Glucagon Training Protocol b For Emergency Glucagon Providers b The Oregon Department of Human Services and the Oregon Department of Education gratefully.

Glucagon Training ProtocolGlucagon Training Protocol

For Emergency Glucagon ProvidersFor Emergency Glucagon Providers

The Oregon Department of Human Services The Oregon Department of Human Services and the Oregon Department of Education and the Oregon Department of Education gratefully acknowledge Multnomah Education gratefully acknowledge Multnomah Education Service District Department of Health and Service District Department of Health and Social Services for their assistance in the Social Services for their assistance in the development of this training material. development of this training material.

These materials may not be reproduced for These materials may not be reproduced for profit. Copyright. All rights reserved.profit. Copyright. All rights reserved.

MESD 8.08MESD 8.08

IntroductionIntroduction

In 1997 “Severe Allergic Reaction” In 1997 “Severe Allergic Reaction” Law was amendedLaw was amended

Allows trained lay persons to Allows trained lay persons to administer epinephrine or glucagonadminister epinephrine or glucagon

Training programs are separate and Training programs are separate and must be conducted independently must be conducted independently

This training is for glucagon onlyThis training is for glucagon only

Training Pre-RequisitesTraining Pre-Requisites

Person to be trained must be at Person to be trained must be at least 21 years of ageleast 21 years of age

Must reasonably expect to have Must reasonably expect to have responsibility for or contact with a responsibility for or contact with a person at known risk for person at known risk for hypoglycemiahypoglycemia• This is usually a person with diabetesThis is usually a person with diabetes

School Health School Health Management PlanManagement Plan

Parents notify school or daycare of Parents notify school or daycare of child’s medical needschild’s medical needs

School initiates a management plan School initiates a management plan (504 or IHP)(504 or IHP)

School documents agreements among School documents agreements among parents/school/daycare/medical parents/school/daycare/medical providerprovider

The School Nurse is usually the lead The School Nurse is usually the lead personperson

The Plan IdentifiesThe Plan Identifies

Specific actions for school personnelSpecific actions for school personnel Plan for communicating with Plan for communicating with

parents and medical providersparents and medical providers School medication policiesSchool medication policies Procedures for handling body fluidsProcedures for handling body fluids Action plan: meal and snack times, Action plan: meal and snack times,

testing, medication, etc.testing, medication, etc.

Key Elements of this Key Elements of this TrainingTraining

Reading through the protocolReading through the protocol Observing procedure for Observing procedure for

administering glucagonadministering glucagon A return demonstration (required)A return demonstration (required) Asking questionsAsking questions Completing the open-book Completing the open-book

evaluationevaluation Discussing CertificationDiscussing Certification

Using The ProtocolUsing The Protocol

Used for first time or re-Used for first time or re-certificationcertification

Covers:Covers:• An overview of diabetesAn overview of diabetes• Recognition of symptomsRecognition of symptoms• Administration of glucagon Administration of glucagon • Necessary follow-up treatmentNecessary follow-up treatment

CertificationCertification

Trainee must satisfactorily complete Trainee must satisfactorily complete the trainingthe training

Certificate must be signed by the Certificate must be signed by the trainertrainer

Certificate is Certificate is provider-specificprovider-specific Re-certification is required every Re-certification is required every

three yearsthree years Annual retraining is strongly Annual retraining is strongly

recommendedrecommended

Overview of DiabetesOverview of Diabetes

A lifelong diseaseA lifelong disease Affects the way the body uses foodAffects the way the body uses food

• Food is digested and changed into Food is digested and changed into glucose (sugar)glucose (sugar)

• Pancreas produces insulinPancreas produces insulin• Insulin allows glucose to go into the cells to be used Insulin allows glucose to go into the cells to be used

for energyfor energy In diabetes this system does not workIn diabetes this system does not work Glucose builds up in the blood streamGlucose builds up in the blood stream

Overview of DiabetesOverview of Diabetes -- -- cont.cont.

