As a new member of Paramedicine 101, I'll be quick with the introductions: I'm an EMT-Paramedic in North Carolina and have been in EMS just long enough to have never recertified. I'll save you the trouble of looking up NC's recertification schedule to let you know I'm green! Recently I was on a call in which a patient choked on a piece of cabbage. The patient was able to clear the foreign body airway obstruction on their own, but continued to have the sensation of choking. Our site MD recommended the administration of 1 mg Glucagon slow IVP in order to alleviate the discomfort. The only alternative usage I had been aware of was for β-blocker overdose.
After this call I found I could not escape these alternative usages of Glucagon! Sitting at the station one night I read a passage in Galvagno's Emergency Pathophysiology where he noted Glucagon could be administered in refractory anaphylaxis, and at that point my mind had been blown enough that I decided it merited an entire article. The structure of this article and the dosages are based on an excellent article by Charles Pollack: Utility of Glucagon in the Emergency Department with a host of support from interesting journal articles. Many of the uses Pollack gives are omitted as they have dubious applications in the field. So sit back and enjoy some well known and not so well known indications for the administration of Glucagon!
- Hypoglycemia
- Symptomatic bradycardia secondary to β-blocker overdose
- Symptomatic bradycardia secondary to Ca-channel blocker overdose
- Steakhouse syndrome
- Refractory anaphylaxis
- Severe asthma (little support)
- Refractory CHF (little support)
- Hypoglycemia: Adults: 1 mg SQ, IM, IV; 2 mg IN. Peds: 0.5 mg SQ, IM, IV; 1 mg IN. Neonates: 50 mcg/kg SQ, IV. (should accompany glucose resuscitation)
- Symptomatic bradycardia secondary to β-blocker overdose: 10 mg IV bolus, 1-5 mg/hr maintenance infusion. (should supplement standard treatment)
- Symptomatic bradycardia secondary to Ca-channel blocker overdose: 2-10 mg IV bolus; consider maintenance infusion. (should supplement standard treatment)
- Steakhouse syndrome: 1 mg SQ, IM, IV, may repeat.
- Refractory anaphylaxis: 1 mg IV q 5 min; consider 3-5 mg IV; consider maintenance infusion. (should supplement standard treatment)
- Severe asthma: 1-2 mg IV; 1-2 mg nebulized. (paucity of literature to support this use)
- Refractory CHF: 0.01-0.05 mg/kg IV bolus, 1-3 mg/hr maintenance infusion. (paucity of literature to support this use)
- Pollock CV: Utility of Glucagon in the Emergency Department. J Emerg Med 1993; 11: 195-205.
- Rosenfalck AM, et al: Nasal glucagon in the treatment of hypoglycaemia in type 1 (insulin-dependent) diabetic patients. Diabetes Research and Clinical Practice 1992; 17: 43-50.
- Love JN, Howell JM: Glucagon Therapy in the Treatment of Symptomatic Bradycardia. Ann Emerg Med January 1997; 29:181-183.
- American Heart Association. Part 7.3: Management of Symptomatic Bradycardia and Tachycardia. Circulation 2005; 112; IV-67-IV-77.
- Stadler J, et al: The "steakhouse syndrome". Primary and definitive diagnosis and therapy. Surg Endosc 1989; 3(4):195-8.
- Glauser J, et al: Intravenous Glucagon in the Management of Esophageal Food Obstruction. JACEP June 1979; 8: 228-231.
- Handal KA, Riordan WM, Siese J: The lower esophagus and glucagon. Ann Emerg Med November 1980; 9: 577-579.
- Galvagno, Samuel M. (2003). Emergency Pathophysiology: Clinical Applications for Prehospital Care (pp. 195-200). Jackson, Wyoming: Teton NewMedia.
- Lieberman MD, et al: The diagnosis and management of anaphylaxis: An updated practice parameter. J Allergy Clin Immunol 115 (2005); 3: S483-S523.
- Gavalas M, Sadana A, Metcalf S: Guidelines for the management of anaphylaxis in the emergency department. J Accid Emerg Med 1998; 15: 96-98.
- Compton J: Use of glucagon in intractable allergic reactions and as an alternative to epinephrine: An interesting case review. J Emerg Nurs 1997; 23: 45-7.
- Wilson JE, Nelson RN: Glucagon as a Therapeutic Agent in the Treatment of Asthma. J Emerg Med 1990; 8: 127-130.
- Melanson SW, Bofante G, Heller MB: Nebulized Glucagon in the Treatment of Bronchospasm in Asthmatic Patients. Am J Emerg Med 1998; 16: 272-275.
- Marik PE, Varon J, Fromm R: The Management of Acute Severe Asthma. J Emerg Med 2002; 23: 257-268.
3 comments:
Great article. This is one of those drugs that most medics take for granted and assume that they will almost never use it.
My paramedic program made us learn most the the possible uses but the CHF one is new to me. I don't think I'm going to be running out and trying it though.
We give Glucagon more commonly than IV D50. It saves the patient an IV so we don't have to pull it when the patient gets better and signs the refusal. I have seen glucagon given for a few reasons in the ED, but this is a great post and very informative. Great job!
I think I am going to add some notes to my pocket protocol book and field guide. The problem is many command MDs taking EMS consult calls may not be aware of these off-label uses or not be confident in trying them. Still, it is worth the try to ask and bring it up.
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