Would you give Glucagon?

[Smellypaddler]

First time post so happy to fill in the blanks as needed:

You are dispatched to a 7mo old pt who has pulled out his PEG tube.

On arrival the mother is distraught and panicking and explains that the pt has pulled out their PEG tube and requires constant feeding to maintain their blood sugar due to having only 5% of their pancreas remaining.

A - patent
B - No respiratory distress
C - Warm, pink and well perfused.

All vitals within normal ranges but patient is lethargic and hard to rouse.

The mother has been advised by the local childrens hospital that should her child have a "hypo" she should give Glucagon.

On dispatch the pt's BGL is - 6.7mmol (259? mg/dl)
On arrival BGL - 4.5mmol (174? mg/dl)
within 5mins BGL - 3.2 (123? mg/dl)

Whilst you are performing your assessment the mother makes up her Glucagon kit and wants to administer 2 iU IM as per the instructions she has from the childrens hospital.

Your guidelines say for a patient under 25Kg you should administer 0.5iU IM.

So do you let her administer her Glucagon and her dose?

or

Do you administer your Glucagon kit at the dose your guidelines recommend?

I'll provide more info as needed. This is my first scenario so I may not have laid it out that well but it is an actual job I went to and I just wonder what the rest of you would do.

 

[firecoins]

Call medical control and explain the situaion to the md. Put the mom on with him.

 

[DesertMedic66]

I'm only a basic but why would you administer it in the first place? The pts. Sugar levels are above the normal. So administering the glucagon would cause the pts sugar levels to go up higher.

 

[Handsome Robb]

Sweet and simple if mom wants to do it I'm not going to box with her over it. If she gives it I'm not touching my meds unless something dictates or they are deemed inefective with post-admin testing. If she doesn't admin it I'll follow protocol.

The babe needs to go to the hospital to have the PEG tube replaced, no if ands or buts about it. If I can't talk the mother out of her glucagon dose I'll document the hell out of what happened.

I don't know enough about the condition to go further than that. Personally I would expect to see elevated CBG levels with decreased pancreatic function not decreased levels but I'm the first to admit (and respond ) that I don't know enough about the condition.

If you have it I'd love a link to some more info on this condition that's beyond "5% pancreatic function left".

 

[Remeber343]

I would assume you'd administer it because of the trending in his sugar. And I'd say if the mother was given direct orders by an md to give a certain dose, I would probably let her do so. She is probably more educated with his issue, but if you would be unsure you can contact med control. I would probably or her administer the dosage.

 

[firecoins]

I like nvrob's response.

 

[Medic Tim]

I would contact med control. But I don't see an issue with mom giving it. 4 mmol is closer to 85 -90mgdl

 

[Handsome Robb]

I would assume you'd administer it because of the trending in his sugar. And I'd say if the mother was given direct orders by an md to give a certain dose, I would probably let her do so. She is probably more educated with his issue, but if you would be unsure you can contact med control. I would probably or her administer the dosage.

The trend in sugar is what I would base it off of. If it continues on the downward I'm going to try to stay ahead of the game.

A thought I had is the mother is given glucagon because it can be given IM. Why couldn't we give D25 or D10 if we could get an IV established? In this situation dextrose or glucagon establish the same goal. Also with a *presumed* feeding/absorption disorder how well is glucagon actually going to work? Hence the larger than usual dose. Now if it's the only option, it's the only option.

Glucagon promotes glycogenolysis of glycogen to glucose in the liver. With abnormal absorption and/or feeding along with a displaced feeding tube how can we presume the kid has adequate glycogen stores?

How long has the PEG been displaced? Did mom spend a bunch of time trying to self-remedy the problem before she called or did she call right off the bat? With the trend of falling CBGs it seems acute but kids can compensate despite popular belief. They cannot do it for nearly as long as adults, especially this one with the preexisting condition, but they can do it.

In the time it took me to formulate this thought the kids sugar is probably very low and we are probably already to the hospital by now.

 

[Smellypaddler]

Ok, the patient was born at 27 weeks gestation and this was his first day at home (poor guy was 7months old).

He had an overactive pancreas that was secreting too much insulin so they removed 95% of it leaving him with the remaining 5% that was still producing too much.

