Hypoglycaemia Scenario

Question 1 of 15

1. Question

What treatment option should you consider first for this patient?

IV cannulation and initially 100 ml 10% glucose
IV cannulation and 10% glucose but keep IV flowing until improvement is seen
IM Glucagon
1-2 tubes of glucose gel rubbed into gums

Question 2 of 15

2. Question

If we predict IV cannulation is going to be very difficult, can we consider giving IM glucagon whilst gaining access?

Yes, but the clinician must be aware that the IM glucagon may not work in certain circumstances
Yes, but the clinician must be aware that the IM glucagon may not work in certain circumstances

Question 3 of 15

3. Question

You have an assessment of the patients’ veins whilst your colleague continues with their basic observations. Their veins look difficult, so you consider IM glucagon. You look in your JRCALC and see it is contraindicated in patients with Pheochromocytoma. What is this?

It is a rare tumour of the adrenal glands causing an overproduction of hormones including epinephrine and norepinephrine
It is a deficiency of platelets in the blood
A type of tumour of the pancreas most commonly found at the head of the pancreas, they are also known as exocrine pancreatic cancers
The umbrella term given to acute and chronic kidney disease

Question 4 of 15

4. Question

Why is IM glucagon contraindicated in patients with pheochromocytoma?

Glucagon can further stimulate the release of catecholamines which may result in a sudden and significant increase in blood pressure
Glucagon can further thin the blood by affecting the integrity of platelets in the blood
Glucagon excretes through the kidneys and therefore can cause further damage with increased kidney workload
Glucagon will continually stimulate the process of glycogenolysis and will cause significantly increased blood sugars for 24 hours

Question 5 of 15

5. Question

Luckily, after your first attempt of IV access, you are successful and therefore avoid giving IM glucagon. You start treatment by giving 100 ml IV 10% glucose. Your colleague has also finished his set of observations which are: 90 HR, 14 RR, 110/76 BP, 98% Sp02 and 36.0 Temperature. You start to see a rapid improvement in the patient’s symptoms, and she starts to converse with you after approximately 10 minutes. You test her blood sugars again and they are now 4.5mmol/L. What next line of treatment would you consider?

Encourage the patient to eat complex carbohydrates including toast or biscuits with a drink
Another 100ml of IV 10% glucose as you have connected
A tube of glucose gel to give another boost of sugar as the reading is still quite low

Question 6 of 15

6. Question

You start to discuss her current management for her diabetes. She hasn’t seen her diabetic nurse for 6 months and she has not had any recent changes to her medications. She does explain that she gets very little warning of when she is getting a hypo, and recently they have been getting more common. She is getting them every 4-5 days now. She could normally tell when her blood sugars were low in the past due to her sweating and feeling nauseous/lethargy, but she doesn’t get this anymore. This can be common in insulin dependent diabetic patients, what is this called?

Impaired awareness to hypoglycaemia
Cognitive dysfunction to hypoglycaemia
Peripheral neuropathy
Diabetic nephropathy

Question 7 of 15

7. Question

What pathophysiology is responsible for the syndrome ‘impaired awareness to hypoglycaemia’?

Counter regulatory mechanisms designed to counter low blood sugar levels are desensitised and impaired. This includes an impaired release of hormones such as glucagon, adrenaline and cortisol which increase blood sugar levels. Adaptation of the brain occurs with recurrent hypoglycaemias, shifting the glycaemic thresholds for the generation of symptoms
Metabolic and ischemic changes to nerves and the capillaries that supply blood to them cause diabetic neuropathies. This reduces the capacity of the body to display symptoms associated with low blood sugars that a healthy individual would rely on to counter these low blood sugars
Metabolic and ischemic changes to nerves and the capillaries that supply blood to them cause diabetic neuropathies. This includes the nerves supplying the pancreas. Once these nerves have been damaged, they are unable to stimulate a release of glucagon which is the hormone responsible for displaying autonomic symptoms associated with low blood sugars

Question 8 of 15

8. Question

The patient has eaten complex carbohydrates and is quickly feeling back to her normal self. The only additional treatment you have given is the 100ml of 10% glucose. Observations are all normal including her blood sugars at 6.9mmol/L after 45 minutes from initial treatment. She is now feeling fit and well, back to her usual self. The patient has no further PMH and the only other medication taken is metformin. What management plan do you think is most appropriate for this patient?

You deem the patient safe to remain at home but are going to make a referral for further primary care assessment to explain your suspicions of impaired awareness of hypoglycaemia and therefore organise a diabetic nurse assessment as soon as possible, a potential medication review and question the need for a continuous glucose monitoring device
You deem the patient safe to remain at home. They have their own blood glucose testing kit so advise to keep a note of the pattern of their blood sugars and call their GP if they keep having hypoglycaemia episodes
Convey to ED for further assessment as regardless of the fast recovery this patient has experienced a severe hypoglycaemic episode

Question 9 of 15

9. Question

What prescribed medications need to be considered when deciding if it is safe to discharge a patient at home due to them being longer acting in effect and may result in a prolonged or recurrent hypoglycaemic event?

Sulfonylurea medications including gliclazide, glipizide, tolbutamide and glimepiride
Biguanide medication, ie. Metformin
Diuretic medication including furosemide, hydrochlorothiazide and metolazone
Beta blocker medications including atenolol, bisoprolol and propranolol.

Question 10 of 15

10. Question

Following further review of normalised observations and assessment of the patient, and the patient feeling their normal selves, you put in the necessary safety netting to leave the patient at home. The further primary care assessment has been booked, and the patient will be assessed later in the day.

What neuroglycopenic signs and symptoms are associated with diabetes? TICK ALL THAT APPLY

Lack of coordination
Confusion
Speech difficulty
Aggressive behaviour
Drowsiness
Nausea
Headache
Sweating
Trembling

Question 11 of 15

11. Question

Considering treatment in non-diabetic patients, you must start hypoglycaemia treatment if they have a blood sugar level of 3.8mmol/L?

False
True

Question 12 of 15

12. Question

What is diabulimia?

The action of insulin-treated patients withholding their own insulin with the intention of losing weight
The action of eating lots of food for a period of time and then ‘purging’ with the intention of losing weight. This can include self-induced vomiting, taking laxatives or diuretics
The intentional chronic overdose of prescribed insulin to keep blood sugars as low as possible to avoid diabetic complications associated with chronically high blood sugars
The refusal of a patient to take any diabetic medication

Question 13 of 15

13. Question

Which complications can be associated with diabetes we should be aware for as it will help our assessment of the general health of our diabetic patients?

Retinopathy
Peripheral neuropathy
Gum disease
Nephropathy
Gastroparesis

Question 14 of 15

14. Question

What percentage of pregnant women will develop gestational diabetes and how likely does this diagnosis transfer into diabetes after pregnancy?

Approximately 5% of pregnant women will be diagnosed with gestational diabetes and up to 50% of these will be diagnosed with type 2 diabetes after pregnancy
Approximately 20% of pregnant women will be diagnosed with gestational diabetes and 10% of these will be diagnosed with type 2 diabetes after pregnancy
Approximately 50% of pregnant women will be diagnosed with gestational diabetes and 5% of these will be diagnosed with type 2 diabetes after pregnancy

Question 15 of 15

15. Question

Can hypoglycaemic episodes be reportable to the DVLA if certain conditions are met?

True
False