5. Hypoglycaemia, seizures, cardiac events and adrenal crisis
Hypoglycaemia
Recognition: occurs in known diabetic patients, particularly if a meal or medication dose has been missed; confusion, sweating, trembling, irritability, pallor; may progress to reduced consciousness or seizure if untreated.
Immediate management:
- If conscious and able to swallow: give oral glucose (gel, tablets, sugary drink) followed by a long-acting carbohydrate.
- If unconscious or unable to swallow safely: give glucagon 1 mg IM/SC, or IV glucose if trained and equipped to do so, and call for emergency help.
- Monitor blood glucose and recovery closely; do not allow the patient to leave until fully recovered.
Epileptic seizure
Recognition: sudden loss of consciousness with tonic-clonic movements, or a focal/absence seizure; may be preceded by an aura; post-ictal confusion and drowsiness are common after a generalised seizure.
Immediate management:
- Protect the patient from injury; do not restrain or put anything in the mouth.
- Time the seizure; give oxygen once safe to do so.
- If the seizure lasts longer than 5 minutes, or a second seizure follows without recovery, give midazolam 10 mg buccally and call for emergency help.
- Once movements stop, place in the recovery position and reassess airway and breathing.
Angina and suspected myocardial infarction
Recognition: central, crushing chest pain, which may radiate to the arm, neck or jaw; breathlessness, sweating, nausea. Pain unrelieved by GTN (or lasting longer than 15 minutes) suggests myocardial infarction rather than stable angina.
Immediate management:
- Stop treatment, sit the patient comfortably and reassure them.
- Give the patient’s own GTN spray sublingually; repeat after 5 minutes if pain persists.
- If pain is unrelieved after two doses of GTN, treat as a suspected myocardial infarction: call emergency services, give 300 mg aspirin (chewed/dispersed) if not contraindicated, and give oxygen.
- Be prepared to start CPR if the patient becomes unresponsive.
Adrenal (Addisonian) crisis
Recognition: occurs in patients on long-term corticosteroids or with adrenal insufficiency, often precipitated by stress, infection or missed medication; profound weakness, hypotension, nausea/vomiting, abdominal pain, confusion.
Immediate management:
- Call for emergency help.
- Give hydrocortisone 100 mg IM if trained and available.
- Lay the patient flat, give oxygen, and monitor closely pending emergency service arrival.