Why this matters: A bedside glucose reading is one of the fastest reversible checks in emergency medicine. Hypoglycaemia can injure the brain within minutes, while marked hyperglycaemia may signal diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS), sepsis, toxic exposure or another time-critical illness. For an EMT, the number is only the beginning: obtain a reliable sample, interpret it with the patient’s presentation, treat immediate threats, reassess and communicate the trend.
Learning outcomes
By the end of this lesson, the learner should be able to:
- Explain what blood glucose is and why the brain and other tissues depend on it.
- Convert glucose values between mg/dL and mmol/L without losing the clinical meaning.
- Identify when a glucose check is indicated in pre-hospital and emergency-department assessment.
- Perform a safe capillary blood-glucose test, recognise sources of error and obtain a confirmatory sample when needed.
- Recognise mild, moderate and severe hypoglycaemia and provide first aid within scope and local protocol.
- Recognise hyperglycaemia, DKA and HHS, start supportive care and arrange urgent transport.
- Document the value, context, intervention and response so the receiving team can act on the information.
1. What is blood glucose?
Blood glucose is the concentration of glucose circulating in plasma or whole blood. Glucose comes mainly from carbohydrate digestion and from hepatic glycogen breakdown or gluconeogenesis. Insulin helps move glucose into cells; glucagon, adrenaline, cortisol and growth hormone raise glucose when the body is fasting or under stress.
The brain uses glucose continuously. Although the body can use ketones during prolonged starvation, an acutely low glucose concentration can impair attention, judgement, coordination, consciousness and seizure control. Skeletal muscle, red blood cells and many other cells also require a reliable energy supply. A single bedside value therefore helps the EMT explain altered behaviour, collapse, weakness or seizure while the wider assessment continues.
2. Important glucose terminology
| Term | Meaning for the EMT | Practical caution |
|---|---|---|
| Capillary blood glucose (CBG) | Finger-stick whole-blood measurement obtained with a lancet and meter. | Fast and useful in the field, but affected by perfusion, sampling technique and device limitations. |
| Plasma glucose | Laboratory or analyser result from separated plasma or a venous sample. | Do not assume a capillary and laboratory value will be identical at the same moment. |
| Point-of-care testing (POCT) | Testing performed near the patient rather than in a central laboratory. | Quality control, strip storage, cleaning and documentation still matter. |
| Fasting glucose | Glucose after a defined period without caloric intake, commonly at least 8 hours for diagnostic testing. | An emergency reading is usually random; it is not automatically a fasting test. |
| Random glucose | A reading taken at any time, regardless of the last meal. | Interpret it with symptoms, food intake, medications and illness. |
| Hypoglycaemia | Glucose below the patient’s safe range; many emergency protocols use <70 mg/dL (3.9 mmol/L) as the action threshold. | Symptoms and risk matter; treat the patient, not only the number. |
| Hyperglycaemia | Glucose above the expected range. | A high result alone does not diagnose DKA or HHS. |
| Neuroglycopenia | Brain dysfunction caused by inadequate glucose delivery. | Confusion, abnormal behaviour, seizure or coma may be the presentation. |
| Ketones | Acidic fuel products formed when fat is metabolised because effective insulin is inadequate. | Ketones plus illness require urgent assessment; a normal-ish glucose does not always exclude ketoacidosis. |
3. Units and conversion
Ugandan facilities may report glucose in mmol/L, while many meters and textbooks use mg/dL. Confirm the unit displayed before acting. The conversion is approximate:
mg/dL ÷ 18 = mmol/L and mmol/L × 18 = mg/dL
| mg/dL | Approximate mmol/L | Clinical meaning (context still required) |
|---|---|---|
| 54 | 3.0 | Very low; severe hypoglycaemia is possible. |
| 70 | 3.9 | Common action threshold for low glucose. |
| 100 | 5.6 | Near the upper end of a typical fasting reference range. |
| 126 | 7.0 | Diagnostic cut-offs require properly collected laboratory testing and confirmation. |
| 180 | 10.0 | Common upper treatment target in some settings; not a universal emergency cut-off. |
| 250 | 13.9 | Hyperglycaemia that warrants symptom and ketone assessment, especially when ill. |
| 300 | 16.7 | Marked hyperglycaemia; look actively for dehydration, DKA or HHS features. |
Exam and field habit: Say the value and unit aloud during handover: “CBG 3.1 mmol/L, symptomatic, treated with oral glucose at 14:20; repeat 4.4 mmol/L at 14:35.” This prevents a ten-fold unit error.
