34.3 Hypoglycaemia, Acute Asthma and Seizures

Detailed Emergency Protocols

3. Hypoglycaemia

• Pathophysiology: Blood glucose falls below $4.0\text{ mmol/L}$ in a diabetic patient, typically triggered by insulin/sulfonylurea administration combined with missed meals, stress, or exertion.
• Clinical Presentation:
  • Autonomic / Sympathetic Signs: Tremor, diaphoresis, pallor, palpitations, anxiety, hunger.
  • Neuroglycopenic Signs: Disorientation, slurred speech, behavioral aggression, ataxia, seizures, progressing to coma.
• Chairside Management:
  • Conscious, Cooperative Patient (Intact Swallow Reflex):
    • Administer 15–20 g of rapid-acting oral carbohydrate: e.g., 1–2 tubes of 40% oral glucose gel (GlucoGel), 150–200 mL of pure fruit juice, or 3–4 heaped teaspoons of sugar dissolved in water.
    • Recheck blood glucose after 10–15 minutes. If still $<4.0\text{ mmol/L}$, repeat oral carbohydrate.
    • Once recovered, provide complex carbohydrates (biscuits, sandwich) to replenish glycogen stores.
  • Unconscious, Aggressive, or Impaired Swallowing Patient:
    • Never attempt to administer oral fluids or gels into the mouth of an unconscious patient (aspiration risk).
    • Administer Glucagon 1 mg IM or SC (adults and children $>8$ years or $>25$ kg; administer 0.5 mg if $<8$ years).
    • Glucagon stimulates hepatic glycogenolysis, restoring normoglycaemia within 10–15 minutes. Note: Glucagon is ineffective in severely malnourished, fasting, or alcoholic patients with depleted glycogen stores.
    • Call 999. If IV access is available to paramedic teams, administer 100 mL of 10% IV glucose.

4. Acute Asthma Exacerbation

• Pathophysiology: Hyperreactive airway disease characterized by chronic bronchial inflammation, episodic bronchospasm, mucosal oedema, and hypersecretion of thick mucus.
• Clinical Signs of Severity:
  • Moderate Asthma: Able to speak in complete sentences, pulse $<110\text{ bpm}$, respiratory rate $<25\text{ breaths/min}$.
  • Severe Asthma: Inability to complete sentences in one breath, tachypnoea ($RR >25\text{ breaths/min}$), tachycardia ($HR >110\text{ bpm}$), accessory muscle use.
  • Life-Threatening Asthma: Silent chest (loss of audible wheezing due to negligible airflow), cyanosis, bradycardia, confusion, exhaustion, $SpO_2 <92%$.
• Chairside Management:
  1. Positioning: Sit the patient upright, leaning slightly forward; never force an asthmatic patient to lie flat.
  2. Short-Acting $\beta_2$-Agonist: Administer Salbutamol 100 mcg/actuation via a large-volume spacer device. Actuate one puff at a time, instructing the patient to take 5 steady tidal breaths per actuation. Repeat up to 10 puffs, waiting 30–60 seconds between puffs.
  3. Oxygen: Administer high-flow oxygen (15 L/min via reservoir mask).
  4. Emergency Escalation: If the patient exhibits life-threatening features or fails to improve within 5 minutes, call 999 immediately. Consider IM Adrenaline 500 mcg (0.5 mL 1:1000) as an adjunct bronchodilator for refractory, life-threatening asthma.

5. Epileptic Seizure & Status Epilepticus

• Pathophysiology: Paroxysmal, abnormal, excessive neuronal discharges in the cerebral cortex. Generalized tonic-clonic seizures feature an initial tonic phase (generalized skeletal muscle spasm, apnoea, cyanosis) followed by a clonic phase (synchronous rhythmic jerking of all limbs, tongue biting, incontinence), ending in post-ictal flaccidity and confusion.
• Chairside Management During Active Convulsion:
  1. Stop dental treatment immediately. Remove all instruments, burs, and dental bib chains from the patient.
  2. Do NOT attempt to restrain the patient's limbs.
  3. Do NOT place any bite-block, fingers, or suction instruments into the patient's mouth.
  4. Protect the patient from surrounding physical trauma by cushioning the head.
  5. Start timing the seizure.
• Management of Status Epilepticus:
  • Defined clinically as a generalized convulsive seizure persisting for $\ge 5\text{ minutes}$, or two or more discrete seizures occurring without complete recovery of consciousness between episodes.
  • Pharmacotherapy: Administer Buccal Midazolam 10 mg (for adults). Instill half the prefilled syringe volume into each buccal sulcus (between the lower gingiva and the cheek mucosa). The drug undergoes rapid transmucosal vascular absorption, crossing the blood-brain barrier to enhance $GABA_A$-mediated neuronal inhibition.
  • Paediatric Dosing: 1–5 years: 5 mg; 5–10 years: 7.5 mg; $>10$ years: 10 mg.
  • Call 999 immediately for any seizure lasting $>5$ minutes or requiring midazolam administration.
  • Once convulsions terminate, position the patient in the recovery position and support the airway.

Preventing These Emergencies

All three are largely preventable by history and scheduling. A patient with diabetes should be asked when they last ate and took their medication, should be seen in a short morning appointment, should be encouraged to bring their own glucose and meter, and should never be kept waiting past a meal. A patient with asthma should be asked about recent exacerbations, hospital admissions, oral steroid courses and inhaler use, and should be asked to bring their reliever inhaler to every appointment. A patient with epilepsy should be asked about seizure type, frequency and triggers, and should take their medication as normal before attending. Recording these checks is part of the examinable standard of care.