Emergency Glucagon Training Protocol

Training Protocol for Emergency Glucagon Providers

• The protocol is for emergency glucagon providers, like paramedics.
• The provider is from Cedar Mountain Fire Rescue, Transylvania County EMS.
• Glucagon is available in 1 mg/vial.

Training Pre-Requisites

• Providers must reasonably expect responsibility for someone at risk for hypoglycemia.
• This usually involves a person with diabetes.
• The person being trained must be at least 18 years old.

Objectives

• Initial training or retraining covers:
  • An overview of diabetes.
  • Recognition of symptoms.
  • Factors leading to hypoglycemia.
  • Glucagon administration.
  • Necessary follow-up treatment.

Protocol (Adult Diabetic)

• Blood glucose analysis is a key procedure.
• Blood glucose ≤69 mg/dl and symptomatic, with no venous access, requires glucagon (1-2 mg IM) repeated in 15 minutes if needed.
• If blood sugar is 70-249 mg/dl, consider oral glucose solutions (juices / food).
• Glucose ≥ 80 mg/dl = monitor and reassess until blood glucose is ≥ 80 mg/dl.
• If condition changes, exit to the appropriate protocol(s).
• Blood glucose ≥ 250 mg/dl requires a normal saline bolus (500 mL IV/10).

Overview of Diabetes

• Diabetes is a chronic, lifelong disease.
• It affects how the body uses food.
• The pancreas produces insulin.
• Insulin allows glucose to enter cells for energy production.
• In diabetes, this system doesn't function correctly.
• Glucose builds up in the bloodstream.
• Insulin must often be replaced with injections.

Overview of Diabetes - Type 1 and 2

• Type 1: The pancreas produces no insulin. Treated with insulin shots or pump, usual type in children and young adults, no prevention, lifelong condition.
• Type 2: Not enough insulin produced or the person doesn't respond to insulin. May be treated orally and/or with insulin, more common in adults.

Hyperglycemia (High Blood Sugar)

• Symptoms include increased thirst, frequent urination, increased hunger, weight loss, irritability, flushed/dry skin, nausea/vomiting, weakness/fatigue.

Complications

• High blood sugar can cause long-term complications, such as blindness, kidney/nerve damage, heart disease.
• Controlling blood sugar levels is crucial.

Balance

• Diabetes management involves balancing food intake, insulin, and physical activity.
• Physical/emotional stress and illness can disrupt this delicate balance.

Hypoglycemia (Low Blood Sugar)

• The most serious "emergency" problem related to blood sugar control.
• It develops quickly and requires early detection and immediate attention.

Common Causes of Hypoglycemia

• Too much diabetes medication.
• Changes in meal/snack times.
• Insufficient food intake.
• Skipping/incomplete meals/snacks.
• Increased physical activity/exercise.
• Alcohol consumption without eating.

Symptoms of Hypoglycemia

• Mild: Hunger, sweating, feeling shaky, feeling nervous.
• Moderate: Headache, behavior changes, blurred/double vision, crabbiness/confusion, drowsiness, weakness, difficulty talking.
• Severe: Unresponsive (including being unable or unwilling to take oral feedings), loss of consciousness, seizure activity.

Intervention for Mild/Moderate Hypoglycemia

• Treat immediately with a fast-acting sugar:
  • Fruit juice (4-8 ounces)
  • Regular soda (6 ounces)
  • Sugar packets/table spoon in water (3/1)
  • Chewable glucose tablets (3-4)
  • Glucose gel (1 dose)
  • Honey (1 tablespoon)
  • Hard candy (2-4 pieces)

15 Minute Rule

• Following initial treatment, observe and recheck blood sugar in 15 minutes.
• Repeat fast-acting carbohydrate if blood sugar level is not within the acceptable range.
• Offer an extra snack if a meal is an hour or more away.

Treatment For Severe Hypoglycemia

• Prepare to treat with glucagon if:
  • The person is unwilling or unable to take treatment.
  • The person does not improve after the second treatment.
  • Symptoms worsen to the point where the person cannot swallow.
  • Loss of consciousness or seizures occur.

Glucagon

• A hormone, similar to insulin, produced by the pancreas.
• Acts on the liver, converting glycogen to glucose.
• Safe and relatively free from adverse reactions.
• No human overdose cases reported.
• May cause nausea and vomiting.

Glucagon Emergency Kit

• Contains:
  • Glucagon powder.
  • Special diluting fluid.
  • Syringe or vial.
• Prescriptions may be needed for individual patients.

Glucagon: Storage and Handling

• Store at room temperature (59° - 86°).
• Do not mix until needed.
• Discard unused portions.
• Glucagon solution should be clear and have a water-like consistency.
• Check expiration dates regularly.
• Inject into fatty tissue or muscle (arm/thigh).

Glucagon - Dosages

• Manufactured in 1 mg vials.
• The person's healthcare provider determines the dose.

Intervention/Severe Hypoglycemia (cont.)

• If the person is unconscious but breathing and has a pulse, assume severe hypoglycemia.
• Cut/clamp insulin tubing (if on insulin pump).
• Obtain the glucagon emergency kit.
• Prepare and administer glucagon.

To Prepare Glucagon

• Put on gloves.
• Remove the flip-off seal from the powdered glucagon.
• Remove the needle cover from the syringe.
• Do not remove the plastic clip from the syringe.
• Insert the needle into the powdered glucagon vial.
• Push the plunger to inject the liquid into the powdered glucagon.

Prepare Glucagon (cont.)

• Leave the needle on the syringe in the vial.
• Gently shake the bottle until the powder dissolves.
• Withdraw the appropriate amount of medication.

Administer Glucagon (cont.)

• Insert the needle into the loose skin/muscle of the upper arm or thigh.
• Administer all the medication.
• Carefully withdraw the needle at the same angle, without releasing the person's limb.
• Discard the needle according to OSHA Bloodborne Pathogen Standards.

Administer Glucagon (cont.)

• If a person is combative or having a seizure, get assistance from another provider.

Glucagon Administration Video

• Visual demonstration of administering glucagon.

Care of the Person

• Position the person on their side.
• Monitor for absent pulse/breath, or seizures.
• Improvement usually seen within 10-15 minutes.
• A person might be unresponsive for other reasons.

Care of the Person (cont.)

• If the person responds and can swallow, feed a fast-acting sugar source (e.g., clear sugar-containing liquids).
• Follow up with longer-acting sources (e.g., carbohydrates and proteins)
• Seek consultation from a medical provider.

Follow Up

• Emergency responders decide if transport to medical facility is needed.
• The person or caregiver seeks consultation to prevent future episodes.
• Dispose of any glucagon remaining from the EMS supply.

Unsolved Questions (ONS)

• Unsolved questions in the video.