Category: Learning

Hypoglycaemia – Adult

Hypoglycaemia (Blood glucose under 4.0 mmol/l) is potentially fatal and should be treated. it may be defined as “mild” self-treated, or “severe” treated by a third party i.e. you.

Hypoglycaemia is a common side-effect of insulin and sulfonylureas (they start with gli-) as they both work by lowering glucose concentration in the blood. Other diabetic medications work by preventing glucose rise, thus posing a lesser risk.

 

Signs & Symps

  • Autonomic: Sweating, Palpitations, Shaking, Hunger
  • Neuroglycopenic: Confusion, Drowsy, Odd behaviour, Incoordination, Speech difficulty
  • General: Nausea, Headache

Risk Factors

  • Medical: 
    • Diabetic: Strict control, Long term Insulin, Lipohypertrophy at injection sites,Impaired awareness of hypoglycaemia
    • Organ dysfunction: Severe hepatic dysfunction, Renal impairment, Cognitive dysfunction/dementia, Endocrine (Addisons, hypothyroid, hypopituitary)
    • GIT: Gastroenteritis, impaired absorption, Bariatric surgery
    • Medication: Concurrent use of medicines with hypoglycaemic agents e.g. warfarin, quinine, salicylates, fibrates, sulphonamides (including cotrimoxazole), monoamine oxidase inhibitors, NSAIDs, probenecid, somatostatin analogues, SSRIs.
    • Sepsis
    • Terminal illness
  • Lifestyle:
    • Reduced/Irregular intake: Poor diet, Irregular lifestyle, Alcohol
    • Increased use: Exercise (relative to usual), Early pregnancy, Breast feeding
    • Poor control: Increasing age, No or inadequate blood glucose monitoring, Alcohol

Treatment

Conscious & Orientated

  1. 15-20g fast acting glucose
    • 4-5 jelly babies
    • 3-4 heaped teaspoons of sugar dissolved in water (milk delays absorption)
    • 150-200ml fresh fruit juice
  2. Rpt Blood Glucose 10-15min
    • if blood glucose remains <4.0mmol/l step one may be repeated up to 3 times in total
  3. Blood Glucose remains <4.0mmol/l
    • 150-200ml 10% Glucose IV
    • 1mg Glucogon IM (if starved or sulfonylureas may not work well)
  4. Blood Glucose >4.0mmol/l – Give long acting Carbs
    • 2 Biscuits
    • 1 Slice bread/toast
    • 200-300ml milk (not soya)
    • Meal
  5. Don’t omit insulin injections
  6. Diabetic review: most patients can be followed up by diabetic nurses but some may need admission.
  7. Patient Advice Sheet

Conscious but agitated, confused, unable to cooperate

  • If patient CAN cooperate – follow guide above
  • If patient CAN’T cooperate
    • 1.5 -2 tubes 40% glucose gel (Glucogel) squeezed into the mouth between the teeth and gums (can be substituted for step 1 above)
    • 1mg Glucogon IM (if starved or sulfonylureas may not work well)
    • Follow subsequent steps as above

Unconscious, seizures, very aggressive

Start at step 3 above (while managing ABC), the choice of whether to use IV glucose or IM glycogen will be determined by practicality of achieving IV/IO access.

Although you will need to follow the remaining steps the patient will almost certainly require admission.

 

Reference

Patient Advice Sheet – Hypo’s

Joint British Diabetic Society – The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus 3rd edition

 

 

Burns Referral Pathway

A new burns referral pathway has been developed with Mid Yorks to securely send images of the patients burn. Allowing the burns team to arrange the most appropriate follow-up for your patient.

This requires BOTH online referral & phone call

The Process

  1. GoTo –  Burns Homepage (NHS computers ONLY)
  2. Select – New Referral (NO login required)
  3. Complete – the following sections (* means required field)
    • Referrers Details – you will need an NHS email address
    • Patient Details
    • Injury Details – Answering “Yes” to airway burns or fluid resuscitation will open further boxes
    • Additional Details – Patient’s phone number and address (only appears if NO airway or resuscitation issues)
  4. Checklist – Ensure ALL completed and submit
  5. Sending an Image – After submission a QR code will appear to send an image you will need to us the SID App
    • Launch the SID App on mobile device – Yours or ED Co-Ordanator (apple/android)
    • Scan the QR code
    • Consent the patient – Patient Information Leaflet
    • Take Photo of Injury  – this will not be saved on the device
  6. Phone Burns team – They can review the details and images and better advise you on management.

Resources

Lateral Canthotomy

Like tension pneumothorax the biggest step is deciding to do it – Remember it it sight saving and they heal well

Retrobulbar Haematoma secondary to blunt eye injury is a a rare but potentially sight threatening injury.

  • Blood collects in the retrobulbar space
  • Pushing the eye forward to accommodate the extra volume.
  • The Orbital Septum (made up of the eyelids and ligaments that attach them to the orbital rim) restricts this forward movement, creating a compartment syndrome for the eye. Thus threatening the patients sight if not treated quickly.

Recognition

From Royal College Ophthalmologists
  • Severe pain
  • Red/Congested conjunctiva
  • Exophthalmos with proptosis – eye pushed forward
  • Internal ophthalmoplegia – impairment or loss of the pupillary reflex.
  • Visual flashes
  • Loss of vision – initially colour vision (esp. red), progressing to local visual loss.

However, this may only be recognised on CT if there is significant facial injury and altered conscious level.

Treatment

Call Ophthalmology immediately to attend. If there is going to be any significant delay, it may be necessary for ED to preform a Lateral Canthotomy, to allow the eye to move forward, reduce the orbital pressure & preserve the patients sight.

Kit needed

  • Lidocaine with adrenaline (needle & syringe)
  • Clamp – ideally curved to crush the tissues
  • Forceps
  • Scissors

Resources

Coroners Referrals

The patients ED needs to report has changed…

The key change with the new guidance is that not all patients who die in the ED need to be reported to the coroner….

Provided that none of the other circumstances as detailed in the guidance note apply deaths within 24 hours of admission to Hospital or a Hospice do not need to be reported with respect to a death of a person over 18 years of age in the following circumstances:

  • A qualified medical practitioner certifies death is due to natural causes and
  • The family or other party do not raise any concerns

The full guidance is available – Guide to Reporting Deaths April19

If you need to report to coroner – Death in ED