Anaphylaxis & Glucagen

[coocoocachoo]

Anaphylaxis & Glucagen
Hi I'm new to the site. I'm a UK Paramedic and have a question regarding the way in which glucagen works.
The reason I'm asking is due to an incident that recently occurred. I shall explain, please bear with me.
Called to a patient in cardiac arrest secondary to anaphylaxis, had to perform a surgical airway due to his airway being too swollen to intubate, he had intravenous access and intraosseous access, IV fluids, 5x 1mg Iv adrenaline 1:10,000 and 3mg atropine. When we arrived at hospital he was worked on for over an hour, including sodium bicarb, chlorphenamine (which we carry aswell but didn't give it as would probably be next to useless in this situation). Now the patient was on beta blockers which may explain why adrenaline was having no effect. The part that I'm really interested in is that one of the DRs said let's try glucagen. There wasn't any close to hand so one of my colleagues got three 1mg vials from the ambulance by which time the DRs in resus had called it and pronounced the patient dead.

So my question is this: would glucagen be effective in anaphylaxis in patients unresponsive to adrenaline, whether they be alert, semi conscious or in cardiac arrest. In a patient who is still alive we give adrenaline 1:1000 I.M. We carry Glucagen but only use it for hypoglycaemia (although I prefer I.V/I.O glucose and only use glucagen if I can't get access), I know glucagen is effective in Betablocker O.D and would call the hospital to get the go ahead in that case. But in anaphylaxis? Any answers would be great. Sorry it was a bit long winded.

[Band6]

Hi, and welcome to the forum.

I've had experience of glucagon therapy for beta-blocker OD's; I was bleeped when on-call for twenty of the 1mg injections. The joy of rumaging in the huge fridge in pharmacy stores at 02:30 and then trying to convince A+E staff that I was a member of staff (I guess I didn't look like my ID photo at that time in the morning!!) with stuff they needed.

I would imagine that the doctors were trying to treat the cardiac arrest, rather than the anaphylaxis. The glucagon works by stimulating the heart (for wont of a better term), but does this by bypassing the beta receptors (it stimulates the production of cAMP). I guess that with a beta blocker floating around their system, the adrenaline would not be as effective. I wonder if it would have made the adrenaline less effective at treating the underlying anaphylaxis?

Dosage for an adult - 3-10mg IVB, followed by 2-5mg/hr CIVI

[Band6]

By the way - intraosseous?! Ow!

[coocoocachoo]

Apparently the cause of the anaphylaxis was down to the beta blockers. Even after they halted resus the patient was still swelling up. I've never seen anything like it!
If we have a patient who has overdosed on beta blockers we end up treating with atropine. If that fails then glucagen (we only carry 3mg) but is not within our clinical practice guidelines however if we called A&E we could get the go ahead or we could just give it and justify our reasons later. I know how it works in BB OD. And in anaphlactic patients on tricylics we give half doses of adrenaline. But in a patient on beta blockers with anaphylaxis (not in cardiac arrest) adrenaline may not be that effective in elevating the blood pressure, surely glucagen would do the trick? It would be interesting to find some literature on-line, I've tried but couldn't find any.

As for intraosseous we use the EZ-IO drill and can gain access in 10 seconds, used on both adult & kids unco or conscious!! We administer lidocaine as an LA prior to fluid or drug therapy because believe it or not the painful bit is when we push fluids/drugs not the actual insertion. We are the only trust in the country to use this I.O method.

[johannes]

Hi,
GlucaGen = Glucagon stimulates the release of catecholamines ((nor)adrenalin, dopamin...) which leads to higher heart beat frequency, hypertension....
Some use isoprenalin(not licenced in UK?) instead of glucagon.
BNF page 32 emergency treatment of poisoning.
jo

(Couldn't it be a diabetic shock?)~ Hm, betablocker can enhance the likelihood of anaphylactic events.

[coocoocachoo]

Thanks for that.

[Band6]

Originally Posted by coocoocachoo

We are the only trust in the country to use this I.O method.

My Father is a paramedic, he's mentioned IO injections before - would you be East of England?

[SolomonQ]

Glucagon may be effective in this circumstance because it increases intracellular cyclic adenosine monophosphate (cAMP).

some alternatives to adrenaline, in this case:

Vasopressin-for very hypotensive patients

Glucagon-short-acting; 1 to 2 mg every 5 minutes IM or IV. Nausea, vomiting, and hyperglycemia are common side effects.(can be combines with ipratropium)