Administration of Glucagon Zegalogue via Injection

Emergency Intervention, Endocrine

Discussion: Just in Time Learning

 


Pursuant to Sec. 5 CSR 20-200.300. Training of School Employees in the Care Needed for Students with Diabetes–Training of school employees in the care needed for students with diabetes shall take place prior to the commencement of each school year, or as needed when a student with diabetes is newly enrolled at a school or a student is newly diagnosed with diabetes, but in no event more than thirty days following such enrollment or diagnosis.  The school nurse or another health care professional with expertise in diabetes shall promptly provide follow-up training and supervision as needed.  Coordination, delegation, and supervision of care shall be performed by a school nurse or other qualified health care professional.

Considerations:

  • Low blood sugar in children with diabetes can have varied symptoms. These can include but are not limited to:
    • nervousness,
    • shakiness,
    • weakness,
    • extreme hunger,
    • slight nausea,
    • dizziness,
    • headache,
    • blurred vision,
    • fast heartbeat and/or
    • feeling tired.
  • Based on the student’s diabetes medical management plan/health care provider’s order, low blood sugar is treated with some type of quick-acting oral sugar, such as candy, icing/cake frosting tubes, and/or juice.
  • Severe low blood sugar symptoms include disorientation, unconsciousness, and seizures. If not treated promptly it could lead to death.
  • Glucagon is a medication used in emergency situations when the student is unresponsive or unable to swallow because of very low blood sugar.
  • Given that when a student is having symptoms of severe low blood sugar, it can be a stressful situation, it is highly recommended that you familiarize yourself with the student’s emergency plan beforehand.
  • The school nurse or other qualified health care professional must review the glucagon procedure with staff to ensure that they have the skills to perform this emergency medication administration.
  • Store the diabetes medical management plan/health care provider’s order and glucagon in a location that is easily accessible during a severe blood sugar event.
  • Be sure that staff members who have regular contact with the student know where the medication is stored.
    • If the student self-carries their glucagon be sure to communicate with the student to know where they store their medication.
  • The school nurse should develop a plan to systematically check the expiration date on medication to ensure medication is not expired.
  • Remember to keep the student’s health care information confidential.
  • Do not use Zegalogue if:
    • the expiration date has passed,
    • gray cap is missing,
    • autoinjector appears damaged.
  • When opening the red protective case make sure to hold it up straight (with the gray lid on top) to avoid dropping the medication.
  • Do not remove the gray cap until you are ready to inject the medication.
  • Zegalogue is approved for use in children with diabetes aged 6 years and older.
  • Medication storage:
    • Store Zegalogue in the refrigerator between 36-46 degrees
    • Zegalogue can also be stored at room temperature between 68-77 degrees for up to 12 months.
    • Do not return to refrigerator after storing at room temperature.
    • Throw away Zegalogue if it has been stored at room temperature for more than 12 months.

Supplies:

  • Zegalogue
  • Alcohol wipe
  • Gauze or cotton ball
  • Gloves
  • Diabetes Medical Management Plan/health care provider’s order and student’s Individualized Health Care Plan (IHCP)
  • Parent/Guardian authorization form

Procedure for administering Zegalogue:

  1. Identify that symptoms of a severe low blood sugar reaction are present and that based on the student’s Diabetes Medical Management Plan/health care provider’s order, emergency medication needs to be given
  2. Call for assistance
  3. Ask that another school staff person call 911 or emergency medical services
  4. If able, move the student to a lying position
  5. Explain the procedure to the student at their level of understanding
  6. Review the six rights of medication administration to be sure it is:
    1. The right student
    1. The right medication
    1. The right dose
    1. Being given at the right time
    1. Being given by the right route
    1. Being given for the right reason
  7. Check the medication expiration date
  8. Ensure proper documentation of parent/guardian authorization to administer medication
  9. Review the student’s allergy status
  10. Wash your hands, if possible
  11. Assemble supplies and place on a clean surface
  12. Review the six rights again to ensure that it is:
    1. For the right student
    1. The right medication
    1. The right dose
    1. Being given at the right time
    1. Being given by the right route
    1. Being given for the right reason
  13. Put on gloves; if gloves are not available, continue with procedure
  14. Hold the red protective case upright with the gray lid on top
  15. Pull the gray lid up to open
  16. Carefully remove Zegalogue from the red protective case without dropping it
  17. Remove the gray cap from needle end
    1. Pull the gray cap straight off
    1. Do not put your hand or fingers anywhere near the yellow needle guard
    1. Touching the yellow needle guard may cause an accidental needle stick injury
  18. Identify the location (lower abdomen, buttock, front or back of thighs, or outer upper arm) for the injection
  19. If you have an alcohol wipe, cleanse the injection site
  20. Push Zegalogue straight down on student’s skin until the yellow needle guard is fully pressed down
    1. You may hear the first click
  21. Keep holding the Zegalogue down and slowly count to 10 seconds
    1. During this time the medicine window will turn red and you may hear a second click
  22. Check that the medicine window is red
    1. Which means that the full dose has been given
  23. Remove Zegalogue by lifting it straight up
    1. The yellow needle guard will cover the needle and lock, preventing an accidental needle stick injury
  24. Apply pressure using the gauze pad or cotton ball
  25. If the student is not lying on their side, move the student to a side-lying position because vomiting often follows the injection of glucagon
  26. If needed, ask another person for assistance
  27. If alone with student, and you have not already called 911 or emergency medical service, do so now
  28. Monitor the student’s arousal, pulse and respirations, and for potential seizure
  29. If the student begins to seize, clear the area of anything hard or sharp, to prevent injury
  30. Place something soft under the student’s head and time the seizure
  31. If breathing stops, move the student onto their back
  32. Begin rescue breaths
  33. If breathing and heartbeat stop, begin CPR
  34. Stay with the student until rescue squad arrives
  35. As soon as the individual is awake and able to swallow, give the individual a fast-acting source of sugar (such as fruit juice)
  36. Once rescue squad arrives, inform them of medication administered, including type of medication, dose and time
  37. Send along glucagon kit with used dose
  38. Dispose of all used materials in proper receptacles
  39. Remove gloves and wash hands
  40. Follow up with the parent or guardian and health care provider, as needed
  41. Document medication administration in the student’s medication administration log

