Hypoglycaemia - Acute Management - Abcde

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TW EE T

Will Freake and Dr Celestine Weegenaar·

Emergency Medicine

Hypoglycaemia | Acute Management |


ABCDE
Table of Contents
is a life-threatening condition that you need to be able to recognise and manage in the
acute setting. This guide gives an overview of the recognition and immediate
management of hypoglycaemia using the ABCDE approach. You can check out our
overview of the ABCDE approach here.

This guide has been created to assist students in preparing for emergency simulation
sessions as part of their training. It is not intended to be relied upon for patient care.

Clinical features of
hypoglycaemia
Hypoglycaemia can present in a variety of different ways. It is a diagnosis that can be
easily missed if you don’t consider it as the cause for your patient’s symptoms.

Reference ranges

 Normal fasting plasma glucose levels: 4.0 – 5.8 mmol/l


 Hypoglycaemia is defined as plasma glucose levels falling below 4.0 mmol/l
 Some patients may experience symptoms and display signs of hypoglycaemia at blood
glucose levels higher than 4 mmol/L
 You should always, therefore, interpret the blood glucose reading in the context of the
clinical presentation

Symptoms and signs

Diabetes UK developed thorough guidelines for


the Hospital Management of Hypoglycaemia in Adults with Diabetes (available
online here). They list the following 11 most common clinical features associated
with hypoglycaemia.

Autonomic:
 Sweating
 Palpitations
 Tremor
 Hunger

Neuroglycopenic:

 Confusion
 Drowsiness
 Odd behaviour
 Speech difficulty
 Incoordination

General malaise:

 Nausea
 Headache

These symptoms can have an insidious onset. It is always possible that the patient is
also suffering from another condition (e.g. a UTI), which can present with similar
symptoms. Consider hypoglycaemia in anyone presenting with these symptoms but
especially those with risk factors.

Any patient with an altered level of consciousness should have hypoglycaemia ruled
out.

Risk factors for hypoglycaemia

 Insulin-dependent diabetes (Type 1 or Type 2)


 Previous history of hypoglycaemic episodes or reduced hypoglycaemia awareness
 Impaired renal function
 Cognitive dysfunction/dementia
 Alcohol misuse
 Profound starvation
 Increased exercise
 Food malabsorption issues (i.e. coeliac disease, bariatric surgery, gastroenteritis)

 
Tips before you begin
 Treat all problems as you find them
 Re-assess regularly and after every intervention to see if your management is effective
 Make use of the team around you to delegate tasks where appropriate
 All critically unwell patients should have continuous monitoring equipment attached for
accurate observations including:
 Blood pressure
 3-lead ECG
 Oxygen saturations
 Heart rate
 Respiratory rate
 Communicate how often you would like these observations to be relayed to you
 Call for help early using an appropriate SBARR handover structure (check out the
guide here)
 You need to both request investigations and review results as they become available
 You don’t have to memorise everything off by heart, ask
for guidelines and algorithms that are relevant (i.e. hypoglycaemia protocols)
 If you would like medications or fluids, these will need to be prescribed
 Don’t forget to document everything you have found and done in the patient notes!

Initial steps
You are likely to be called to see this patient either:

 On the ward having become more drowsy and unwell OR


 Presenting to ED with an unknown cause for reduced consciousness

 
Inspection

If you are assessing the patient outside of the hospital setting (e.g. pre-hospital
care) you need to assess for danger before approaching the patient:

 A collapsed casualty may be under the influence of drugs or alcohol and could be violent
when roused, so be aware of this.
 If you see that multiple people have collapsed, be aware of the possibility of chemical,
biological, radiological and nuclear causes (e.g. carbon monoxide poisoning). The “Rule of
Three” is sometimes used to help decide on how to approach in this situation:
 If there is 1 collapsed casualty, proceed as normal
 If there are 2 collapsed casualties, with no obvious explanation (e.g. road traffic
collision), approach with extreme caution (call 999 before you approach)
 If there are 3 or more collapsed casualties, with no obvious explanation, do not
approach and call 999, requesting specialist support

Once you reach the patient, perform a quick general inspection to get a sense of
how unwell they are:

 If the patient is unconscious, check for a pulse and check that the patient is breathing.

If the patient is unconscious or unresponsive and not breathing start the basic
life support (BLS) algorithm as per resuscitation guidelines. Call 2222 for help!

 Perform AVPU and assess their consciousness level


 How do they look?
 What is their breathing like?
 Are there any clues from around the bedside? (look for drug charts, medication, IV lines,
monitoring equipment etc)

Interaction

 Introduce yourself to the patient even if they appear unconscious as they may still be
able to hear you.
 If the patient is able to answer questions- ask them how they are feeling.
Preparation

Ensure you have as much information as possible available to


you

 Patient notes
 Drug charts including diabetes charts!
 Observations charts

Airway
Assessment

Assess the patient’s ability to speak, listen to the patient’s breathing for added
sounds and inspect the mouth.

 The presence of stridor (a high pitched inspiratory noise) indicates upper airway
obstruction. In post-op bleeding, this might indicate that your patient’s consciousness level is
impaired enough to compromise airway patency (the brain is being hypoperfused).

Intervention

If you think your patient has a compromised airway you need help. Put out a crash call
immediately as you require urgent anaesthetic input to secure the airway. You can
perform some simple airway manoeuvers in the meantime.

Maintaining the airway whilst awaiting senior support


1.  Perform a head tilt, chin lift manoeuvre.

2.  If noisy breathing persists, try a jaw thrust.


3.  If this is still not enough to open up the airway you can consider the use of an airway
adjunct:

 If your patient is still semi-conscious then consider using a nasopharyngeal


(NP) airway.
 If your patient is able to tolerate an oropharyngeal (OP, or Guedel) airway then you can
use one of these. However, this indicates that your patient is seriously unwell as they no
longer have a gag reflex.

Re-assess after any intervention


If your patient starts to improve throughout your assessment, they may no longer be
able to tolerate the OP airway and you should remove it as soon as possible to prevent
gagging/aspiration.

Breathing
Assessment

Oxygen saturation: aim for 94-98%.

Respiratory rate:

 Impaired consciousness may lead to a reduced respiratory rate (bradypnoea).


 Severe hypoglycaemia may be associated with an irregular breathing pattern- this is a
very worrying sign!

Examination

Auscultate both lungs:
 Reduced air entry bilaterally suggests significant airway compromise and the need for
critical care input.

Investigations

Arterial blood gas


An arterial blood gas may be useful to quantify the degree of hypoxia if your patient has
very low oxygen saturations, however, it should not delay the treatment of
hypoglycaemia.

Chest x-ray

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