You are doing an evening clinic when the social worker calls you about Mr Hilroy, whom she is seeing for grief counselling after the loss of his sister. The social worker says he is sweaty and confused.
You know him to be a 70 yo diabetic with poor control of his blood glucose.
What actions would you take, and what would your initial assessment include?
Quickly go and assess Mr Smith, including his blood glucose. Obtain a full set of vitals.
Discuss what equipment you would use to do so, within the context of your clinic.
You have a high index of suspicion that Mr Hilroy is experiencing hypoglycemia, but consider other causes of altered mental status as you assess him.
The social worker says he was ‘fine’ when he came in, but had gradually become confused over the past 3 minutes.
Hypoglycemia can cause adrenergic and neuroglycopenic symptoms - describe.
Adrenergic: associated with elevated epinephrine
The sympathetic nervous system activates a “fight or flight” response to hypoglycemia. The adrenal glands release a surge of epinephrine to tell the liver to release glycogen (stored glucose) to raise blood sugar.
The release of epinephrine also causes symptoms
- diaphoresis
- shakiness
- anxiety
- nervousness
- dry mouth
- pallor
- pupil dilation
- tremors
- hunger
- palpitations
- lightheadedness
Neuroglycopenic: results from neuronal deprivation of glucose in the brain.
The brain needs a constant source of glucose to function well; hypoglycemia will rapidly lead to neurogical symptoms. These include:
- abnormal mentation, confusion, stupor
- irritability
- visual disturbances
- difficulty speaking
- ataxia
- paresthesias
- headaches
- seizures
- coma
- death
What are some risk factors for hypoglycemia?
Risk factors for hypoglycemia include:
- history of previous hypoglycemia
- hypoglycemia unawareness
- increased age
- impaired cognitive status
- autonomic neuropathy
- long duration of insulin therapy
- current low A1C
- renal dysfunction
- low socioeconomic status, poor health literacy, food insecurity
Mr Hilroy has a plasma glucose of 2.6 mmol/L. He is able to follow commands. How do you treat him?
Administer 15-20g of fast acting carbohydrates (simple carbohydrates such as commercial dextrose tablets, 175mL of fruit juice, 6-8 lifesavers, or 3 packages of sugar in water).
Describe how you would do this within your clinic.
Repeat if no improvement within 15 minutes.
Administer additional longer-acting food combinations after symptoms subside.
You leave him with his wife and go attend to the patient in your room.
When you check on him in 15 minutes, he is now more confused, though does have a pulse of 60 and a RR of 22. His plasma glucose is now 1.8 mmol/L. How do you respond?
Call for help via 911.
Provide basic life support as needed.
If available, provide glucagon sub cut or IM.
Continue to closely monitor ABCs until EMS arrives.
You hand over to EMS, who transport him to the hospital for stabilization. He regains full function within 30 minutes and is discharged home after a few hours, to follow up with you tomorrow for insulin adjustment.
Given the severity of his condition, you alert the Ministry of Health to prompt a driving safety assessment.
