Glucagon rescue

Glucagon rescue is the emergency injection of glucagon in case of severe diabetic hypoglycemia. It is needed during seizures and/or unconsciousness by an insulin user who is unable at that point to help themself. Glucagon will facilitate the release of stored glucose back into the bloodstream, raising the blood glucose level.

Rescue has been simplified by the development of the glucagon emergency kit, consisting of:

• rDNA-synthesized human glucagon, in a freeze dried form within a vial,
• a sturdy syringe, pre-filled with a sterile diluting solution, and
• a conspicuous orange colored plastic storage box, which includes instructions.

At the first signs of hypoglycemia, an insulin user should treat it immediately by consuming carbohydrate to restore blood glucose to safe levels (thereby preventing progression to severe hypoglycemia). However, not all insulin users can feel and recognize the early signs, particularily when sleeping. This can quickly lead to an emergency resulting in unconsciousness, inability to swallow, seizures, and in extreme cases death. In the past, treatment consisted of intravenous delivery of dextrose (glucose) usually in the emergency room; however, the delay in treatment due to emergency response and transport to a medical facility is life threatening.

The glucagon emergency kit facilitates rapid rescue by a simple injection, which does not require medical expertise, and can be done quickly and easily outside of a medical facility.^[1]

Additional recommended knowledge

Essential Laboratory Skills Guide

How to ensure accurate weighing results every day?

Daily Sensitivity Test

Manufacturers of Glucagon Rescue Kits

"Glucagon Emergency Kit" from Eli Lilly and Company

"GlucaGen Hypo Kit" from Novo Nordisk

Vials of GlucaGen from Bedford Laboratories

Glucagon Rescue Instructions

Simplified instructions

The instructions for using the emergency glucagon rescue kit can be simplified to the 4 essential steps as shown in the pictures inside the orange box cover.^[2]

1. open the vial by breaking off the grey plastic cover from the glucagon vial,
2. inject the diluting solution into the vial of dry glucagon by first removing the cover from the syringe needle, and then injecting the diluting fluid from the syringe into the glucagon vial,
3. swirl to mix by withdrawing the syringe from the vial and swirl slowly by hand until the white glucagon powder is dissolved in the fluid,
4. inject the glucagon mixture by reinserting the needle back into the vial and drawing the glucagon mixture back into the syringe, and then injecting into the unconscious person's leg or abdomen muscle: the dosage is approximately half (500µg) for small children and approximately all (1000µg) for larger children and adults. Roll the unconscious person onto their side in case they vomit upon recovery, and then wait for the glucagon to take effect.

Controversial Instructions

The steps to perform glucagon rescue and perhaps save a life are few and simple. However, the instructions that are supplied with the glucagon emergency rescue kit are long, and potentially complicated to use.

There are three counter-productive issues with the instructions:

1. The instructions are folded tightly into a flat roll and glued at one end to keep the paper folded tight. When the instructions are unrolled, they are intimidating because of their length and small print.
2. The instructions are divided in half. The left half is intended for the pharmacist, while the right half in intended for the user of the kit. The instructions for the pharmacist ask that the paper roll be cut in half, and that only the user half be included with the kit. However, it is rare for the pharmacist to do this, so the entire instructions are likely to be received by the user. In this case, reading starting from the left margin at the top will tell the reader about the chemical formula for glucagon, its organic sequence, pharmacokenetics, pharmacodynamics, indications and contraindications, etc. In an emergency situation, where a rapid response time equates to brain cells saved, the pharmacists instructions are counter productive.
3. On the usage side of the instructions, the instructions for giving the injection state that the injection should be cleansed with an alcohol swab prior to injection, and then the alcohol swab should be pressed to the injection site when removing the needle from the tissue. The swab is not included in the kit. Many insulin users rarely follow sterile procedures (preferring to follow clean procedures instead) because it is typically unnecessary. However some potential rescuers may erroneously decide to postpone rescue and wait for emergency personnel because they are unable to follow the instructions to give a sterile medical injection.

This is avoidable because the 4 necessary steps, as illustrated in instructional pictures inside the top cover of the plastic box, do not require additional detail. The kit has been carefully designed to facilitate rescue outside of a medical facility by non-medical personnel. So while the information is helpful to the pharmacist and in prior training for glucagon administration, perhaps the instructions should just be removed by the user before carrying the kit in a situation where it might possibly be needed for them.

Politics of Glucagon Rescue

Public awareness of other forms of life saving measures has increased dramatically in the past, such as:

• artificial respiration (or "mouth to mouth")
• CPR
• the Heimleich Maneuver, etc.

However, despite public relations to increase the awareness of the life saving capability of glucagon rescue, it is still largely unknown by the general public.^[3] An unfortunate example is seen in public school policy and some teacher's union contracts in the U.S., which require that union teachers shall not be allowed to deliver glucagon or even be trained in administration of glucagon. ^{[4] [5] [6]} This can only be due to the ignorance of glucagon as a life saving measure, as it would obviously be absurd to prohibit training and delivery of CPR or any other life saving first aid in a public school.

Many insulin users now carry the kit with them at all times. It is imperative that the public learn to search an unconscious person for an identification of a medical alert: and upon finding information about diabetes or insulin use, the public must then learn to search the unconscious person for a glucagon emergency rescue kit and use it.

Glucagon "Mini-dose" Instruction

The purpose of the "mini-dose" is to avoid an emergency condition that may require glucagon rescue. This might be needed in cases such as when a diabetic child is injected with insulin before breakfast, eats, and then vomits and cannot eat again: with the injected insulin working its way into the bloodstream and no carbohydrate to balance, there may soon be a hypoglycemic emergency.

To avoid severe hypoglycemia (or alternatively avoid a trip to the hospital for intravenous glucose), the glucagon from the emergency rescue kit can be used in a measured dose to maintain the blood glucose level. Instead of the glucagon emergency syringe and its large bore needle, a standard U-100 insulin syringe can be used. The recommended dose is:

• ages 2 years and under: 2 units (20µg)
• age 2 to 15 years: 1 unit (10 µg) for each year of age (6 units for a 6 year old, etc)
• age 15 years and older: 15 units (150 µg)^[7]

The mini-dose treatment should be repeated as necessary to maintain blood sugar until food can be eaten.

Medical studies have shown that the mini-dose rescue is tolerated well and effective.^[8]

References

1. ^ http://pi.lilly.com/glucagon-patient.pdf
2. ^ http://pi.lilly.com/glucagon-patient.pdf
3. ^ http://www.diabetes.org/uedocuments/GlucagonLifeSaverStories02-06.pdf
4. ^ http://www.diabetes.org/advocacy-and-legalresources/discrimination/school/schoolefforts-news.jsp
5. ^ http://www.diabetes.org/advocacy/nasnschool.pdf
6. ^ http://www.diabetes.org/advocacy-and-legalresources/discrimination/school/legislation.jsp
7. ^ http://www.diabetes123.com/d_0j_20w.htm
8. ^ http://care.diabetesjournals.org/cgi/content/abstract/24/4/643