Diabetic Patient Becomes Sweaty and Confused
At 9:30 a.m., a 58-year-old man with type 2 diabetes arrives for cementation of a crown on tooth #19. During scheduling he mentioned he takes insulin twice daily. As you seat him, he says he was running late and 'skipped breakfast.' Twenty minutes into the appointment, while the dentist is out of the operatory retrieving a shade guide, the patient becomes pale and diaphoretic, his hands are trembling, and his speech is slurred. He is conscious but confused and does not answer questions appropriately. His blood pressure is 118/72 mm Hg, pulse 104 beats per minute, and respirations 20 per minute. His medical history also includes hypertension and high cholesterol. The dentist is expected back in about one minute, and the emergency kit is in the hallway.
1. What is the most likely cause of these signs, and how would you distinguish it from vasovagal syncope?
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The most likely cause is hypoglycemia. He took insulin and skipped breakfast, and his signs - pallor, diaphoresis, tremor, confusion, slurred speech, and tachycardia - fit the adrenergic and neuroglycopenic phases of low blood glucose. Vasovagal syncope usually produces bradycardia, not tachycardia, and the patient feels lightheaded, nauseated, and warm before fainting; mental status clears quickly when supine. This patient is already reclined and remains confused, which points away from simple syncope. Hyperglycemia would develop over hours to days with polyuria, thirst, and possibly Kussmaul respirations, not acute tremors. I would not try to diagnose by glucose meter unless the office has one and policy allows; the clinical picture and history are enough to act.
2. What should you do in the next one to two minutes, including positioning and any medication or sugar?
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Stay with the patient and call for the dentist and another staff member. Do not leave him alone. Place him in a supine or semi-supine position with legs elevated if blood pressure allows, and suction the mouth. If he is conscious and able to swallow, give 15-20 g of fast-acting oral carbohydrate: 4 oz of juice, a regular soft drink, glucose tablets, or a tube of glucose gel. Do not give food if he is unable to swallow or is drifting in and out of consciousness. Recheck his mental status and vital signs in 10-15 minutes; if he improves, give a longer-acting snack such as crackers and cheese, and do not dismiss him until he is stable. If there is no improvement, activate EMS. Oxygen may be given if indicated by office protocol.
3. What changes if the patient becomes unresponsive?
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If he becomes unresponsive, protect the airway: place him supine, turn him to the side if vomiting, and do not put anything in his mouth. Check breathing and circulation and call 911 immediately. If the office protocol and training allow, administer glucagon, but only if the assistant is trained and authorized; otherwise wait for EMS and continue monitoring. Do not attempt to give oral sugar to an unresponsive patient. Document the time of onset, vital signs, interventions, and response, and complete an incident report. The dentist should follow up with the patient's physician about his insulin regimen and meal timing before the next appointment.