Medical

Altered consciousness with high BGL — suspected diabetic ketoacidosis

Intermediate

Adult · 22yr · female

Patient Information

Dispatch	You are called to a 22-year-old female (Caitlin Doyle) at a music festival who has been found by her friends in a distressed and confused state near the camping area. Friends report she has Type 1 diabetes and 'forgot her insulin' over the weekend.
Patient	Caitlin Doyle — 22yr (58kg)
Incident History	Patient's friends report she has been unwell for approximately 8 hours — progressively nauseated, vomiting twice, and increasingly confused and drowsy over the last 2 hours. She missed her insulin doses for approximately 36 hours as she forgot her insulin pen at home. Friends initially thought she was unwell from the festival but became concerned when she became difficult to rouse. One friend mentions her breath 'smells sweet, like nail polish remover.'
Emergency Contact	Sandra Doyle (Mother) — 0412 663 094

Initial Rapid Assessment

Response	Responds to voice — drowsy but rousable
Airway	Patent but requires monitoring — drowsy patient at risk of loss of protective reflexes. No vomit in airway at present. Lateral position if consciousness deteriorates.
Breathing	Deep, sighing respirations — Kussmaul breathing pattern. RR 22. No wheeze or crackles. SpO2 96% on room air. Sweet/fruity odour on breath (ketones).
Circulation	Radial pulse present — rapid and weak. Skin dry and warm centrally, cool peripherally. Mucous membranes dry. CRT 3s.
Disability	GCS 12 (E3V4M5). Responds to voice but disoriented. Eyes open to voice. Confused speech — answers questions but is incorrect about the date and her location.
Exposure	No rashes. No trauma. No focal neurological deficit. Abdomen soft — mild diffuse tenderness on palpation.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	96% (RA)	Nil	22	118	100/68	3s	12	4 4 ++	37.4	24.6 mmol/L	3
15 mins	96% (RA)	Nil	20	114	102/70	3s	12	4 4 ++	37.4	24.6 mmol/L	3

History Taking

Treatment Response

Diagnosis

Suspected diabetic ketoacidosis (DKA) in a Type 1 diabetic who has missed insulin for approximately 36 hours. Key features: BGL 24.6 mmol/L (markedly elevated), GCS 12 (altered consciousness), Kussmaul breathing (deep sighing respirations — compensatory respiratory alkalosis for metabolic acidosis), ketotic (sweet/fruity) breath, tachycardia, hypotension, dry mucous membranes (dehydration), nausea and vomiting, gradual onset. CRITICAL distinction from hypoglycaemia: BGL is very HIGH (not low). Do NOT administer oral glucose gel — it is contraindicated (altered consciousness = aspiration risk; high BGL = will worsen hyperglycaemia). Do NOT administer insulin — out of EHS scope and dangerous without IV access and monitoring. Management is supportive: airway protection, position, monitoring, and URGENT CSP escalation.

Facilitator Triggers — if trainees miss a critical step

! (If trainees reach for oral glucose gel because the patient has diabetes and is altered — facilitator STOPS this immediately. 'Before you give that — what is her blood glucose level?' BGL is 24.6 mmol/L. Facilitator note: oral glucose gel is ONLY appropriate for hypoglycaemia (BGL <4.0 mmol/L in a symptomatic patient). Giving glucose to a patient with a BGL of 24.6 will worsen hyperglycaemia. Additionally, a GCS of 12 increases the risk of aspiration.)
! (If trainees do not measure the BGL — patient becomes more difficult to rouse over 5 minutes. Prompt: 'She is a known Type 1 diabetic who has missed her insulin — what is the single most important measurement you need right now?' Facilitator note: BGL must be measured in any diabetic with altered consciousness BEFORE any intervention.)
! (If trainees do not recognise the Kussmaul breathing pattern — prompt: 'Her breathing rate is 22 and the pattern looks unusual — how would you describe it?' Facilitator note: deep, slow, sighing respirations in a diabetic with altered consciousness should prompt DKA as the primary diagnosis.)
! (If trainees do not recognise that insulin is out of scope — prompt: 'You know she needs insulin — is that something you can give?' Facilitator note: insulin administration is outside EHS scope and requires IV access, monitoring, and electrolyte management. This must not be attempted.)
! (If trainees do not promptly call for CSP — facilitator note at 5 minutes: 'Her GCS is dropping and her BP is low. What is the urgency here?' DKA with GCS <14, hypotension, and vomiting is a time-critical presentation. Escalation must be immediate.)

