Clinical Judgment and Protocols

[emtannie]

Johnboy,

This is what I have found so far (yes, Google is my friend):

"Glucagon administered intranasally has been proven to raise blood glucose levels in volunteers. The effect of intranasal glucagon on blood glucose is similar to that seen after intramuscular administration for the first 15 minutes following administration."

(Carstens, S. and I. Andersen (1994). "[intranasal glucagon in the treatment of hypoglycemia. A therapeutic possibility in the future]." Ugeskr Laeger 156(30): 4339-42.)

"Glucagon in solution with a surfactant (deoxycholic acid 1% w/v) was administered by intranasal spray to 6 healthy fasting subjects and 6 insulin-dependent diabetics with insulin-induced hypoglycaemia. In the normal subjects, intranasal glucagon increased plasma glucose levels, with a dose-response effect. In the diabetic patients, plasma glucose levels showed a mean increase of 100% above nadir values in approximately 26 min in response to 7.5 mg intranasal glucagon; hypoglycaemic symptoms were relieved within about 7 min. These results suggest that intranasal glucagon is effective and may represent an alternative to parenteral glucagon or glucose or to oral sugar as the first-line treatment of hypoglycaemic episodes in insulin-dependent diabetics."

(Freychet, L., S. W. Rizkalla, et al. (1988). "Effect of intranasal glucagon on blood glucose levels in healthy subjects and hypoglycaemic patients with insulin-dependent diabetes." Lancet 1(8599): 1364-6.)

"We conclude that glucose recovery was significantly better after i.m. administration of glucagon than after intranasal administration. However, the differences between the incremental plasma glucose and the time for incremental plasma glucose to exceed 3 mmol.l-1 were not considered of major clinical importance."

(Hvidberg, A., R. Djurup, et al. (1994). "Glucose recovery after intranasal glucagon during hypoglycaemia in man." Eur J Clin Pharmacol 46(1): 15-7.)

"Intranasal glucagon raised blood glucose levels in patients with hypoglycemic episodes, although less effectively than intramuscular glucagon."

(Pontiroli, A. E., A. Calderara, et al. (1989). "Intranasal glucagon as remedy for hypoglycemia. Studies in healthy subjects and type I diabetic patients." Diabetes Care 12(9): 604-8.)

"There was no difference between nasal treatment with 2 mg ( and i.m. treatment ©, both being more effective than 1 mg (A) nasal treatment, P less than 0.1. BG continued to increase up to 10 mmol/l 90 min after i.m. glucagon administration, whereas it stabilized at a level of 4.6-6 mmol/l, 30-45 min after nasal administration. Eighty percent of the patients had side-effects to nasal administration - local irritation, rhinitis or sneezing."

(Rosenfalck, A. M., I. Bendtson, et al. (1992). "Nasal glucagon in the treatment of hypoglycaemia in type 1 (insulin-dependent) diabetic patients." Diabetes Res Clin Pract 17(1): 43-50.)

A 2006 article in EMSWorld calles nasal administration a milestone yet the references cited do not support it (http://www.emsworld.com/print/EMS-World/A-Milestone-Change-in-Practice/1$5165) and are based on versed and narcan intranasally, not glucagon.

I have not found any research articles or studies dated in the past 5 years, even after reviewing more than 10 pages of Google hits. If it is the new standard, one would think that I should have found a recent study, or references to services using it in their protocols. So, again I will ask you, as I did in my previous post: Could you tell me a little more about using Glucagon IN, and what your protocol dosages and recommendations are?

Please provide the references so I can follow up. If you are going to make the comment it is the standard now please provide the evidence to support it. I would love to read the research that supports this, and be able to bring it to my medical director.

(Edited to bold segments only)

Edited April 4, 2011 by emtannie

[DwayneEMTP]

Hmmm....I'll be curious what research has shown up on the last 5 years to back our young heros claim...

Dwayne

[Johnboy]

D- back to the matter- you were apparently fired over this, and now a complete stranger agrees with the outcome. Wake up.... It is this attitude, that gets paramedics in hot water and you are living proof.....

[paramedicmike]

...by your rah rah bullshit.

What?!?! There's MORE?! Could it be true? MORE rah rah bullshit?!?!

Rock on! I'm just in time!

D- back to the matter- you were apparently fired over this, and now a complete stranger agrees with the outcome. Wake up.... It is this attitude, that gets paramedics in hot water and you are living proof.....

Speaking of proof, I believe you were asked to provide some to back your statements.