References

American Diabetes Association. (n.d.). Hypoglycemia (low blood sugar). Retrieved June 2, 2023, from https://diabetes.org/healthy-living/medication-treatments/blood-glucose-testing-and-control/hypoglycemia

American Diabetes Association. (n.d.). Medications and treatments. Glucagon and other emergency glucose products. Retrieved June 2, 2023, from https://diabetes.org/healthy-living/medication-treatments/glucagon-other-emergency-glucose-products#:~:text=Glucagon%E2%80%94a%20hormone%20that%20raises,you%20in%20case%20of%20emergencies

Centers for Disease Control and Prevention. (2022, January 2). Seizure first aid. Retrieved June 6, 2023, from https://www.cdc.gov/epilepsy/about/first-aid.htm

Diabetic care may be provided to students, when, trained personnel to be on site. Missouri Revisor of Statutes 167.809. (2013). https://revisor.mo.gov/main/OneSection.aspx?section=167.809

Fresenius Kabi. (2019, November). Summary of instructions for use. Glucagon emergency kit for injection, 1mg/ml. Retrieved June 2, 2023, from https://glucagonemergencykit.com/wp-content/uploads/2019/12/Glucagon_IFU_191122.pdf

Levitsky, L.L., & Misra, M. (2022). Hypoglycemia in children and adolescents with type 1 diabetes mellitus. In a J. I. Wolfsdorf (Ed.), UpToDate. Retrieved: June 2, 2023, from https://www.uptodate.com/contents/hypoglycemia-in-children-and-adolescents-with-type-1-diabetes-mellitus

National Association of School Nurses. (2022, June 15). School nursing evidence-based clinical practice guideline: Students with type 1 diabetes toolkit. Retrieved June 2, 2023, from https://cdn.fs.pathlms.com/HRuI7pAvQWiJPZdzH6i8

National Association of School Nurses. (2021). School nursing evidence-based clinical practice guideline: Students with type 1 diabetes. Silver Spring, MD: Author. Retrieved June 2, 2023, from https://learn.nasn.org/courses/37660

National Diabetes Education Program. (2016). Helping the student with diabetes succeed: a guide for school personnel. Retrieved June 2, 2023 from https://diabetes.org/sites/default/files/2020-02/NDEP-School-Guide-Full-508.pdf

National Library of Medicine. (2019). Glucagon injection. Retrieved June 2, 2023, from https://medlineplus.gov/druginfo/meds/a682480.html#:~:text=Glucagon%20can%20be%20injected%20with,and%20how%20to%20administer%20glucagon

Plan to be submitted by parent or guardian of student with diabetes — review by school. Revisor of Statutes 167.806. (2013). https://revisor.mo.gov/main/OneSection.aspx?section=167.806

Training of school employees, content, requirements. Revisor of Statutes 167.803. (2013). https://revisor.mo.gov/main/OneSection.aspx?section=167.803&bid=8398&hl=.

Training of school employees in the care needed for students with diabetes. Missouri Secretary of State: Code of State Regulations. Division 20–Division of learning services. Chapter 200–Office of college and career readiness. (2022).https://www.sos.mo.gov/cmsimages/adrules/csr/current/5csr/5c20-200.pdf

Rechon Life Science. (2021, April). Instructions for use. Zegalogue injection. Retrieved August 2, 2023, from https://www.zegalogue.com/content/dam/diabetes-patient/zegalogue/en/pdf/zegalogue-autoinjector-instruction-for-use.pdf

Wyckoff, L. (2019). Students with diabetes. In J. Selekman, Shannon, R.A., Yonkaitis, C.F. (Eds.). School nursing, a comprehensive text (3rd ed., pp. 575-602). Philadelphia PA.: F.A. Davis Co.

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Acknowledgement of Reviewers:

Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services

Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services

Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing
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Page last updated February 21, 2024
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