Type 1 diabetesType 1 diabetes• Pancreas Pancreas

produces no produces no insulininsulin

• Treated with Treated with insulin (by shots insulin (by shots or pump)or pump)

• Usual type for Usual type for children and children and young adults young adults

Type 2 diabetesType 2 diabetes• Not enough insulin Not enough insulin

produced orproduced or• Person does not Person does not

respond to insulinrespond to insulin• May be treated May be treated

orally and/or with orally and/or with insulininsulin

• More common in More common in adultsadults

High Levels of Blood High Levels of Blood GlucoseGlucose

increased thirstincreased thirst frequent urinationfrequent urination increased hungerincreased hunger weight lossweight loss irritabilityirritability flushed, dry skinflushed, dry skin nausea and vomitingnausea and vomiting weakness and fatigueweakness and fatigue

ComplicationsComplications

High blood sugar levels may cause High blood sugar levels may cause serious complications over timeserious complications over time• blindnessblindness• kidney disease or nerve damagekidney disease or nerve damage• heart diseaseheart disease

It is important to control blood It is important to control blood sugar levelssugar levels

BalanceBalance

Management of diabetes consists Management of diabetes consists of an intricate balance of:of an intricate balance of:• insulininsulin• food intakefood intake• physical activityphysical activity• Physical/emotional stress, illness Physical/emotional stress, illness

Anything that tips this delicate Anything that tips this delicate balance can cause fluctuations in balance can cause fluctuations in blood sugarblood sugar

Hypoglycemia (Low Blood Hypoglycemia (Low Blood Sugar)Sugar)

Most serious “emergency” problem Most serious “emergency” problem that can occur with blood sugar that can occur with blood sugar controlcontrol

Anyone taking insulin or diabetes pills Anyone taking insulin or diabetes pills can have blood sugar that is too lowcan have blood sugar that is too low

Comes on very quicklyComes on very quickly Requires early detection and Requires early detection and

immediate attentionimmediate attention

HypoglycemiaHypoglycemia -- cont. -- cont.

Usually mild if symptoms detected Usually mild if symptoms detected and treated earlyand treated early

Can become life-threateningCan become life-threatening Person can become unconscious Person can become unconscious

and have seizures or convulsionsand have seizures or convulsions

Common Causes of Low Common Causes of Low Blood SugarBlood Sugar

Too much diabetes medicationToo much diabetes medication Change in meal or snack timesChange in meal or snack times Not enough foodNot enough food Skipping or not finishing meals or Skipping or not finishing meals or

snackssnacks Getting more physical activity or Getting more physical activity or

exercise than usualexercise than usual Drinking alcohol without eatingDrinking alcohol without eating

Mild SymptomsMild Symptoms

HungerHunger SweatingSweating Feeling shakyFeeling shaky Feeling nervousFeeling nervous

Moderate SymptomsModerate Symptoms

HeadacheHeadache Behavior changesBehavior changes Blurred, impaired or double visionBlurred, impaired or double vision Crabbiness or confusionCrabbiness or confusion DrowsinessDrowsiness WeaknessWeakness Difficulty talkingDifficulty talking

Severe Symptoms Severe Symptoms

UnresponsivenessUnresponsiveness• Unwilling or unable to take oral Unwilling or unable to take oral

feedingsfeedings Loss of consciousnessLoss of consciousness Convulsions (seizure activity)Convulsions (seizure activity)

Symptoms of Symptoms of HypoglycemiaHypoglycemia

Mild

Hungry Sweaty Shaky Nervous

Moderate

Headache Behavior

Change Vision Change Confusion Drowsiness Weakness

Severe

Unresponsive Unable to Eat

or Drink Unconscious Convulsions or

Seizures

Intervention For Mild Intervention For Mild /Moderate/Moderate

HypoglycemiaHypoglycemia

Treat right away with a Treat right away with a fast acting fast acting sugar: sugar:• 4-8 ounces fruit juice4-8 ounces fruit juice• 6 ounces 6 ounces regularregular (not diet) soda (not diet) soda • 3 packets or 1 tablespoon sugar in water3 packets or 1 tablespoon sugar in water• 3-4 chewable glucose tablets3-4 chewable glucose tablets• 1 dose of glucose gel (15 g dose)1 dose of glucose gel (15 g dose)• 1 tablespoon of honey1 tablespoon of honey• 2-4 pieces of hard candy2-4 pieces of hard candy

Mild/Mild/ModerateHypoglycemiaModerateHypoglycemia15 Minute Rule15 Minute Rule

TREAT BLOOD SUGAR RIGHT AWAYTREAT BLOOD SUGAR RIGHT AWAY Observe and recheck in 15 minutesObserve and recheck in 15 minutes Repeat fast-acting carbohydrate if Repeat fast-acting carbohydrate if

blood sugar not in acceptable range blood sugar not in acceptable range Follow treatment with extra snack if Follow treatment with extra snack if

meal is one hour away or moremeal is one hour away or more If not above 80 or falling, call for helpIf not above 80 or falling, call for help 9-1-1, parent, contact person9-1-1, parent, contact person

