((If trainees reach for oral glucose gel because the patient has diabetes and is altered — facilitator STOPS this immediately. 'Before you give that — what is her blood glucose level?' BGL is 24.6 mmol/L. Facilitator note: oral glucose gel is ONLY appropriate for hypoglycaemia (BGL <4.0 mmol/L in a symptomatic patient). Giving glucose to a patient with a BGL of 24.6 will worsen hyperglycaemia. Additionally, a GCS of 12 increases the risk of aspiration.))

((If trainees do not measure the BGL — patient becomes more difficult to rouse over 5 minutes. Prompt: 'She is a known Type 1 diabetic who has missed her insulin — what is the single most important measurement you need right now?' Facilitator note: BGL must be measured in any diabetic with altered consciousness BEFORE any intervention.))

((If trainees do not recognise the Kussmaul breathing pattern — prompt: 'Her breathing rate is 22 and the pattern looks unusual — how would you describe it?' Facilitator note: deep, slow, sighing respirations in a diabetic with altered consciousness should prompt DKA as the primary diagnosis.))

((If trainees do not recognise that insulin is out of scope — prompt: 'You know she needs insulin — is that something you can give?' Facilitator note: insulin administration is outside EHS scope and requires IV access, monitoring, and electrolyte management. This must not be attempted.))

((If trainees do not promptly call for CSP — facilitator note at 5 minutes: 'Her GCS is dropping and her BP is low. What is the urgency here?' DKA with GCS <14, hypotension, and vomiting is a time-critical presentation. Escalation must be immediate.))

Suspected diabetic ketoacidosis (DKA) in a Type 1 diabetic who has missed insulin for approximately 36 hours. Key features: BGL 24.6 mmol/L (markedly elevated), GCS 12 (altered consciousness), Kussmaul breathing (deep sighing respirations — compensatory respiratory alkalosis for metabolic acidosis), ketotic (sweet/fruity) breath, tachycardia, hypotension, dry mucous membranes (dehydration), nausea and vomiting, gradual onset. CRITICAL distinction from hypoglycaemia: BGL is very HIGH (not low). Do NOT administer oral glucose gel — it is contraindicated (altered consciousness = aspiration risk; high BGL = will worsen hyperglycaemia). Do NOT administer insulin — out of EHS scope and dangerous without IV access and monitoring. Management is supportive: airway protection, position, monitoring, and URGENT CSP escalation.

• Ensure scene safety — festival camping area; clear bystanders, create access space.
• Don appropriate PPE.
• Perform Primary Survey — GCS 12, Kussmaul breathing, tachycardia, hypotension, dehydration.
• MEASURE BLOOD GLUCOSE IMMEDIATELY — 24.6 mmol/L. This is markedly elevated. This is hyperglycaemia, NOT hypoglycaemia.
• Do NOT administer oral glucose gel — BGL is 24.6 mmol/L (contraindicated) and GCS is 12 (aspiration risk).
• Position patient in lateral (recovery) position — GCS 12 with prior vomiting creates aspiration risk. Monitor airway continuously.
• Apply oxygen via nasal cannula — maintain SpO2 ≥95%.
• Complete Vital Sign Survey — BGL 24.6, GCS 12, HR 118, BP 100/68, RR 22 deep sighing pattern, SpO2 96%, CRT 3s, Temp 37.4.
• Recognise clinical features of DKA: very high BGL, missed insulin, gradual onset, Kussmaul breathing, ketotic breath, tachycardia, hypotension, dehydration, nausea/vomiting, altered consciousness.
• Call for CSP immediately — DKA with altered consciousness, hypotension, and vomiting is a time-critical presentation requiring IV fluids, insulin infusion, and electrolyte monitoring in hospital. This is beyond EHS management scope.
• Conduct history via friends while monitoring patient — establish insulin omission, duration, last oral intake, vomiting.
• Do NOT attempt to administer insulin — out of EHS scope and dangerous without IV access and monitoring.
• Monitor GCS, airway, and breathing continuously — GCS trajectory is critical. If GCS drops below 10 or airway is compromised, prepare to support airway.
• Keep patient warm — she is peripherally shutdown and dehydrated.
• Provide regular verbal reassurance to patient — even at GCS 12, auditory processing may be partially intact.
• Provide IMISTAMBO handover to transporting crew including: GCS 12, BGL 24.6, insulin omission history, Kussmaul breathing, vomiting ×2, no oral glucose given, oxygen applied.
• Scenario ends on arrival of ambulance and handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Hypoglycaemia · Altered Consciousness · Primary Survey · Blood Glucose Monitoring · Oxygen · Secondary & CNS Survey