11/13/24, 7\:37 PM Guide | Hypoglycaemia
Hypoglycaemia
Table of contents
Introduction
This guide provides an overview of the recognition and immediate management of hypoglycaemia using an ABCDE
approach.
The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working
through the following steps\:
Airway
Breathing
Circulation
Disability
Exposure
Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed
as they are identi
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
Hypoglycaemia can present with a variety of di
presenting with a reduced level of consciousness.
Clinical features
Autonomic features
Autonomic features of hypoglycaemia include\:
Sweating
Palpitations
Tremor
Hunger
Neurological features
Neurological features of hypoglycaemia include\:
Confusion
Drowsiness
Behavioural changes
Speech abnormalities
Incoordination
Other symptoms
Other symptoms of hypoglycaemia include\:
Nausea
Headache
https\://app.geekymedics.com/osce-guides/emergency/hypoglycaemia/ 1/911/13/24, 7\:37 PM Guide | Hypoglycaemia
Risk factors for hypoglycaemia
Risk factors for hypoglycaemia include\:
Insulin-dependent diabetes
Previous history of hypoglycaemic episodes or reduced hypoglycaemia awareness
Impaired renal function
Cognitive dysfunction/dementia
Alcohol misuse
Profound starvation
Increased exercise
Food malabsorption issues (e.g. coeliac disease, bariatric surgery, gastroenteritis)
Glucose reference ranges
The normal reference range for fasting plasma glucose is 4.0 - 5.8 mmol/l.
Hypoglycaemia is de≤4.0
mmol/L should be treated if the patient is symptomatic.
1
Some patients may display clinical features of hypoglycaemia at blood glucose levels higher than 4 mmol/L, therefore
it is important to interpret blood glucose readings in the context of the patient's previous readings.
Tips before you begin
General tips for applying an ABCDE approach in an emergency setting include\:
Treat all problems as you discover them.
Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
Make use of the team around you by delegating tasks where appropriate.
All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
Clearly communicate how often would you like the patient’s observations relayed to you by other sta
If you require senior input, call for help early using an appropriate SBARR handover structure.
Review results as they become available (e.g. laboratory investigations).
Make use of your local guidelines and algorithms in managing speciacute asthma).
Any medications or will need to be prescribed at the time (in some cases you may be able to delegate this to another
member of sta
Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical
assessment, investigations and interventions.
Initial steps
Acute scenarios typically begin with a brief handover from a member of the nursing sta
name, age, background and the reason the review has been requested.
You may be asked to review a patient with hypoglycaemia due to confusion and/or reduced level of consciousness.
Introduction
Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.
Interaction
Introduce yourself to the patient including your name and role.
https\://app.geekymedics.com/osce-guides/emergency/hypoglycaemia/ 2/911/13/24, 7\:37 PM Guide | Hypoglycaemia
Ask how the patient is feeling as this may provide some useful information about their current symptoms.
Preparation
Make sure the patient’s notes, observation chart and prescription chart are easily accessible.
Ask for another clinical member of sta
If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.
Airway
Clinical assessment
Can the patient talk?
Yes\: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.
No\:
Look for signs of airway compromise\: these include cyanosis, see-saw breathing, use of accessory muscles, diminished
breath sounds and added sounds.
Open the mouth and inspect\: look for anything obstructing the airway such as secretions or a foreign object.
Interventions
Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the
emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway
manoeuvres to help maintain the airway whilst awaiting senior input.
Head-tilt chin-lift manoeuvre
Open the patient’s airway using a head-tilt chin-lift manoeuvre\:
1. Place one hand on the patient’s forehead and the other under the chin.
2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.
3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a
remove it.
Jaw thrust
If the patient is suspected to have su
than a head-tilt chin-lift manoeuvre\:
1. Identify the angle of the mandible.
2. With your index and other
lift the mandible.
3. Using your thumbs, slightly open the mouth by downward displacement of the chin.
Oropharyngeal airway (Guedel)
Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction
with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.
An oropharyngeal airway is a curved plastic tube with a
relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may
induce gagging and aspiration.
To insert an oropharyngeal airway\:
1. Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is
present, attempt removal using suction.
2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which
point you should rotate it 180°
. The reason for inserting the airway upside down initially is to reduce the risk of pushing the
tongue backwards and worsening airway obstruction.
https\://app.geekymedics.com/osce-guides/emergency/hypoglycaemia/ 3/911/13/24, 7\:37 PM Guide | Hypoglycaemia
3. Advance the airway until it lies within the pharynx.
4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for
signs of breathing.
Nasopharyngeal airway (NPA)
A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a
tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients
who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the
NPA.