4. Reference ranges and emergency thresholds
Reference intervals vary with age, pregnancy, fasting state, diabetes treatment and the analyser. The table below supports rapid EMT reasoning; it does not replace a Ugandan Ministry of Health, facility or ambulance protocol.
| Finding | Approximate value | Immediate EMT approach |
|---|---|---|
| Low glucose / action threshold | <70 mg/dL (<3.9 mmol/L) | Repeat if the result conflicts with the patient, check consciousness and swallowing, and treat promptly according to protocol. |
| Severely low glucose | <54 mg/dL (<3.0 mmol/L) | High risk of neuroglycopenia, seizure or coma; urgent treatment and transport. |
| Typical fasting reference | About 70–99 mg/dL (3.9–5.5 mmol/L) | Use only as a reference; illness and timing of meals change interpretation. |
| Possible diabetes-range random result | Often ≥200 mg/dL (≥11.1 mmol/L) with classic symptoms | Needs clinical assessment and formal diagnostic confirmation; do not diagnose from one field reading. |
| Marked hyperglycaemia | Often ≥250–300 mg/dL (13.9–16.7 mmol/L) | Assess hydration, mental status, respirations, vomiting, abdominal pain and ketones if available. |
| Any value with altered consciousness | Any number | Manage ABCs, reassess the meter/sample, search for other causes and transport urgently. |
5. Why EMTs check glucose early
- Altered mental status, confusion, agitation, drowsiness or coma.
- Seizure, a first seizure, prolonged postictal state or unexplained abnormal behaviour.
- Collapse, syncope, weakness, dizziness, tremor, sweating or palpitations.
- Suspected stroke or focal neurological deficit, because hypoglycaemia can mimic stroke.
- Known diabetes, insulin or sulfonylurea use, insulin pump use, or a history of severe lows.
- Vomiting, abdominal pain, dehydration, deep breathing or fruity-smelling breath.
- Sepsis, severe infection, shock, trauma, poisoning, alcohol use or prolonged exertion.
- Unwell children, neonates, pregnant patients and frail older adults when local protocol indicates testing.
- Any patient whose presentation is not explained by the initial history and vital observations.
6. Equipment for capillary glucose testing
| Item | Purpose and safety point |
|---|---|
| Glucose meter | Reads the strip reaction; check battery, display, calibration/code requirements and quality-control status. |
| Compatible test strips | Use the strip made for that meter; check expiry, lot, container closure and storage temperature. |
| Single-use safety lancet | Creates the puncture. Never share a lancet or finger-stick device between people. |
| Gloves and hand-hygiene supplies | Protect the patient and provider from blood exposure. |
| Alcohol wipe or clean water and gauze | Cleans visibly soiled skin; allow alcohol to dry completely before puncture. |
| Dry gauze or cotton | Applies gentle pressure after the sample. |
| Sharps container | Immediate disposal of the lancet without recapping. |
| Disinfectant approved for the meter | Clean the device between patients exactly as the manufacturer and IPC policy direct. |
| Documentation or electronic record | Captures time, unit, site, symptoms, intervention and repeat value. |
7. Infection prevention, consent and dignity
- Explain the test, obtain consent when the patient has capacity and preserve privacy.
- Perform hand hygiene before and after contact; wear gloves when blood may be encountered.
- Use a new single-use, auto-disabling lancet for every patient and every puncture.
- Never place a used lancet back on a tray, recap it or leave it on the stretcher.
- Do not share finger-stick devices. Assign a meter to one person when possible; if a meter is shared, clean and disinfect it between patients according to the manufacturer’s instructions.
- Control bleeding with clean gauze and dispose of contaminated material according to the facility’s waste policy.
- Do not allow blood to contaminate the meter, strip vial, medicines or other equipment.
Why this is non-negotiable: Blood glucose monitoring has caused outbreaks of hepatitis B when lancing devices or meters were shared unsafely. Infection prevention is part of accurate emergency care.
8. Capillary blood-glucose procedure
Use the device’s instructions as the final authority because meters differ. The following sequence is a safe EMT framework.
- Prepare the scene and patient. Confirm identity, explain the finger-stick, assess immediate ABC threats and position the patient safely. A critically ill patient must not be delayed for a routine test.
- Check the kit. Confirm the meter is on, the strips match the meter, the expiry date and container are acceptable, and the control or quality-check status is valid.
- Perform hand hygiene and put on gloves. Use standard precautions even when the patient reports no infection.
- Select the site. Use the side of the distal finger, usually the middle or ring finger. Avoid a swollen, bruised, infected, cold, cyanotic or previously punctured site.
- Improve circulation. If the hand is cold, warm it gently and let the arm hang briefly. Do not squeeze forcefully because tissue fluid can dilute the sample.
- Clean and dry. If using alcohol, allow it to dry fully. Wet alcohol can sting and may dilute or contaminate the drop.
