Sweating and Confused at the Sports Day: Hypoglycaemia or Heat?
During the annual sports day at a government senior secondary school, at 10:40 a.m., a 14-year-old girl in Class 9 who is known to have type 1 diabetes collapses near the long-jump pit. She skipped breakfast because of a 7 a.m. rehearsal, took her usual insulin at 7:30 a.m., and has been running events since 9 a.m. She is sweating heavily, her hands are trembling, she is confused and pushes away the glass of water a teacher offers, muttering "leave me alone." Her pulse is about 110 per minute and her skin feels cold and clammy. The school has no nurse. The nearest PHC is 9 km away and an ambulance would take 20 to 25 minutes. You are the only student who has taken the Health Care NSQF course. The teacher says, "Let her rest, she is just tired and dehydrated."
1. What is the most likely condition? Give three findings from the case that support it and explain why heat exhaustion is a weaker explanation.
Read the worked answer
The most likely condition is hypoglycaemia (low blood sugar).
Supporting findings:
- She missed breakfast and took her usual insulin, so there is insulin in the body with little glucose coming in, and she has been exercising since 9 a.m., which burns glucose faster.
- Cold, clammy, sweating skin with trembling is the classic adrenaline response to falling blood sugar.
- Confusion and irritability show the brain is already short of glucose; she is refusing help, which is itself a warning sign.
Heat exhaustion is weaker because in heat exhaustion the skin is usually hot and often dry or very flushed, the child is thirsty rather than refusing fluids, and the story fits exertion in heat but not the missed meal plus insulin. More importantly, the two conditions cannot be told apart with certainty in the field, and the safe rule is: when a known diabetic on insulin is confused and sweating, treat for low sugar first, because sugar given to a slightly high blood sugar does little harm, while sugar withheld in hypoglycaemia can cause a convulsion or coma.
2. She is still conscious and able to swallow. Set out your immediate management step by step, including what you must not give.
Read the worked answer
- Stop all activity, sit or lie her down in the shade, and stay with her. Do not let her walk to the sick room alone.
- Confirm she can swallow safely and is not drowsy. Only then give oral sugar.
- Give about 15 g of fast-acting carbohydrate: three to four level teaspoons of sugar stirred into water, glucose powder, 1 tablespoon of honey, or 3 to 4 toffees. Fluids are needed because she is also likely short of water.
- Wait 15 minutes and reassess. If she is still sweating and confused, repeat the same dose.
- Once she is alert, give a longer-acting snack such as roti with sabzi or a banana, so the sugar does not fall again.
- Inform the parents and the class teacher, record the time, what was given and the response.
Never give insulin or a diabetes tablet, never give anything by mouth to a drowsy child, and do not force fluids into someone who is resisting and might aspirate. Insisting on "just water and rest" as the teacher suggested wastes the safest window for treatment.
3. Ten minutes later she becomes sleepy and will not swallow. How does your plan change?
Read the worked answer
This is now a medical emergency: the airway is at risk and oral sugar is no longer safe.
- Give nothing by mouth - no water, no sugar, no spoon. She cannot protect her airway.
- Place her in the recovery position on her side with the upper leg bent forward and the head tilted slightly back, so vomit drains out and the tongue does not block the airway. Keep her covered and continue to watch her breathing.
- Call 108 immediately and tell them it is a known type 1 diabetic with suspected severe hypoglycaemia who is becoming unresponsive; give the school address and the nearest landmark.
- Check if the school or her bag has a glucagon kit; glucagon is given by injection only by someone trained and authorised to do so, so call the ANM or the PHC while waiting.
- Keep monitoring breathing and pulse every few minutes, note the times, and hand over the full history - insulin at 7:30 a.m., no breakfast, exercise since 9 a.m., sugar given at about 10:45 a.m. - to the ambulance team.
After recovery she must be reviewed by a doctor, and the school should plan a written diabetic-care protocol with a named responsible adult.