August 16, 2024

Welcome to UH EMS-I’s Pharmacy Phriday. This week we’ll continue our review of recent medication changes within the protocol that resulted from updates to Ohio’s EMS Scope of Practice. Click here for the most recent UH protocol or visit uhems.org. 

In this installment, we’ll review changes affecting Glucagon use. Glucagon, given as an IM injection, is an optional treatment when: 

• an IV cannot be established for whatever reason and 

• the patient’s point of care glucose measurement is <70 mg/dl, and/or 

• is symptomatic (i.e., an altered mental status) and 

• is unable to protect their airway thereby prohibiting the use of oral glucose (It is not glucose but a naturally occurring hormone produced in the pancreas that is released when blood glucose levels drop.) 

Glucagon breaks down glycogen—stored up energy in the liver. Glycogen is leftover glucose stored for later use by the body. When blood glucose levels drop due to low food intake, excessive activity, persistent nausea, vomiting, or any other reason, the glycogen is broken down to provide glucose for the cells. Glucagon also prohibits the storing of glycogen from existing glucose, assuring all the glucose in the bloodstream can be used by the cells for current energy demands. 

One circumstance when Glucagon is not effective is when the stores of energy (glycogen) do not exist in the liver. This situation can be seen in the malnourished patient or patient with a history of liver disease. Remember: Glucagon is NOT glucose. The hormone only contributes to increased blood glucose levels through the breakdown of stored energy. Bottom line: empty stores mean no energy for the cells! 

As mentioned earlier, Glucagon is given as an IM injection at a dose of 1mg for the adult patient (and in the pediatric patient weighing <20 kg, 0.5 mg IM). The medication can be given by the Advanced or Medic level provider, but now can also be administered by the EMT who has received proper training. UH requires that the EMT who will give Glucagon for hypoglycemic emergencies must have completed the epinephrine IM anaphylaxis training. This will ensure IM competency. 

The medication is supplied as a powder that must be reconstituted before administration. To reconstitute the Glucagon: 

• Draw up 1 mL of sterile water for injection (or the diluent supplied by the manufacturer) and add to the vial of powdered Glucagon. 

• Shake the vial gently until the powder is completely dissolved (the reconstituted injection should have a clear, water-like consistency).  

• The concentration is approximately 1 mg/mL Glucagon.  

• Use the reconstituted injection immediately and discard any unused portion.  

Follow this link to view a video demonstrating the above process.  

It is worth mentioning that the added competencies to Ohio’s EMS Scope of Practice list Glucagon administration via the intranasal route as an additional option. UH’s preference is that the medication be given via the IM route.  

Response to the administration of Glucagon should be seen in about 5-20 minutes. If no response is noted, the original dose may be repeated if the provider has a second vial. In cases where an IV line is established after administering Glucagon and the patient remains hypoglycemic, administer IV Dextrose, too. 

Glucagon does have other effects on the body. It is known to cause relaxation of the smooth muscles of the stomach and parts of the intestine, which is thought to lead to the most common side effect of nausea and/or vomiting. Hyperglycemia may also occur following the administration of Glucagon, but, as with most other emergency treatments used in hypoglycemic events, it is short-lived. Glucose stores will be used quickly requiring replenishment. Additionally, hypersensitivity is a possibility.

Until the next installment of Pharmacy Phriday, stay safe! 

Sincerely,



The UH EMS-I Team

University Hospitals

November 10, 2023

Welcome to Uh EMS-I’s Pharmacy Phriday. This week, we finish our series based on National Diabetes Month by reviewing Glucagon, the last of the medications within the “Diabetic Emergencies” algorithm not covered in this year’s series of articles.

Glucagon, given as an IM injection, is an optional treatment when the patient has a decreased level of consciousness that prohibits the use of oral glucose and EMS crews are unable to establish a peripheral IV line for the administration of IV dextrose. It is not glucose but is a naturally occurring hormone produced in the pancreas that is released when blood glucose levels drop.  

Glucagon breaks down glycogen, which is stored up energy in the liver. Glycogen is basically leftover glucose stored for later use by the body. When blood glucose levels drop due to low food intake, excessive activity, persistent nausea and vomiting, or any other reason, the glycogen is broken down to provide glucose for use by the cells. Glucagon also prohibits the storing up of glycogen from existing glucose, assuring all the glucose in the bloodstream can be used by the cells for current energy demands.

One circumstance when Glucagon is not effective is when the stores of energy, or glycogen, do not exist in the liver. This situation can be seen in the malnourished patient or patient with a history of liver disease. Remember: Glucagon is NOT glucose. The hormone only contributes to increased blood glucose levels through the breakdown of stored energy. Bottom line: empty stores mean no energy for the cells!

As mentioned earlier, Glucagon is given as an IM injection at a dose of 1mg for the adult patient (in the pediatric patient weighing <20 kg, 0.5 mg IM). It can be administered by the Advanced or Medic level provider. The medication is supplied as a powder that must be reconstituted prior to administration. 

To reconstitute the Glucagon, draw up 1 mL of sterile water for injection, or the diluent supplied by the manufacturer and add to the vial of powdered Glucagon. Shake the vial gently until the powder is completely dissolved. The reconstituted injection should be clear and of water-like consistency. The concentration is approximately 1 mg/mL of Glucagon. Use the reconstituted injection immediately. Discard any unused portion. 

Response to the administration of Glucagon should be seen in about 5-20 minutes. If no response is noted, the original dose may be repeated if the provider has a second vial. In cases where an IV line has been established following the administration of Glucagon and the patient remains hypoglycemic, IV Dextrose should be administered as well.

Glucagon does have other effects within the body. It is known to cause relaxation of the smooth muscles of the stomach and parts of the intestine, which is thought to lead to the most common side effect of nausea and/or vomiting. Hyperglycemia may also occur following the administration of Glucagon, but as with most other emergency treatments used in hypoglycemic events, it is short-lived. Glucose stores will be used quickly requiring replenishment. Additionally, hypersensitivity is a possibility.

November is also celebrated by the Epilepsy Foundation as National Epilepsy Awareness Month, so in our next installment, we will review the first-line medication in the case of seizures. Do you know the medication? The doses? The routes?

Until then, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals