EMS State of the Sciences Conference: Treatment Options for Hypoglycemia: Should It Be Gluca-gone?

The annual EMS State of the Sciences Conference, colloquially known as the “Gathering of Eagles,” is held to share the most cutting-edge information and advances in EMS patient care, research and management issues, trending challenges and lessons learned. Speakers include medical directors from the EMS systems of America’s largest cities, plus prestigious physician guests.                               

Presentation: Low-Tide for the Peptide: Is Stocking Glugacon Worth It? Presented by Peter Taillac, MD, FACEP, Clinical Professor, Division of Emergency Medicine, University of Utah School of Medicine; Utah State EMS Medical Director; Medical Director, West Valley City, UT, Fire and EMS

Sometimes the patients who seem the simplest can become very challenging, very fast.

You are called to the scene of a diabetic patient “acting crazy.” You arrive to find the patient confused, combative, staggering and diaphoretic. A quick fingerstick glucose reads “low.” No problem, let’s get an IV and give him some D50, right? Simple! However, at your first IV attempt, he pulls his arm away, screams and curses, and takes a swing at you. Then he staggers towards the door, yelling that you’re trying to kill him. What are your management options now?

Or say you are called to a home where a 12-year-old diabetic child is unconscious, with diaphoresis and sonorous respirations. Your fingerstick glucose check registers “low.” As you begin to set up for your IV, the child begins convulsing: a grand mal seizure. Because of his violent movements, you are unable to start your IV. What are your management options now?

Management of hypoglycemia with oral glucose or IV dextrose is such a simple and satisfying intervention. The patient wakes up in minutes and the family thinks you’re a magician! However, when faced with a patient in whom IV access is difficult, this simple situation rapidly becomes complicated…and potentially life-threatening.

The Problem of Hypoglycemia

Low blood sugar results in the brain being starved for fuel and therefore malfunctioning, manifested by confusion, coma or seizures. The body’s initial response to hypoglycemia is to mobilize the glucose stored in the liver in the form of glycogen. Glycogen is a complex molecule made up of thousands of glucose molecules. Under the influence of glucagon, secreted by the pancreas, the glycogen stored in the liver is broken down into individual glucose molecules. These are released into the bloodstream to fuel the brain and the rest of the body.

The usual causes of life-threatening hypoglycemia in the diabetic patient include an imbalance between their hypoglycemic medication (insulin or oral hypoglycemics) and their glucose intake. This is often the case in a patient who takes their medication and forgets to eat, or in one who develops nausea and vomiting and can’t hold down food but still takes his medication. Occasionally, increased exertion or physical activity can result in hypoglycemia if the usual insulin dose is used and extra calories are not consumed to compensate for the increased activity.

For the non-diabetic patient, hypoglycemia is generally the result of either accidental or intentional overdose on hypoglycemic medications. Keep in mind that most of the oral hypoglycemics have much longer effects than does regular insulin. Therefore, for the oral hypoglycemic overdose patient, they may awaken with IV dextrose, but the prolonged effect of the hypoglycemic medication my result in recurrent hypoglycemia. All oral hypoglycemic overdose patients should be transferred to the hospital for prolonged dextrose replacement and careful monitoring of their glucose levels.

Frequency of Glucagon Use

Because of the increasing price of glucagon, approximately $400 per 1 mg vial, I was asked if we could remove it from the rigs. Providers told me they “never use it” and “it always just expires.” So I began some research into the frequency of glucagon use in the field and investigated other options. I was surprised by some of my findings.

Glucagon is not commonly used, but isn’t rarely used either. In a survey of 33 large urban EMS agencies across the U.S., it was used in approximately 1–2 in every 1,000 calls. This number was surprisingly constant from agency to agency. Next, I checked the Utah State EMS Registry and discovered that in my state, it was also used in just under 1 per 1,000 calls. Finally, I queried the National EMS Information System (NEMSIS) database for the rate of use across the U.S. as a whole. Guess what? Nationally the rate is, you guessed it, just over 1 glucagon use per 1,000 calls! At that rate, any one medic may go several years without using it, but most agencies use it multiple times per year. Unfortunately, a great deal of glucagon sitting on rigs does, indeed, expire unused. One large agency calculated that it threw away 3 vials of glucagon for every one used. At $400/vial (1 mg), this is $1,600 per actual use. Pretty darn expensive, but it is lifesaving.