To insert a nasopharyngeal airway\:
1. Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through
the
2. Lubricate the NPA.
3. Insert the airway bevel-end
4. If any obstruction is encountered, remove the tube and try the left nostril.
Other interventions
our anaphylaxis guide.
If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Breathing
Clinical assessment
Observations
Review the patient’s respiratory rate\:
A normal respiratory rate is between 12-20 breaths per minute.
Patients with severe hypoglycaemia may develop a slow, irregular pattern of breathing.
Review the patient’s oxygen saturation (SpO )\:
2
A normal SpO 2
range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk
of CO retention.
2
Hypoxaemia may occur due to aspiration or bradypnoea in the context of severe hypoglycaemia.
Auscultation
Auscultate the chest to screen for evidence of other respiratory pathology (e.g. coarse crackles may be present if the patient
has developed aspiration pneumonia secondary to a reduced level of consciousness).
Investigations and procedures
Arterial blood gas
Take an ABG if indicated (e.g. low SpO ) to quantify the degree of hypoxia.
2
Chest X-ray
A chest X-ray may be indicated if abnormalities are noted on auscultation (e.g. reduced air entry, coarse crackles) to screen for
evidence of aspiration pneumonia. A chest X-ray should not delay the emergency management of hypoglycaemia.
See our CXR interpretation guide for more details.
Interventions
https\://app.geekymedics.com/osce-guides/emergency/hypoglycaemia/ 4/911/13/24, 7\:37 PM Guide | Hypoglycaemia
Oxygen
Administer oxygen to all critically unwell patients during your initial assessment. This typically involves the use of a non-
rebreathe mask with an oxygen 2
retention you should switch to
a venturi mask as soon as possible and titrate oxygen appropriately.
If the patient is conscious, sit them upright as this can also help with oxygenation.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Circulation
Clinical assessment
Pulse and blood pressure
Assess the patient’s pulse and blood pressure\:
Tachycardia may be present in the context of hypoglycaemia.
Bradycardia is a late sign and often precedes cardiac arrest.
Hypovolaemia may be present secondary to reduced
Inspection
Inspect the patient from the end of the bed\: they may appear drowsy, confused and/or clammy/pale.
Capillary re
Capillary re
Fluid balance assessment
Calculate the patient’s
Calculate the patient's current
drain output, stool output, vomiting) to inform resuscitation e
Reduced urine output (oliguria) is typically de
Investigations and procedures
Intravenous cannulation
Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.
See our intravenous cannulation guide for more details.
Blood tests
Collect blood tests after cannulating the patient including\:
FBC\: to screen for anaemia and signs of infection.
U&Es\: to assess renal function and electrolyte levels.
CRP\: to screen for evidence of infection.
Serum glucose\: useful to con
Record an ECG
An ECG should be performed to screen for cardiac pathology such as myocardial infarction which may be precipitated by
hypoglycaemia. Performing an ECG should not delay the emergency management of hypoglycaemia.
Interventions
Fluid resuscitation
Hypovolaemic patients require
Administer a 500ml bolus of Hartmann’s solution or 0.9% sodium chloride (warmed if available) over less than 15 mins.
Administer 250ml boluses in patients at increased risk of
https\://app.geekymedics.com/osce-guides/emergency/hypoglycaemia/ 5/911/13/24, 7\:37 PM Guide | Hypoglycaemia
After each
Repeat administration of
reassessing the patient each time.
Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn’t responding
adequately to repeated boluses (i.e. persistent hypotension).
See our for more details on resuscitation
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Disability
Clinical assessment
Consciousness
In the context of hypoglycaemia, a patient's consciousness level may be reduced.
Assess the patient's level of consciousness using the AVPU scale\:
Alert\: the patient is fully alert, although not necessarily orientated.
Verbal\: the patient makes some kind of response when you talk to them (e.g. words, grunt).
Pain\: the patient responds to a painful stimulus (e.g. supraorbital pressure).
Unresponsive\: the patient does not show evidence of any eye, voice or motor responses to pain.
If a more detailed assessment of the patient's level of consciousness is required, use the Glasgow Coma Scale (GCS).
Pupils
Assess the patient's pupils\:
Inspect the size and symmetry of the patient's pupils
Assess direct and consensual pupillary responses
Patients with severe hypoglycaemia and associated metabolic encephalopathy may develop bilateral miosis.
3
Drug chart review
Review the patient's drug chart for medications which may cause a reduced level of consciousness (e.g. opioids, sedatives,
anxiolytics, insulin, oral hypoglycaemic medications).
Investigations and procedures
Blood glucose and ketones
Measure the patient's capillary blood glucose and ketone levels to screen for causes of a reduced level of consciousness (e.g.
hypoglycaemia, DKA).
