( Check for any obstruction )
O2 Low = give 100% O2 high flow rate 15L/min via face mask.
O2 Normal = Move to B.
Breathing
1- Examine chest in order ( Inspection. Auscultation ).
2- Take Chest X-ray + ECG + ABG.
Circulation
1- Check : Capillary Refill + Pulse + BP + Insert 1 Cannula.
2- Take Blood ( routine blood invx).
Disability
1- Check : Blood Sugar + Temperature + Pupillary Reflexes.
2- BS Low :
Give Dextrose ( 20% 100ml or 10% 200ml I.V. repeated 3 times every 15mins).
Exposure
1- Check Abdomen : ( Quickly ).
2- Re-assess BS = Low = Give Another Dextrose dose ( re-assess after 15mins).
3- Check Private Area = Insert Catheter.
4- Re-assess BS : A- Improved = start Discussion with Pt.
B- Still Low = Give Another Dextrose Dose.
Discussion
Initiate discussion once blood sugar starts improving.
Introduce yourself + Patient.
Explain Situation + Positive findings + what was done.
Admit. Involve Senior. Further Investigations (HbA1c).
Once Pt recovers + BS above 4mmol/L ( Give him two biscuits, slice of bread or 300ml milk + Ask history + Advise Regarding ( Attack signs. Triggers. Medications).
Once discharged refer to Diabetic Clinic. Safety Netting.
Managment :
Pt conscious = Start Oral Gel then Dextrose .
Pt Unconscious :
A- Have I.V. Access = Start Dextrose.
B- No I.V. Access = Start Glucagon 1mg I.M then Dextrose.
You are FY2 in A&E. Mr Frank Escobar, a 50-year-old, was brought into the hospital by ambulance as he was found unconscious.
Please talk to the patient, assess the patient do the initial management.
D: Try and TALK to the patient: Patient is not talking back Tap on the shoulders: Patient is not responding again.
Patient is UNCONSCIOUS.
D: Now check whether the patient is breathing or not?
D: Look/ Listen/ Feel: Patient is breathing - his airway is patent.
D: I would like to check my patient’s vitals.
NOTE: Vitals are Stable.
As the patient is Unconscious and Breathing. Continue with ABCDE approach and keep an eye on the vitals.
D: Start ABCDE approach immediately.
D: I would like to arrange for blood sugars as my patient is unconscious in the mean while I would like to proceed with ABCDE.
A:
Patient is breathing. There are no added sounds. His airway is patent.
I would like to start my patient on high flow O2 – 15L/min via non-rebreather mask.
B:
Trachea and Chest Ex
Trachea is central and Chest Ex is Normal.
C:
Peripheral signs of perfusion - Pulse, Cold peripheries, Cap refill, Cyanosis, Pallor, Active bleeding site.
Mx: HR & BP stable. Insert one IV cannula and draw some bloods at the same time for routine investigations including blood sugars.
Blood Glucose = 1.8
D:
My patient has Hypoglycaemia, and I would like to give IM Glucagon as my patient is unconscious and start him on IV Dextrose 20% in 100 mls NS bolus. I would like to check his blood sugars every 10-15 minutes. I would like to check my patient’s GCS. Examiner will give you the findings.
E:
Expose the patient fully for Head-to-Toe examination. Look for any redness, rashes,
swelling, injuries, head trauma, temperature.
Summarise your initial assessment: ABCDE – O2 and Low Blood Sugars.
Give the diagnosis and definitive management for the diagnosis: Hypoglycaemia and I have already given IM Glucagon as my patient is unconscious and started him on IV Dextrose 20% in 100 mls NS. I would like to check his blood sugars every 15 minutes.
Start talking to the patient and take history if the patient gains consciousness.
Blood Glucose: 3.2
My patient’s blood sugars are improving. I would like to check his response.
Start talking to the patient and take history if the patient gains Consciousness.
If patient is not regaining his consciousness, start verbalising that I would like to continue the same management plan after involving my seniors and keep checking his blood sugars every 10-15 mins. Once the blood sugars are above 4 and Pt regains his consciousness, I would like to give him a full meal and check his blood sugars until they are normal. Then I would like to take a full detailed Hx of the event and PMHx and refer him to Endocrinology. I would like to counsel him about management of Diabetes before discharge.
On the other hand, if the Pt doesn’t regain his consciousness even after his blood sugars are improved, I would like to discuss with my senior and investigate for other causes of unconsciousness (CT Head, Toxicology screen, etc).
Thiamine (B1) is given in wenickies korsakoff psychosis and in thiamine deficiency, which will occur in more chronic heavy drinkers. If they have thiamine deficiency , we give thiamine before glucose. But in plab 2 it’s unlikely for them to make the case that complicated.
So, to answer your question, we’ll not give thiamine.
Since the patient is unconscious, isn’t it better to put the pt to recovery position to prevent aspiration?
In case of unconscious hypoglycemic simman
It would be appropriate in an outside hospital situation where you are waiting for the EMS to arrive & take over, but I think since we are in hospital, we have to proceed with the ABCDE assessment and so its better that we can keep the patient in supine position. This is just my opinion but I’d appreciate if someone could shed some light about this.
Very solid notes. There are some points that I’d like to add to this-
Initially when we are doing the “look, listen and feel” its better to open the patient’s airway and that too with the jaw thrust method.
Once we determine that the vitals are stable before proceeding with the ABCDE- it’ll be better if we ask for a small collateral history from the ambulance staff & maybe mention that “I’d also like to go through the ambulance notes as well to check if there are any significant information about the pt”.
Immediately after this its best to do a triple immobilization of the neck & mention that you’ll send for a cervical x-ray down the line.
If the examiner doesn’t give the GCS finding its better to do a trapezius squeeze to elicit a pain response from the pt
if “Dextrose 20% in 100 ml NS” is not available we can use “Dextrose 10% in 200 ml NS”
I await any corrections of the above points.
Thank you so much for the post & I appreciate it as always.
Yup this is correct. We learned this in plab q preparation as well. If the patient is ubder the influence of alcohol no matter how much time it takes we hv to wait until the iv line is inserted . Coz we cannot give IM glucagon in alcoholoc patients