It is much slower acting. I have had people rouse anywhere between 3 and 20 minutes after I gave them the drug.

***

There are other uses for Glucagon. We can give it in beta blocker overdose. In cases of “persistent hypotension or symptomatic bradycardia refractory to atropine and fluids,” we can consider Glucagon at 0.1 mg/kg (max 5mg) IV. Repeat every 5 minutes as needed. There’s the problem. The dose is way more than any ambulance carries. Glucagon is very expensive and comes in 1 mg vials (actually 1 mg of powder and 1 vial of dilutant that are combined and mixed to become active.) We carry two mgs in our kit and maybe another 3 mgs in our spare box. Glucagon has a very short half-life (3-6 minutes) while a beta blocker like Propranolol has a half life of 12 hours. An old medic I know told me about a beta blocker overdose he did many years ago where the hospital sent ambulances out to other hospitals and ambulance companies to bring back more Glucagon because the hospital had exhausted its stores treating one patient.

***

Glucagon can also be used to help dislodge food caught in the esophagus. I used it this way once for a lady with a fish bone caught in her throat, but I had no immediate suuccess with it. It is not a magic bullet instant results drug like adenosine, narcan or D50. I know a Doctor who treats food caught in the throat by giving the patient glucagon, having them take a nitro, and then drink a soda. We carry nitro, but have no sodas, not even in the cooler where we keep the chilled saline we use for our induced hypothermia protocol.

***

Glucagon

Class: Pancreatic hormone

Action: Increases blood glucose by converting liver glycogen to glucose

Indication: Hypoglycemic patient who does not have IV access
Beta-blocker or calcium channel blocker overdose
Food bolus impaction in the esophagus

Contraindication: Known hypersensivity
Pheochromocytoma / insulinoma

Precaution: Mix with own diluent – do not mix with saline

Side effect: Nausea / vomiting
Hyperglycemia

Dose: 1mg (1unit)

Route: IM

Pedi dose: 0.5 – 1mg

7 Comments

  • ICU Nurse says:

    I once used glucagon on a mixed overdose of anti-hypertensives, in the ICU. Within 2 hours we had exhausted the entire (major city hospital) supply, and to get us through the next 36 hours we virtually emptied out every hospital in the north of the UK. You would think that the manufacturers would create a larger vial (say 50mg/50mL) for use in these patients – it was a pain in the a*se trying to draw them all up individually.

    I have to tell you, it was the strangest thing I’ve ever done, to watch a patient with a BP of 60/20 and a heart rate of 35 not have any response whatsover to TEN milligrams of adrenaline given as a rapid IV bolus.

  • Medic In Training says:

    I love reading this stuff. Where I am from we do not even carry this drug in our box!

  • Kel says:

    thought Magensium was the 18th drug O.o?

  • medicscribe says:

    Thanks for the great story, ICU nurse. Very interesting.

    Kel, thanks for catching my error. I made the change to 17

  • CBEMT says:

    There are some drawbacks to Glucagon. It doesn’t always work. Glucagon converts the liver glycogen to glucose, but if the person doesn’t have any glycogen stores, then there is nothing to convert and so no revival.

    I’m not sure of the exact details, but I’ve heard that this can have some nasty blood chemistry effects.

  • Being much less trained than a paramedic, the only drug I can carry is salbutamol neb. However, if the patient has glucagon, I can give it. (I’m a UK CFR, a volunteer.)

    Since glucagon training I’ve been to only one patient who fitted the guidelines. (Obvious hypoglycaemia and having the drug available.) The patient’s next door neighbour actually gave it – not only was she a nurse but she knew where it was kept!

    OK, it took 7-8 minutes to work, but work it did. By the time the ambulance crew arrived, the patient was fully aware and eating a sandwich.

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Peter Canning

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