On Exam: No evidence of trauma Loc—Groans to painful stimulus

Kyle Glucagon 2004Kyle Glucagon 2004

Glucagon Case Study


Glucagon Case Study

You are dispatched Code 3 for a Diabetic….13C2, at 0730….You arrive at a townhouse and are led by the parents to the upstairs. They state their son is a insulin dependent diabetic and has been sick for two days with flu like symptoms.

This morning they could not wake him and he sleep thru his alarm and they called for a Ambulance. You find a 13 year old male, lying supine in bed………


Glucagon Case Study

The parents also tell you he went to bed early last night, and skipped his bedtime snack. Last night his blood sugar was 4.1 mmol/l.

On Exam: No evidence of trauma

Loc—Groans to painful stimulus

Airway—Inadequate, snoring-will not take an airway

positioned ¾ prone—airway clears

Breathing—Adequate

Circulation—Easily felt radial pulse/rapid

RBS—unremarkable


Glucagon Case Study

Should you initiate your Diabetic emergencies Protocol or should you load and go?

What are the 4 things required to initiate your protocol?


Glucagon Case Study

On further Exam:

IDDM since the age of 8 years old, sick for 2 days, infrequent episodes of hypoglycemia that are usually resolved with food. The patient has never required an ambulance before.

Vitals—108/64, Pulse 96 regular and easily felt, respirations are 20 regular and adequate, skin is pale, cool and clammy, GCS 1,2,4 = 7, O2 sat on high flow o2 is 99%

Blood glucose is 1.7 mmol/l


Glucagon Case Study

Patient takes Humulin N and R on a sliding scale in the morning and evening. He has also been taking Ibuprofen for the last 2 days. The Patient has no drug allergies.


Glucagon Case Study

Type of Insulin Name Time to Take Effect Lowest Sugar Levels DurationVery fast acting Lispro, humalog, novolog 5-15 minutes 60-90 minutes 4-5 hours

Regular Humulin R 30-60 minutes 2-3 hours 5-7 hoursIntermediate Lente, Humumlin L, NPH,Humulin N 2-4 hours 4-12 hours 14-20 hoursLong Acting Ultralente, Humulin U 6-10 hours 14-24 hours 20-36 hoursTime Release Lantus 1-2 hours no peak for 24 hours

Blended 70/30, Humulin N and R 30 minutes 2-12 hours 18 hours


Glucagon Case Study


Glucagon Case Study

What are the S/S of hyperglycemia?

What are the S/S of Hypoglycemia?What are the common causes of Hyperglycemia?

What are the common causes of Hypoglycemia?


Glucagon Case Study

• Taking too much insulin• Excessive exercise• Inadequate food intake• Oral Hypoglycemic Agents

Common causes of hypoglycemia include:


Glucagon Case Study

Common causes of hyperglycemia include:

• Failing to take insulin• Taking inadequate amounts of insulin• Infection• Excessive food intake• Pregnancy• Increased stress (both emotional and physical;

E.G., Surgery


Glucagon Case Study

You start administering gluco-gel…..

If IV endorsed what do you do?

If you miss the IV or are not IV endorsed what do you do?

What is the first choice, an IV or glucagon?


Glucagon Case Study

So we are now into the Glucagon!!!!!!!Drug Monograph:

Classification: Hyperglycemic Agent (antihypoglycemic)

Mechanism: Pancreatic Hormone, which acts on the glycogen in the liver, converting it to glucose. Producing a temporary rise in blood glucose. (Glycogenolysis)

Indication: Hypoglycemia (if unable to establish an IV for ALS and EMA II, P1 hypoglycemia when patient is unable to obey commands)

Contraindications: Known allergy to Glucagon

Pheochromocytoma (an adrenal gland tumor, can cause sudden and marked increase in BP)


Glucagon Case Study

Drug Monograph:

Route and Method: IM (ACP/CCP only)

SC (ACP/CCP/ PCP)

Onset/Duration: IM 8-15 minutes, 10-30 minutes

SC—similar to IM (a little slower)

Elimination: rapidly degraded by the liver, kidneys and in the plasma. Half life 3-6 minutes in plasma


Glucagon Case Study

Dose: Patients > 20 kg—1.0 mg

Patients < 20 kg—0.5 mg

Side Effects: Nausea and Vomiting (common)

(infrequent) Hypokalemia, Generalized allergic reaction

Hypertension, Hypo tension

Diarrhea

Increased pulse and BP

(rare) Hypoglycemia


Glucagon Case Study

So back to the patient:

IV attempts are unsuccessful (or if you are not licensed to that level…)

Lets give Glucagon:

How much Glucagon do we give to this patient?

What are the doses and weight guidelines?


Glucagon Case Study

We give the glucagon—What route and what is the preferred site?

What do we do next?

We initiate transport, it has been about 5 minutes after Glucagon administration, we do another set of Vitals and find:

BP-105/68 Pulse-92 Resp-20

Skin-Pale, cool, clammy GCS-1,2,4 = 7

Pt is unable to follow instructions, O2 saturation is 99% on high flow O2


Glucagon Case Study

Another 5 minutes goes by:

Current Vitals: 110/70, pulse 88, resp 18, skin is pale cool and dry, GCS is now 4,4,6 = 14, o2 sat 99%

Patient is now able to follow instructions, what do you do now?


Glucagon Case Study

Commercial Break!!!!!


Glucagon Case Study

So back to the patient:

You have given gluco-gel and you are well on the way to the hospital…current vitals are now:

BP-110/72 Pulse-82 Resp-18 Skin-Normal, Cool, Dry

GCS- 4,5,6 = 15, O2 sat 99 % on high flow

The patient is able to follow instructions, things are looking pretty good!

The rest of the trip to the hospital is uneventful….


Glucagon Case Study

What is Type I Diabetes and describe the typical patient?

What is Type II Diabetes and describe the typical patient?


Glucagon Case Study

Oral Hypoglycemic Drugs:

There are a number of medications taken orally to control blood sugars. These drugs are grouped into a number of categories and are prescribed to target certain areas of the body, such as the liver or muscle cells.


Glucagon Case Study

Oral Hypoglycemics:

Stimulating Insulin production:

• Diabeta, Glyburide

Decreasing Glucose Release from the Liver:

• Glucophage, Metformin

Slowing down the absorption of sugars from the Gut:

• Prandase, Acarbose

Increasing glucose Uptake by fat and muscle cells:

•Pigoglitazone, Avandia


Glucagon Case Study

Questions:

Can glucagon be repeated if the patient doesn’t respond to the first dose?

Do we give thiamine after administering Glucagon?

What are the chances of an overdose?

If a patient doesn’t respond to IV glucose do we give Glucagon?

Can an IV be started on a patient after Glucagon has been given?

Can Glucagon be used in the NYD protocol?


Glucagon Case Study

Can we “Code X” a patient that we’ve given Glucagon to?

Glucagon is only effective if the patient has adequate stores of glycogen, what conditions cause depleted glycogen stores?

What else is in the glucagon solution that we are giving?

Will glucagon be effective if a patient has had a hypoglycemic reaction in the last 24-48 hours?

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On Exam: No evidence of trauma Loc—Groans to painful stimulus