Hypoglycaemia in an elderly male at a community fair

Patient Information

Dispatch: You are called to a patient (Robert Hennessey, 75-year-old male) who is sitting on a bench near the main stage looking confused and sweaty. A bystander says he was 'fine a few minutes ago.'
Patient: Robert Hennessey — 75yr (75kg)
Incident History: Pt was walking around the Mandurah Community Fair when bystanders noticed he became confused, pale and sweaty. Pt is known diabetic. Last ate breakfast approximately 5 hours ago.
Emergency Contact: Margaret Hennessey (Wife) — 0412 883 047

Initial Rapid Assessment

Response: Voice
Airway: Patent. Nil airway obstructions. Nil stridor or gurgling. Patient able to maintain own airway.
Breathing: Adequate. RR 16, no increased work of breathing, nil audible adventitious sounds.
Circulation: Radial pulse present — rapid and weak. Skin pale, cool and diaphoretic. Nil visible bleeding.
Disability: GCS 13 (E3V4M6). Not orientated to time or place. Confused and slow to respond. Blood glucose level 2.1 mmol/L.
Exposure: No rashes, wounds or injuries visible. Patient dressed in light clothing appropriate for warm conditions.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	96% (RA)	Nil	16	108	118/74	3s	13	4 4 ++	36.4	2.1 mmol/L	0
10 mins	98% (RA)	Nil	14	86	124/78	<2s	15	4 4 ++	36.4	5.8 mmol/L	0

History Taking

Treatment Response

Diagnosis

This patient is suffering from hypoglycaemia secondary to sulphonylurea medication use (gliclazide) and missed meal in a 75-year-old male with known Type 2 diabetes mellitus.

Facilitator Triggers — if trainees miss a critical step

! (If BGL is not checked within the first 2 minutes, the patient's GCS drops to 11 — he becomes increasingly drowsy and stops responding to questions coherently.)
! (If Glucose Oral Gel is not administered within 5 minutes of BGL result, patient becomes more diaphoretic and GCS drops to 10 — facilitator states patient is no longer able to safely swallow oral glucose gel.)
! (If trainees do not reassess BGL 10 minutes after glucose administration, inform them the patient is asking 'where am I?' and appearing more alert — prompt them to recheck BGL to confirm response to treatment.)
! (If trainees do not offer complex carbohydrates following BGL recovery, prompt by having patient say 'I'm feeling better but still a bit wobbly — should I eat something?')

Treatment Objectives

1 Don PPE and approach scene safely — confirm scene safety at community fair.
2 Perform Primary Survey — assess DRSABCD.
3 Confirm patient response level — responds to voice, GCS 13.
4 Assess airway — patent, self-maintaining.
5 Assess breathing — adequate, RR 16, SpO2 96% on room air. Apply oxygen only if SpO2 falls below 94%.
6 Assess circulation — rapid weak pulse, pale diaphoretic skin, CRT 3 seconds.
7 Perform Blood Glucose Level (BGL) measurement — result 2.1 mmol/L, confirming hypoglycaemia.
8 Perform Vital Sign Survey — record HR, RR, BP, SpO2, GCS, BGL, temperature.
9 Confirm GCS is 15/15 prior to oral glucose administration — GCS 13, patient is NOT 15/15. Do NOT give oral food or gel unsupported without reassessment.
10 Re-assess patient capacity to safely ingest oral glucose — at GCS 13 patient is drowsy but able to follow commands and swallow. Administer Glucose Oral Gel 15g (entire tube) into buccal mucosa in small amounts, monitoring for aspiration risk.
11 Position patient seated and supported — do not allow patient to stand or walk. Keep patient at rest on bench with support.
12 Reassess GCS and BGL at 10 minutes post glucose gel administration.
13 At 10 minutes: BGL 5.8 mmol/L, GCS 15 — confirm patient is alert and oriented.
14 Provide complex carbohydrates following BGL recovery (e.g. biscuits, sandwich) to prevent delayed hypoglycaemia.
15 Advise patient not to stand or mobilise until fully assessed and BGL stable.
16 Contact patient's wife (Margaret Hennessey, 0412 883 047) to attend FAP.
17 Arrange ambulance transport — gliclazide (sulphonylurea) poses risk of recurrent hypoglycaemia and patient requires hospital assessment.
18 Document all vital signs, BGL readings, treatment administered and patient response on patient care record.
19 Scenario ends on arrival of ambulance and IMISTAMBO handover.
20 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) · Pulse Oximetry · Oxygen Delivery

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