Treatment Objectives

1. Ensure scene safety — festival camping area; clear bystanders, create access space.
2. Don appropriate PPE.
3. Perform Primary Survey — GCS 12, Kussmaul breathing, tachycardia, hypotension, dehydration.
4. MEASURE BLOOD GLUCOSE IMMEDIATELY — 24.6 mmol/L. This is markedly elevated. This is hyperglycaemia, NOT hypoglycaemia.
5. Do NOT administer oral glucose gel — BGL is 24.6 mmol/L (contraindicated) and GCS is 12 (aspiration risk).
6. Position patient in lateral (recovery) position — GCS 12 with prior vomiting creates aspiration risk. Monitor airway continuously.
7. Apply oxygen via nasal cannula — maintain SpO2 ≥95%.
8. Complete Vital Sign Survey — BGL 24.6, GCS 12, HR 118, BP 100/68, RR 22 deep sighing pattern, SpO2 96%, CRT 3s, Temp 37.4.
9. Recognise clinical features of DKA: very high BGL, missed insulin, gradual onset, Kussmaul breathing, ketotic breath, tachycardia, hypotension, dehydration, nausea/vomiting, altered consciousness.
10. Call for CSP immediately — DKA with altered consciousness, hypotension, and vomiting is a time-critical presentation requiring IV fluids, insulin infusion, and electrolyte monitoring in hospital. This is beyond EHS management scope.
11. Conduct history via friends while monitoring patient — establish insulin omission, duration, last oral intake, vomiting.
12. Do NOT attempt to administer insulin — out of EHS scope and dangerous without IV access and monitoring.
13. Monitor GCS, airway, and breathing continuously — GCS trajectory is critical. If GCS drops below 10 or airway is compromised, prepare to support airway.
14. Keep patient warm — she is peripherally shutdown and dehydrated.
15. Provide regular verbal reassurance to patient — even at GCS 12, auditory processing may be partially intact.
16. Provide IMISTAMBO handover to transporting crew including: GCS 12, BGL 24.6, insulin omission history, Kussmaul breathing, vomiting ×2, no oral glucose given, oxygen applied.
17. Scenario ends on arrival of ambulance and handover.
18. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Hypoglycaemia · Altered Consciousness · Primary Survey · Blood Glucose Monitoring · Oxygen · Secondary & CNS Survey

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Signs/Symptoms	Progressively drowsy and confused over 2 hours. Nausea and vomiting. Deep sighing respirations. Sweet/fruity breath. Dry mouth. Abdominal discomfort. Did not take insulin for approximately 36 hours.
Allergies	NKDA.
Medications	Insulin — Novorapid (rapid-acting, with meals) and Lantus (long-acting, nightly). MISSED for approximately 36 hours. No other medications.
Pertinent History	Type 1 diabetes diagnosed age 14. Usually well controlled. Forgot insulin pen at home when leaving for the festival on Friday. Has been trying to 'manage' with diet restriction for the weekend. No prior DKA admissions. No other medical history.
Last Oral Intake	Vomited twice this afternoon. Last kept-down oral intake was this morning — small amount of water.
Events Leading	Patient attended the music festival for a long weekend and packed in a hurry, leaving her insulin at home. She tried to manage her diabetes with carbohydrate restriction but over 36 hours her blood glucose climbed, triggering DKA. Friends noticed her deteriorating consciousness and called for help.
Treatment Prior	Nil. Friends tried to give her a sports drink as they thought her sugar was low — she refused because she felt too sick.

Onset	Gradual onset over 8 hours — worsening progressively. Not sudden.
Pain	Mild diffuse abdominal pain. No focal tenderness.
Quality	Generalised ache and nausea.
Radiates	Nil radiation.
Severity	3/10 abdominal discomfort.