Treatment For Severe Treatment For Severe Symptoms Symptoms of Hypoglycemiaof Hypoglycemia

Prepare to treat with glucagon if: Prepare to treat with glucagon if: • the person is unwilling or unable to the person is unwilling or unable to

take a treatmenttake a treatment• the person does not feel better after the person does not feel better after

the second treatmentthe second treatment• the symptoms worsen to the point the the symptoms worsen to the point the

person is unable to swallowperson is unable to swallow• loss of consciousness or seizures occurloss of consciousness or seizures occur

GlucagonGlucagon

A hormone, like insulin, and made in A hormone, like insulin, and made in the pancreasthe pancreas

Acts on the liver by converting Acts on the liver by converting glycogen to glucoseglycogen to glucose

Safe and relatively free from Safe and relatively free from adverse reactionsadverse reactions

No human overdose has been No human overdose has been reportedreported

May cause nausea and vomitingMay cause nausea and vomiting

Glucagon Emergency KitGlucagon Emergency Kit

Available in package with supplies Available in package with supplies needed for administrationneeded for administration

Contains:Contains:• a bottle of glucagon in powder forma bottle of glucagon in powder form• a syringe filled with special diluting a syringe filled with special diluting

fluidfluid

Obtained by prescription only for the Obtained by prescription only for the individual with diabetesindividual with diabetes

Glucagon: Storage and Glucagon: Storage and HandlingHandling

Store at room temperature {59° - Store at room temperature {59° - 86°}86°}

Do not mix until neededDo not mix until needed Discard any unused portionDiscard any unused portion Glucagon solution should be clear Glucagon solution should be clear

and of a water-like consistencyand of a water-like consistency Check expiration dates periodicallyCheck expiration dates periodically Injection in fatty tissue of arm/thighInjection in fatty tissue of arm/thigh

Access to GlucagonAccess to Glucagon

Assure a plan for emergenciesAssure a plan for emergencies Kits need to be readily available and Kits need to be readily available and

in close proximity to the child/personin close proximity to the child/person On field trips, student may carry own On field trips, student may carry own

kit if age/development appropriatekit if age/development appropriate Glucagon provider must accompany Glucagon provider must accompany

the childthe child

Glucagon - DosagesGlucagon - Dosages

Manufactured in 1 - mg vialsManufactured in 1 - mg vials Person’s health care provider will Person’s health care provider will

determine individualized dosedetermine individualized dose Usual doseUsual dose

• Adults and children 1 Adults and children 1 mg mg

• Smaller children 0.5 Smaller children 0.5 mgmg

Equipment neededEquipment needed

Glucagon Emergency KitGlucagon Emergency Kit

Alcohol swab Alcohol swab if if available available

Non-sterile glovesNon-sterile gloves

Observation and Observation and Intervention Steps for Intervention Steps for Severe HypoglycemiaSevere Hypoglycemia

IF PERSON IS UNRESPONSIVE AND IF PERSON IS UNRESPONSIVE AND BREATHING OR PULSE ARE ABSENTBREATHING OR PULSE ARE ABSENT

CALL 9-1-1 CALL 9-1-1

Initiate cardiopulmonary Initiate cardiopulmonary resuscitationresuscitation

(CPR)(CPR)

Intervention/Severe Intervention/Severe Hypoglycemia—cont.Hypoglycemia—cont.

If breathing and pulse present, assume severe If breathing and pulse present, assume severe hypoglycemia.hypoglycemia.

DO NOT give DO NOT give anythinganything by mouth by mouth Delegate someone to call 9-1-1/EMSDelegate someone to call 9-1-1/EMS Obtain glucagon emergency kitObtain glucagon emergency kit Check the name and verify any special Check the name and verify any special

instructionsinstructions Do not move the person-bring supplies to Do not move the person-bring supplies to

him/herhim/her Prepare and administer glucagonPrepare and administer glucagon Cut/clamp insulin tubing (if on insulin pump)Cut/clamp insulin tubing (if on insulin pump)

To Prepare GlucagonTo Prepare Glucagon

Remove the flip-off seal from powdered Remove the flip-off seal from powdered glucagonglucagon

Remove needle cover from syringeRemove needle cover from syringe Do not remove plastic clip from syringeDo not remove plastic clip from syringe Insert the needle into the vial of Insert the needle into the vial of

powdered glucagonpowdered glucagon Push the plunger to inject the entire Push the plunger to inject the entire

contents of the liquid into the vial of contents of the liquid into the vial of powdered glucagonpowdered glucagon

Prepare GlucagonPrepare Glucagon -- cont. -- cont.

