Confused Man at the Bus Stop: Hypoglycaemia or Stroke?
A passer-by asks you to help a man sitting on a bench at a bus stop because he 'isn't making sense'. The man is about 62 years old, pale, and sweating heavily despite the cold. His speech is slurred. He is fidgeting with his jacket and becomes mildly aggressive when you ask his name. He tells you he is diabetic and 'takes insulin'. He is sitting upright, is able to swallow, and can answer simple questions, though his answers are muddled. His right arm seems weaker than his left, but you are not sure whether that is because he is gripping the bench. His blood glucose meter is in his bag but the test strips are out of date. You have a first aid kit containing 20 g of oral glucose gel and a bottle of water, and your phone has signal.
1. How do you weigh up hypoglycaemia against stroke here, and what tips the balance for a first aider?
Read the worked answer
Both are genuinely possible and you may not be able to separate them at the roadside. Hypoglycaemia typically develops over minutes with sweating, pallor, hunger, confusion, aggression and slurred speech, and it reverses within minutes of glucose. Stroke typically comes on suddenly with focal signs - facial droop, arm weakness, speech disturbance - usually without profuse sweating.
This man has sweating and aggression, which point to hypoglycaemia, but also possible one-sided weakness, which points to stroke. The safe rule is: if the person is conscious and able to swallow, treat for hypoglycaemia. Glucose given to a stroke patient who can swallow causes no short-term harm, whereas withholding glucose from a hypoglycaemic patient can cause permanent brain injury. So treat, and keep reassessing - if the weakness persists after glucose, treat it as a stroke and use the FAST signs in your handover.
2. What exactly do you give, how do you monitor him, and when do you call 112?
Read the worked answer
Keep him sitting upright, since he can swallow and sitting reduces aspiration risk. Give 15–20 g of fast-acting carbohydrate - the 20 g glucose gel is exactly the right choice - and note the time. Do not give insulin, and do not give anything sweetened only with artificial sweetener.
Recheck after 10–15 minutes. If he is still confused or symptomatic, repeat the 15–20 g. Once he is alert and safe, give a longer-acting carbohydrate such as a sandwich, biscuits or milk to prevent a recurrence, and stay with him.
Call 112 if: there is no improvement after two doses, he loses the ability to swallow, his consciousness drops, it is a first episode, or focal weakness or speech disturbance persists once his glucose has corrected - that is a suspected stroke and time-critical. Do not let him leave alone or drive.
3. He suddenly becomes drowsy and stops responding. What changes in your management?
Read the worked answer
Stop oral glucose immediately. Nothing goes into the mouth of a person who cannot protect their airway - the gel, water or food could be aspirated. Place him in the recovery position, check that he is breathing normally, call 112, and monitor airway, breathing and circulation continuously with the phone on speaker beside you. Be ready to start CPR if he stops breathing normally.
If a glucagon kit is available and you are trained to use it, give 1 mg intramuscularly (adult dose) - but never delay calling or moving him for it. Do not put your fingers in his mouth, and only remove obviously visible fluid or debris.
On arrival of the crew, hand over: the glucose given and at what times, the change in consciousness, whether he was able to swallow beforehand, and the possibility of a stroke.