We allowed mum to draw up the Glucagon at the same time educating her in what to do as she hadn't done it before.

The thinking was that the doctors who had prescribed her Glucagon dose (which was checked on paper) knew more about the child's condition than we ever would.

There was some concern that there would not be enough stored liver glycogen to convert into glucose but 10-15 mins after the Glucagon going in his sugars where back up to 5.5 where they started to instantly drop again.

By this point it didn't make much difference as we had applied liberal pressure to the pedal and where pulling into the ED.

All in all I reckon we made the right call but it never hurts to run through what you did and if you'd do it differently next time.

I'm only a basic but why would you administer it in the first place? The pts. Sugar levels are above the normal. So administering the glucagon would cause the pts sugar levels to go up higher.

My bad. I used an online converter to convert the blood sugar from mmol's to mg/dl. This patients sugars where trending low.

 

[BEorP]

Ok, the patient was born at 27 weeks gestation and this was his first day at home (poor guy was 7months old).

He had an overactive pancreas that was secreting too much insulin so they removed 95% of it leaving him with the remaining 5% that was still producing too much.

We allowed mum to draw up the Glucagon at the same time educating her in what to do as she hadn't done it before.

The thinking was that the doctors who had prescribed her Glucagon dose (which was checked on paper) knew more about the child's condition than we ever would.

There was some concern that there would not be enough stored liver glycogen to convert into glucose but 10-15 mins after the Glucagon going in his sugars where back up to 5.5 where they started to instantly drop again.

By this point it didn't make much difference as we had applied liberal pressure to the pedal and where pulling into the ED.

All in all I reckon we made the right call but it never hurts to run through what you did and if you'd do it differently next time.



My bad. I used an online converter to convert the blood sugar from mmol's to mg/dl. This patients sugars where trending low.

I'm getting in on this late, but I absolutely degree with what you did. If what the mom said checked out, then the kid needed more glucagon than a typical patient of similar size. It was best for the patient that you got the larger dose.

Unfortunately, most on this site work in places where paramedics are not expected to think like Australian paramedics. This is a case where a paramedic who can think is a good thing. Well done.

 

[Smellypaddler]

I'm getting in on this late, but I absolutely degree with what you did. If what the mom said checked out, then the kid needed more glucagon than a typical patient of similar size. It was best for the patient that you got the larger dose.

Unfortunately, most on this site work in places where paramedics are not expected to think like Australian paramedics. This is a case where a paramedic who can think is a good thing. Well done.

Thanks mate, Australia pre-hospital is a completely different system and culture than the USA but there are still people on here that will have forgotten more than I'll ever know.

 

[mycrofft]

Parsing: you do not have control over the mother's actions, and if there is a valid MD order and she is meeting it and you countervene you are overriding a MD. However, if you suspect that harm may result to a child, you have a duty to intervene at least by reporting it. Call medical control, stand by a little, make small talk, praise her kid for being so handsome or smart or whatever, then follow with whatever is most prudent clinically and legally. A call to the kid's MD might be indicated?
ADDIT: the profile of glucometry, if accurate , portrays someone sliding for a crash. I have seen something like that after Glucagon was given and nothing else was done (like serving lunch). Also, sort of resembles the downside of an oral sugar spike. Anyway, at that rate, you would soon be chasing a low sugar. One more fingerstick to decide.

 

[jjesusfreak01]

A thought I had is the mother is given glucagon because it can be given IM. Why couldn't we give D25 or D10 if we could get an IV established? In this situation dextrose or glucagon establish the same goal. Also with a *presumed* feeding/absorption disorder how well is glucagon actually going to work? Hence the larger than usual dose. Now if it's the only option, it's the only option.

I'm with Rob. I don't see any reason we can't start a D10 drip on this kid. It will perform the same essential function as the Glucagon (ie, keeping his sugar up) but will save him from the rollercoaster of blood glucose levels he's going to have if we chase his levels with Glucagon. Although overproduction of insulin may be this kid's major problem, it was being treated successfully with constant feeding, and we can mimic that to a degree using dextrose.

 

[mycrofft]

But Smelly sounds like they done good.