I'm not taking sides on this one as it's a little late in the discussion. But I'm interested in the evidence to support your claims.

You made the argument, you cite the evidence. That's how it works.

[BAYAMedic]

D- back to the matter- you were apparently fired over this, and now a complete stranger agrees with the outcome. Wake up.... It is this attitude, that gets paramedics in hot water and you are living proof.....

Back to the matter? How so? Being new to the forum I will happily explain where the true matter herein lays. Are we to toss our experiance and best clinical judgement aside to follow a written piece of paper that doesn't follow that minutes problem? We are medical professionals who are globally spread and sit on this forum not to quote what our Medical Program director has written for us, But rather to share our experiances and to learn from each others successes and mistakes. I have heard it said that "A smart man uses all of his brain, but a genius uses all brains at his disposal." We talk here to cause ourselves to be better practitioners and back our methodologies with hard science and medical research. I understand not to treat based on what I have learned on this forum but rather can use this as a stepping stone to getting protocols changed, to ultimatly provide best care to our patients. I can't remeber whos tag line used to state a waiver of "follow your local protocols". I believe that there is a best of both worlds here. I believe that to be by the book, Online Medical control could have been contacted. But I also can't argue with positive outcomes.

Fireman1037

[Just Plain Ruff]

What?!?! There's MORE?! Could it be true? MORE rah rah bullshit?!?!

Rock on! I'm just in time!

Speaking of proof, I believe you were asked to provide some to back your statements.

I'm not taking sides on this one as it's a little late in the discussion. But I'm interested in the evidence to support your claims.

You made the argument, you cite the evidence. That's how it works.

I have also done some pretty extensive searching of the web and many on this site know that I'm pretty thorough and have multiple search sites that I use and I have found a single article written after 2009. Not much from 2003-2009 and lots written before 2003.

I'd be curious as to how many services are using this Intranasally?

I have a couple of friends in some pretty progressive services and they are only giving Narcan and Versed IN, glucagon isn't even on their radar at this time.

So far from you have been "It's the standard" which is long on boasting and short on substance. You have not produced any sources that show it as a standard or sources that prove that the time of onset is any better than IM Glucagon.

I and others are awaiting your reply.

[usalsfyre]

No IN glucagon here, we deliver fentanyl, naloxene, midazolam, and lidocaine (for nasal and awake intubation) via MAD.

[Johnboy]

If you people can't find a procedure that has been going on since 2008, then you all need some help.. The problem

Here is we have a person here that can't face the fact that he was wrong. Hopefully you are not around myself or my loved ones....maybe someone should buy you a holster so you can wear that EZ io gun all day long...people like you are the reason why procedures like RSI are not available to educated paramedics...

[paramedicmike]

And you have STILL not provided any evidence to back up your statements. You are now engaging in deflection and misdirection. This isn't about Dwayne and his actions at this point. This is about you and your inability to substantiate your claims.

Cite the evidence to back your claims or we'll pretty much have to dismiss any comments you've made thus far.

[DwayneEMTP]

If you people can't find a procedure that has been going on since 2008, then you all need some help.. The problem

Here is we have a person here that can't face the fact that he was wrong. Hopefully you are not around myself or my loved ones....maybe someone should buy you a holster so you can wear that EZ io gun all day long...people like you are the reason why procedures like RSI are not available to educated paramedics...

Yeah, now you're showing your true colors. I was hoping that you weren't going to prove to be a troll. Shame on me. You haven't made a sound argument that I was wrong, though you have been shown to be so on nearly every acct. No one besides you has posited that I was terribly wrong, though perhaps some others would have made different, likely better decisions. You need to produce to be taken seriously here my friend. At this time you're simply the kid at the back of the room making fart sounds hoping someone will think he's cool.

Just because you believe that starting an I/O is a big deal doesn't make it a big deal Hot Shot. A gazillion are started and removed every day. I can't wait for your argument against EJs. And for the record? Each place that I've worked with the exception of my current location has had RSI. Perhaps there's a reason that YOU don't have access to it.

You were caught talking out of your ass and now you're going to cry instead of step up to the plate. This is the exact reason you will likely always be a protocol money instead of a thinking clinical provider. I hope for better for you. But as long as you pout instead of debate, as long as you cry each time someone doesn't cave into one of your arguments, you will never grow.

Stop telling stories to those that think your brilliant brother. Step away from the basics and start debating with the medics that have been somewhere and done something...come back and play. It would be good for you. And I have a feeling when you're not bent that you have a lot to offer.

Dwayne