Simulated Patient Scenario

Scenario Details

MDT Information

• Urgent Response - Altered Consciousness / Diabetic Problem
• 55-year-old male, known diabetic
• Found slumped in chair, difficult to rouse
• Spouse reports he seemed unwell earlier
• Location: Home address

On Arrival

You arrive at a house where an anxious spouse meets you. They lead you to the living room where the patient, a 55-year-old male, is slumped in an armchair. He appears pale and diaphoretic (sweaty). His eyes are closed, and he is only minimally responsive to verbal stimuli. His breathing is regular.

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History (obtained primarily from spouse)

Vital Signs/Assessment (Initial)

Physical Examination

• General Appearance: Unresponsive to voice, responds to pain. Pale, profusely sweaty.
• Neurological: GCS 8. Withdraws from painful stimuli. No focal neurological deficits apparent (assess limb movement).
• Cardiovascular: Tachycardic. Skin signs as above.
• Respiratory: Airway patent, breathing adequate currently.
• Other: No signs of trauma. Check for medical alert bracelets/necklaces.

Assessment and Treatment

Appropriate Management Focus

• Primary Survey (ABCDE): Recognize altered LOC. Check BGL IMMEDIATELY. Identify severe hypoglycaemia as the likely cause. Manage airway/breathing as needed (positioning, adjuncts if required).
• Glucose Administration (Urgent):
  • IV Access: Establish IV access urgently.
  • IV Dextrose: Administer IV Dextrose according to local protocols (e.g., Dextrose 10% 150-200mL bolus, or Dextrose 50% 25-50mL - check concentration and dose guidelines).
  • IM Glucagon: If IV access cannot be obtained promptly, administer IM Glucagon (1mg) into a large muscle (e.g., thigh, deltoid). Note: Glucagon is slower acting and less reliable than IV Dextrose, especially if glycogen stores are depleted.
  • Oral Glucose: Not appropriate currently due to decreased LOC / aspiration risk.
• Reassessment After Glucose: Monitor for improvement in LOC (GCS), vital signs, and diaphoresis after glucose administration. Recheck BGL 5-10 minutes after initial treatment. Repeat glucose administration if BGL remains low or LOC does not improve significantly.
• Airway Management: Maintain airway patency. Consider nasopharyngeal airway (NPA) if needed. Have suction ready. Place in recovery position if LOC remains low and airway is at risk.
• Oxygen Therapy: Apply oxygen if hypoxic (SpO2 < 94%) or if required during airway management.
• Monitoring: Continuous ECG, SpO2 monitoring. Frequent vital signs and GCS reassessment.
• Consider Underlying Cause: Note the use of Gliclazide (sulfonylurea) - high risk of prolonged/recurrent hypoglycaemia.
• Post-Recovery Care (Once Alert): If patient recovers fully (GCS 15), provide oral complex carbohydrates (e.g., sandwich, biscuits) to prevent recurrence, especially if sulfonylurea induced.
• Transport Decision: Transport to ED is mandatory, even if patient recovers fully prehospital, due to the severity of the episode and the risk of recurrence (especially with sulfonylurea use).
• Teamwork & Communication: Clear roles (airway, IV access, glucose admin). Communicate plan to spouse. Clear handover to ED, emphasizing likely cause (hypoglycaemia, likely sulfonylurea-induced), treatment given, response, and risk of recurrence.

Debrief Focus Points

• Recognizing the signs and symptoms of severe hypoglycaemia.
• Importance of rapid BGL measurement in patients with altered LOC.
• Prioritizing glucose administration (IV Dextrose preferred, IM Glucagon alternative).
• Understanding appropriate doses and concentrations of IV Dextrose.
• Airway management considerations in patients with decreased LOC.
• Importance of reassessment (LOC, BGL) after glucose administration.
• Recognizing medications associated with high risk of severe/prolonged hypoglycaemia (sulfonylureas like Gliclazide, insulin).
• Rationale for mandatory hospital transport even after prehospital recovery.
• Providing complex carbohydrates post-recovery.