Leave the needle on the syringe in the vial; gently Leave the needle on the syringe in the vial; gently shake bottle until powder dissolvesshake bottle until powder dissolves

Withdraw the right amount of medicationWithdraw the right amount of medication Put on glovesPut on gloves Cleanse site with alcohol if availableCleanse site with alcohol if available

Administer GlucagonAdminister Glucagon – –cont. cont.

Insert the needle into the loose Insert the needle into the loose skin/muscle of the arm or thighskin/muscle of the arm or thigh

Administer all the medicationAdminister all the medication Apply light pressure at the injection Apply light pressure at the injection

site and withdraw the needlesite and withdraw the needle Discard needle according to Oregon Discard needle according to Oregon

OSHA Bloodborne Pathogen OSHA Bloodborne Pathogen StandardsStandards

Administer Glucagon—Administer Glucagon—cont.cont.

It may be difficult to give an It may be difficult to give an injection to a person who is injection to a person who is combative or having a seizurecombative or having a seizure• Get assistance from another Get assistance from another

caregivercaregiver

Care Of The PersonCare Of The Person

Position person on sidePosition person on side Monitor for absent pulse/breath, Monitor for absent pulse/breath,

or seizuresor seizures Improvement will usually be seen Improvement will usually be seen

within 10- 15 minuteswithin 10- 15 minutes• Although rare, the person may be Although rare, the person may be

unresponsive for other reasonsunresponsive for other reasons

Care Of The PersonCare Of The Person -- -- cont.cont.

When responds and able to swallow, When responds and able to swallow, feed a fast-acting source of sugar feed a fast-acting source of sugar (page 7)(page 7)• Start with clear liquidsStart with clear liquids

Feed longer-acting source of sugar if Feed longer-acting source of sugar if possible (carbohydrate and protein)possible (carbohydrate and protein)

Seek consultation from medical Seek consultation from medical provider for further directionprovider for further direction

Follow-UpFollow-Up

Emergency responder will make decision Emergency responder will make decision about need for transport to medical facilityabout need for transport to medical facility

Students in school or daycare need to be Students in school or daycare need to be taken from school by parent or 9-1-1taken from school by parent or 9-1-1

Seek consultation with school nurse, Seek consultation with school nurse, parents, and/or healthcare provider to parents, and/or healthcare provider to prevent future episodes of low blood sugarprevent future episodes of low blood sugar

Ask parents to provide another Ask parents to provide another Glucagon Glucagon Emergency KitEmergency Kit

REVIEW: Assessment and REVIEW: Assessment and TreatmentTreatment

Determine if person is experiencing Determine if person is experiencing symptoms of hypoglycemiasymptoms of hypoglycemia

Test blood sugar if possible and if Test blood sugar if possible and if trainedtrained

Prepare to treat for low blood sugarPrepare to treat for low blood sugar

Mild/Moderate Mild/Moderate HypoglycemiaHypoglycemia

Give oral treatmentGive oral treatment

Monitor for 15 minutesMonitor for 15 minutes

Retest blood sugarRetest blood sugar

15 Minute Rule: (page 7)15 Minute Rule: (page 7)

Review-Mild/Moderate Review-Mild/Moderate HypoglycemiaHypoglycemia

No improvement in 15 minutes-No improvement in 15 minutes-retestretest

If no improvement, give second If no improvement, give second fast acting treatmentfast acting treatment

If no improvement after two If no improvement after two treatments. . .treatments. . .

Mild/Moderate-cont.Mild/Moderate-cont.

If blood glucose is below 80 or falling:If blood glucose is below 80 or falling:• Call parent, designated contact, or 911Call parent, designated contact, or 911

If meal is more than 1 hr. away, If meal is more than 1 hr. away, follow with a carbohydrate/protein follow with a carbohydrate/protein snacksnack

If on insulin pump, treat and consult If on insulin pump, treat and consult medical ordersmedical orders

REVIEWREVIEW Severe Severe HypoglycemiaHypoglycemia

• Delegate call to 9-1-1Delegate call to 9-1-1• If on pump, clamp/cut tubingIf on pump, clamp/cut tubing• Prepare and administer glucagonPrepare and administer glucagon• Position person on sidePosition person on side• Monitor for absent pulse/breathingMonitor for absent pulse/breathing• If person responds and can swallow-If person responds and can swallow-

provide oral treatmentprovide oral treatment• Follow-up with health care providerFollow-up with health care provider

QUESTIONS?QUESTIONS?