Hypoglycaemia in a known diabetic at a community fun run

Patient Information

Dispatch: You are called to a patient (Sarah Nguyen, 45YO female) who is sitting slumped against the fence near the finish line of the Fremantle Community Fun Run. Bystanders report she finished her race and then became confused and unsteady.
Patient: Sarah Nguyen — 45yr (65kg)
Incident History: Pt completed the 10km fun run approximately 10 minutes ago. She was found sitting on the ground by a volunteer, confused and sweating heavily. Bystanders state she 'doesn't seem right' and is not responding normally to questions.
Emergency Contact: David Nguyen (Husband) — 0412 384 917

Initial Rapid Assessment

Response: Voice
Airway: Patent. Nil airway obstruction. Nil stridor or swelling.
Breathing: Breathing present and adequate. RR slightly elevated. Nil audible wheeze or crackles.
Circulation: Radial pulse rapid and weak. Skin pale, cool and diaphoretic. Nil external bleeding.
Disability: GCS 12 (E3V3M6). Disoriented to time and place. Restless and irritable. Not orientated to time, place or person.
Exposure: Nil visible injuries. Wearing running gear. Medical alert bracelet on left wrist — 'Type 1 Diabetic'.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Nil	20	112	108/70	<2s	12	4 4 ++	37.2	2.1 mmol/L	2
10 mins	98% (RA)	Nil	16	90	118/76	<2s	15	4 4 ++	37.2	5.8 mmol/L	0

History Taking

Treatment Response

Diagnosis

This patient is suffering from hypoglycaemia secondary to insulin use combined with exertion and inadequate carbohydrate intake prior to exercise.

Facilitator Triggers — if trainees miss a critical step

! (If BGL is not checked within the first 3 minutes of assessment, the patient's GCS drops to 10 and she becomes increasingly difficult to rouse — prompt trainees: 'She's going quieter, what do you want to check?')
! (If Glucose Oral Gel is not administered within 5 minutes of identifying BGL < 4 mmol/L, patient begins to show teeth-clenching and arm trembling — prompt trainees: 'She appears to be getting worse — what is your next step?')
! (If trainees attempt to administer Glucose Oral Gel without first confirming GCS 15/15 or adequate swallow reflex — remind them: 'Her GCS is 12 — is she safe to swallow? Administer in small amounts into the cheek pouch if GCS is not 15.')
! (If trainees do not reassess BGL and GCS after 10 minutes — prompt trainees: 'It has been 10 minutes since treatment — what do you need to reassess?')
! (If trainees do not encourage complex carbohydrates after BGL normalises — prompt trainees: 'Her BGL is now 5.8 — is there anything else you should provide to prevent delayed hypoglycaemia?')

Treatment Objectives

1 Don PPE — gloves at minimum prior to patient contact.
2 Perform Primary Survey — confirm patent airway, adequate breathing, and radial pulse present.
3 Position patient — seated on ground or supported against fence; do not stand patient up.
4 Identify medical alert bracelet — 'Type 1 Diabetic'; factor into clinical suspicion.
5 Perform Vital Sign Survey — obtain BGL, GCS, SpO2, RR, pulse, BP, temperature.
6 Confirm BGL 2.1 mmol/L — hypoglycaemia identified (< 4 mmol/L).
7 Assess conscious state — GCS 12; patient is not GCS 15/15, administer Glucose Oral Gel in small amounts into the buccal mucosa (cheek pouch) rather than having patient swallow directly.
8 Administer Glucose Oral Gel (Glutose/Glucogel) 15g (entire tube) — administered in small amounts into buccal mucosa given GCS 12 — indication: BGL 2.1 mmol/L with altered conscious state.
9 Reassess GCS and BGL at 10 minutes — expect GCS to improve toward 15/15 and BGL to rise above 4 mmol/L.
10 Once GCS 15/15 — encourage patient to consume complex carbohydrates (e.g. banana, muesli bar, sandwich from FAP supplies) to prevent delayed hypoglycaemia.
11 If BGL remains < 4 mmol/L at 10 minutes and patient GCS has improved to 15/15 — administer second dose of Glucose Oral Gel 15g orally.
12 Apply oxygen only if clinically indicated — SpO2 97% on RA, oxygen not required at this stage.
13 Monitor patient persistently — repeat full observations every 10 minutes.
14 Arrange transport via ambulance — encourage hospital transport for assessment and observation given insulin-dependent diabetes and exercise-induced hypoglycaemia episode.
15 Complete IMISTAMBO handover to ambulance crew on arrival.
16 Scenario ends on arrival of ambulance and IMISTAMBO handover.
17 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Hypoglycaemia · Glucose Oral Gel · Blood Glucose Monitor · Glasgow Coma Scale (GCS) · Primary Survey · Pulse Oximetry

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