Scenario — Hypoglycaemia in elderly female — Perth Royal Show

foundation Metabolic · Elderly · 75yr · female

Patient Information

Dispatch	You are called to the First Aid Post at the Perth Royal Show. A 75-year-old female is seated in a chair, confused and shaking. Bystander states she 'doesn't seem right' after lunch.
Patient	Margaret Hollis — 75yr (60kg)
Incident History	Pt was sitting at a food court when her daughter noticed she became confused, trembling and sweaty. Daughter states she has Type 2 diabetes and took her insulin this morning.
Emergency Contact	Susan Hollis (Daughter) — 0412 334 788

Initial Rapid Assessment

Response	Voice
Airway	Patent. No airway obstructions. No stridor.
Breathing	Spontaneous respirations. Rate slightly elevated. No accessory muscle use. No abnormal sounds.
Circulation	Radial pulse present — rapid and weak. Skin pale, diaphoretic. No visible haemorrhage.
Disability	GCS 12 (E3V3M6). Not oriented to time or place. Responding to voice but confused. Pupils equal and reactive to light.
Exposure	No visible injuries. Skin pale and sweaty. Medical alert bracelet present — reads 'Type 2 Diabetic, Insulin Dependent'.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Nil	18	108	108/68	3s	12	3 3 ++	36.5	2.1 mmol/L	–
10 mins	98% (RA)	Nil	14	88	118/74	2s	15	3 3 ++	36.5	5.8 mmol/L	–

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from hypoglycaemia secondary to insulin use with insufficient carbohydrate intake, presenting with altered consciousness (GCS 12), diaphoresis, tachycardia, and a BGL of 2.1 mmol/L.

Facilitator Triggers — if trainees miss a critical step

! (If BGL is not measured within the first 2 minutes, patient's GCS drops to 10 — daughter becomes distressed and calls out 'she's getting worse'.)
! (If Glucose Oral Gel is administered to the patient without confirming she can safely swallow — patient begins to cough and partially drools — facilitator to warn 'patient has reduced swallow reflex at this GCS'. Only administer buccally in small amounts.)
! (If no repeat BGL is taken at 10 minutes, patient appears to improve but daughter asks 'is she okay now?' — prompt trainees to reassess and document repeat BGL before concluding treatment.)
! (If patient is not encouraged to eat a complex carbohydrate post-recovery, facilitator prompts: 'The patient asks if she can go back to looking at the animals now. What do you advise?')

Treatment Objectives

1. Ensure scene safety and don appropriate PPE throughout.
2. Perform Primary Survey — airway patent, breathing adequate, circulation assessed (pale, diaphoretic, tachycardic).
3. Perform Vital Sign Survey — GCS 12, pulse 108, BP 108/68, SpO2 97% RA, RR 18, temp 36.5.
4. Obtain blood glucose level immediately — BGL 2.1 mmol/L confirms hypoglycaemia.
5. Note GCS is 12 — patient is not fully conscious (not GCS 15), therefore oral administration of gel is appropriate BUT must be administered carefully in small amounts to the buccal mucosa to reduce aspiration risk.
6. Administer Glucose Oral Gel (GLUTOSE/Glucogel) 15g buccally — place small amounts into the buccal mucosa and titrate to effect as per CPG.
7. Position patient upright/semi-recumbent — maintain airway patency. Ensure lateral position is ready if conscious state deteriorates.
8. Reassess GCS and BGL at 10 minutes — target BGL > 4 mmol/L and GCS 15.
9. Expected BGL at 10 minutes: 5.8 mmol/L. GCS returns to 15. Patient now oriented.
10. Encourage patient to consume a long-acting complex carbohydrate (e.g. sandwich, biscuit) following glucose gel administration to prevent delayed hypoglycaemia.
11. Continuous reassurance to patient and daughter throughout.
12. Advise patient and daughter of importance of transport to a medical facility for follow-up review, even if patient feels recovered.
13. Record full observations every 10 minutes.
14. Complete documentation and prepare for IMISTAMBO handover if ambulance transport arranged.
15. Scenario ends on arrival of ambulance and IMISTAMBO handover.
16. Attention to hand hygiene will be given throughout the scenario.

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

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Signs/Symptoms	Confusion, trembling, diaphoresis, weakness.
Allergies	No known drug allergies.
Medications	Insulin (type unknown, taken this morning). Metformin daily. Daughter believes she may have taken her insulin but not eaten enough before leaving home.
Pertinent History	Known Type 2 diabetes — insulin dependent for 8 years. No prior history of cardiac or neurological conditions per daughter.
Last Oral Intake	Small breakfast approximately 6 hours ago. Had a light snack at the show — insufficient to cover insulin dose.
Events Leading	Attended the Perth Royal Show with her daughter. Took insulin this morning and had a small breakfast. After several hours of walking the show, became progressively confused and shaky.
Treatment Prior	No treatment prior to EHS arrival. Daughter tried to give her a biscuit but patient was too confused to eat safely.

Onset	Gradual onset over approximately 20–30 minutes while seated at the show. Daughter noticed something was wrong after lunch.
Pain	Nil pain reported.
Quality	Confusion and weakness — patient unable to give clear history.
Radiates	Nil
Severity	Nil pain score. GCS 12 on arrival.