A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).
The normal reference range for fasting plasma glucose is 4.0 - 5.8 mmol/l.
Hypoglycaemia is de≤4.0
mmol/L should be treated if the patient is symptomatic.
1
See our blood glucose measurement guide for more details.
Imaging
Request a CT head if intracranial pathology is suspected after discussion with a senior.
See our guide on interpreting a CT head for more details.
Interventions
https\://app.geekymedics.com/osce-guides/emergency/hypoglycaemia/ 6/911/13/24, 7\:37 PM Guide | Hypoglycaemia
Reverse hypoglycaemia
Always refer to local guidelines when managing hypoglycaemia.
The method you choose to reverse the hypoglycaemia will depend on your patient’s consciousness level.
Below is a brief overview of some of the common treatment options available.
1
If the patient is conscious\:
Administer glucose gel by mouth (e.g. GlucoGel®).
Repeat capillary blood glucose after 10-15 minutes and if the patient is still hypoglycaemic, repeat administration of glucose
gel a further 2-3 times.
When the patient is fully alert, provide a longer-acting carbohydrate for the patient to eat (e.g. toast).
If the patient is unconscious\:
Administer intravenous glucose (e.g. 150-160 ml of 10% glucose).
If the patient then regains consciousness, switch to using oral glucose as above.
If intravenous access is not able to be established rapidly, administer glucagon 1mg via the intramuscular or subcutaneous
route. Glucagon stimulates the conversion of stored glycogen within the liver into glucose. As a result, glucagon is ine
in patients with depleted glycogen stores (e.g. elderly patients with poor oral intake and patients with eating disorders).
Maintain the airway
Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants
urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient's airway as
explained in the airway section of this guide.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
If symptoms persist once hypoglycaemia has been corrected, consider alternative pathology (e.g. head injury, alcohol
intoxication, drug intoxication, stroke).
If hypoglycaemia persists, or hypoglycaemia relapses, consider the possibility of\:
Insulin overdose
Oral hypoglycaemic overdose (e.g. sulphonylureas)
In the case of overdose, continued monitoring and glucose infusions may be required.
Exposure
It may be necessary to expose the patient during your assessment\: remember to prioritise patient dignity and conservation of
body heat.
Clinical assessment
Inspection
Inspect for evidence of self-injection sites (e.g. areas of lipohypertrophy) if it is unclear if the patient is diabetic.
Temperature
Measure the patient’s temperature\:
If fever is present, make sure to consider co-existing infection.
Hypothermia may be present if the patient has been unconscious and exposed for some time.
Interventions
Reverse hypothermia
Use blankets to re-warm patients who are mild to moderately hypothermic.
Consider active re-warming techniques in patients with severe hypothermia.
https\://app.geekymedics.com/osce-guides/emergency/hypoglycaemia/ 7/911/13/24, 7\:37 PM Guide | Hypoglycaemia
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Re-assess ABCDE
Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the
e
Deterioration should be recognised quickly and acted upon immediately.
Seek senior help if the patient shows no signs of improvement or if you have any concerns.
Support
You should have another member of the clinical team aiding you in your ABCDE assessment, such as a nurse, who can perform
observations, take samples to the lab and catheterise if appropriate.
You may need further help or advice from a senior sta
about your patient.
Use an eSBARR handover to communicate the key information e
Next steps
Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do…
Take a history
Revisit history taking to explore relevant medical history. If the patient is confused you might be able to get a collateral history
from sta
See our history taking guides for more details.
Review
Review the patient’s notes, charts and recent investigation results.
Review the patient’s current medications and check any regular medications are prescribed appropriately.
Document
Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the
patient’s response.
See our documentation guides for more details.
Discuss
Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover.
Questions which may need to be considered include\:
Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Does the patient need reviewing by a specialist?
Should any changes be made to the current management of their underlying condition(s)?
Handover
The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated.
References
1. Diabetes UK\: The hospital management of hypoglycaemia in adults. Available from\: [LINK].
https\://app.geekymedics.com/osce-guides/emergency/hypoglycaemia/ 8/911/13/24, 7\:37 PM Guide | Hypoglycaemia
2. Generic core material\: prehospital emergency care course/core material. Editorial leads\: Andrew Thurgood, Darren Walter;
Clinical review team\: Andrew Thurgood [et al.]; Contributors, Adrian Noon [et al.]
3. Ilse Gradwohl-Matis et al. Prolonged Bilateral Reactive Miosis as a Symptom of Severe Insulin Intoxication. Available from\:
[LINK].
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/emergency/hypoglycaemia/ 9/9