Other Treatment Options for Hypoglycemia Without IV Access

If a patient is awake enough to swallow, oral glucose works great. This can be accomplished by sugary drinks, hard candies, oral glucose paste, or a peanut butter and jelly sandwich. However, many hypoglycemic patients have a severely depressed mental status and impaired swallowing. They can’t be given oral glucose or food without the danger of choking or aspirating.

In the absence of an IV line, what about giving dextrose via the intraosseous (IO) route? This is, indeed, an option and will deliver the glucose to the brain as quickly as an IV. In fact, this is what three large urban EMS agencies actually do. What’s the down side? Well, first, you drill a hole in the patient’s bone, which we know is really quite safe and not terribly painful, but it still seems rather dramatic, relative to an IM glucagon injection. And those IO needles are very expensive. However, IO dextrose is an option for our hypoglycemic patient without IV access. Please keep in mind that D50 is very hyperosmotic and the actual effect on the bone marrow is unknown. A less osmotic, and possible safer, option is D10 given by IO infusion (see below).

Any other choices for getting sugar into the body? Several researchers have investigated rectal glucose administration for hypoglycemia. Unfortunately (or perhaps fortunately!), this technique doesn’t work. These studies have shown that the rectum absorbs glucose very poorly and with little effect on the blood glucose level.

IM epinephrine has been demonstrated to raise blood glucose levels. In a study of hypoglycemic children, blood glucose levels were raised slightly after IM injection of epinephrine. However, the effect was small and transient (30 minutes). It’s not clear if the minor elevation in blood glucose seen after IM epinephrine would be enough to reverse severe hypoglycemic symptoms. However, if you’re ever in a hypoglycemic situation with only epinephrine available, it may be better than nothing.

One final finding I thought intriguing, which I’ve incorporated into my practice: instead of reflexively using “an amp” of D50 either IV or IO, D10 can be dripped in by IV infusion. In an elegant study by UK investigators Chris Moore and Malcolm Woollard, the time required to achieve a normal mental status was the same for the D50 bolus and the D10 infusion. However, the patient’s resulting blood sugar level was much lower with the D10, (112 mg/dl) than with the D50 (170 mg/dl). There was less “overshoot” of the glucose level for the patient.

So, for the difficult hypoglycemic patient without IV access, there appear to be only two options to treat this not common, but not rare, life threat: IM (or intranasal) glucagon or IO dextrose. As one agency medical director said, “If you drilled my leg instead of using glucagon, I’d be pissed!” Personally, I agree. So after researching this, I’ve decided we’ll be keeping the expensive glucagon on our rigs.

There are rumors of a cheaper intranasal version, designed for EMS, in the works that may help reduce our eventual costs. We’ll see.

Thanks to Clay Mann, PhD (NEMSIS), Mathew Christiansen, PhD (Utah POLARIS database), and the Eagles Coalition for their assistance with determining the frequency of glucagon use. E-mail questions or comments to peter.taillac@hsc.utah.edu.

References

1. Attvall S, Lager I, Smith U. Rectal glucose administration cannot be used to treat hypoglycemia. Diabetes Care 1985;8(4):412–3.

2. Aman J, Wranne L. Treatment of hypoglycemia in diabetes: failure of absorption of glucose through rectal mucosa. Acta Paediatr Scand 1984;73(4):560–1.

3. Kiefer M, Gene Hern H, Alter H, Barger J. Dextrose 10% in the treatment of out-of-hospital hypoglycemia. Prehosp Disaster Med 2014;29(2):190–4.

4. Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial. Emerg Med J 2005;22(7):512–5.

5. Monsod T, et al. Epipen as an alternative to glucagon in the treatment of hypoglycemia in children with diabetes. Diabetes Care 2001;24(4):701–4.