Related Cases:
|Case #1 Potassium
|Case #2 Calcium
|Case #3 Calcium
|Case #4 Glucose
|Case #5 Shakes
|Case #6 Weakness
|Case #7 Headache
|Case #8 Weakness
|Case #9 Weakness
|Case #10 Weakness
|Case #11 Weak face
|Case #12 Weak eyes
|Case #13 Shakes
|Case #14 Confusion
|Case #15 Headache
|Case #16 Breathless
|Case #17 Unconscious
|Case #18 Breathless
|Case #19 Weakness
|Case #20 Breathless
An 83-year-old gentleman presents with a reduced level of conscious to the Emergency Department. His GCS is 9. He was up at 7 am and took his tablets and then walked the dog and came home at 8 am for breakfast and was then found on the floor barely conscious. His wife who found him on the floor called an ambulance but as there was a delay his sons lifted him and brought him in the car. He is known to have Type 2 Diabetes and Ischaemic heart disease. His usual medications are
Immediately administer 100 mls of 20% Glucose IV or equivalent. An alternative is 50% glucose/dextrose but this may damage veins so ensure well flushed. An alternative would be 200 mls of 10% glucose. Use whatever can be given most rapidly. There is insufficient glucose supply to the brain. Any delays can result in progressive coma, seizures and brain injury and death.
The effects should be rapid recovery as he has what is called neuroglycopenia. If there is a delayed response or none then consider other causes. Continue to give Glucose until the BM is normal and continue to monitor. It may be that the patient has already developed brain damage and may have cerebral oedema. Consider CT scan to look for a structural lesion and specialist advice.
Consider giving Glucagon 1 mg IM. In most algorithms, this can be given before glucose depending on which is easiest to administer.
Glucagon is a polypeptide hormone produced by the alpha cells of the islets of Langerhans, which increases blood-glucose concentration by mobilising glycogen stored in the liver. It may not work in those without liver stores e.g. severe cachexia or liver disease. It is given by the intramuscular route.
Gliclazide 160 mg BD
Metformin 500 mg BD
Clopidogrel 75 mg OD
Simvastatin 20 mg ON
The staff have managed to get a venous cannula in and have sent bloods.
What is the first actions that you would wish to do
2. What would you do now
3. What other options could you consider if he had no IV access
4. What is Glucagon
5. What drug caused the hypoglycaemia and what other drugs can do the same
6. What should you do when the patient regains consciousness
Even after regaining consciousness a long-acting carbohydrate should be given to maintain their blood-glucose concentration above 4 mmol/litre (e.g. two biscuits, one slice of bread, 200-300 mL of milk (not soya or other forms of 'alternative' milk, e.g. almond or coconut), or a normal carbohydrate-containing meal if due).
Patients who have received glucagon require a larger portion of long-acting carbohydrate to replenish glycogen stores (e.g. four biscuits, two slices of bread, 400-600 mL of milk (not soya or other forms of 'alternative' milk, e.g. almond or coconut), or a normal carbohydrate-containing meal if due).
If the patient is conscious and there are further concerns of hypoglycaemia and the patient is nil by mouth then consider giving a Glucose 10% intravenous infusion should be given
7. What else is recommended
It would be reasonable to arrange a diabetic team review for education and adjustment of his ongoing diabetic medications in the next 24 hrs. It would be useful to keep a chart of BM measurements.
It would be reasonable to send a HbA1c to give an idea of glucose control over the past 3 months
Also check Renal function to ensure this is stable
8. Do you know any diseases that cause Hypoglycaemia
9. What are the symptoms of hypoglycaemia in the conscious patient
Symptoms and signs
Symptoms of hypoglycaemia during sleep include:
Severe cases can lead to:
References
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Case #4 Glucose
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