- Insert the strip. Follow the meter’s sequence; some devices switch on automatically. Confirm the display is ready for blood.
- Lance the side of the finger. Use the smallest depth that produces a free-flowing drop. Warn the patient before the puncture.
- Obtain the sample. Let the blood form naturally. If needed, apply gentle pressure from the base toward the fingertip, avoiding vigorous milking. Touch the strip edge to the drop as the manufacturer shows.
- Wait and read. Keep the meter still. Note the number, unit, time, error messages and whether the result is unexpectedly high or low.
- Finish safely. Apply gauze, discard the lancet immediately into sharps, remove gloves safely and perform hand hygiene.
- Act and reassess. Match the number to mental status, breathing, circulation and history. Treat within scope, repeat at the required interval and arrange transport when indicated.
9. Choosing the best puncture site
| Site or situation | Preferred action | Reason |
|---|---|---|
| Warm adult finger | Side of middle or ring finger. | Good capillary flow with less pain than the fingertip pad. |
| Cold or shocked patient | Warm the hand, improve perfusion and consider venous confirmation. | Peripheral vasoconstriction can produce an inadequate or misleading sample. |
| Callused, oedematous or injured finger | Choose another clean finger or follow the device’s approved alternative site. | Thick or damaged skin makes sampling difficult. |
| Very young child | Use the age-specific device and facility protocol; an approved heel site may be used in neonates. | Adult finger-stick depth and thresholds may injure a child or mislead interpretation. |
| Severe hypotension, oedema or poor circulation | Do not rely on one capillary result; obtain a venous or laboratory sample when feasible. | Capillary readings may be inaccurate when tissue perfusion is abnormal. |
10. What to do when the meter gives an error
| Display or problem | Likely causes | Corrective action |
|---|---|---|
| “Not enough blood” | Small drop, strip filled late, poor circulation or strip not fully inserted. | Use a new strip and lancet; warm the hand; obtain a larger natural drop without forceful squeezing. |
| “Strip error” | Wrong strip, damaged strip, expired strip or incorrect insertion. | Discard it; check the vial, lot and meter compatibility; repeat. |
| “HI” or above range | Glucose exceeds the meter range or a sample/device problem exists. | Repeat with a new strip, assess DKA/HHS features and obtain confirmatory testing urgently. |
| “LO” or below range | Very low glucose or sampling/device problem. | Assess consciousness and swallowing immediately; treat as a critical low while confirming if safe. |
| Unexpected value | Contamination, wet finger, cold perfusion, medication interference or patient change. | Repeat after cleaning and drying a different finger; never delay life-saving care. |
| Meter will not start | Flat battery, damaged device or temperature outside range. | Use a checked backup meter or venous sample; label the failed device for review. |
11. Factors that distort a capillary reading
- Food, sugar or lotion on the finger: wash and dry the hand; alcohol alone may not remove sugar.
- Wet alcohol: can dilute the drop and create an artificially low or variable reading.
- Cold, shock or peripheral vasoconstriction: may make sampling difficult and reduce reliability.
- Excessive squeezing: mixes interstitial fluid with capillary blood.
- Expired, heat-damaged or damp strips: cause inaccurate results or errors; keep the vial closed.
- Wrong strip coding or incompatible strips: follow the exact meter instructions.
- Extremes of haematocrit, dehydration or severe illness: may affect some meters; confirm with laboratory or blood-gas testing when clinically important.
- Medication or chemical interference: some devices are affected by substances such as maltose, icodextrin or high-dose vitamin C; consult the manufacturer and receiving facility.
- Rapidly changing glucose: a finger-stick is a snapshot; trends and repeat readings are essential.
12. When capillary results need confirmation
Request venous, laboratory or blood-gas confirmation as soon as feasible when the value is incompatible with the patient, treatment decisions are high risk, the patient is in shock or has severe oedema, the meter displays HI/LO, or the result remains abnormal after a careful repeat. Never postpone airway support, glucose rescue or urgent transport while waiting for a laboratory number.
| Situation | Interpretation rule |
|---|---|
| Patient awake, looks well, CBG 2.8 mmol/L | Assume clinically important hypoglycaemia, treat promptly and repeat; do not dismiss it as a device error. |
| Patient unconscious, CBG 18 mmol/L | Hyperglycaemia does not explain every coma. Manage ABCs and search for stroke, seizure, poisoning, sepsis, trauma and other causes. |
| Patient in shock, CBG 5.0 mmol/L | A normal peripheral reading does not rule out serious illness; perfusion, lactate and other investigations remain urgent. |
| “HI” plus vomiting and deep breathing | Treat as a hyperglycaemic crisis until proven otherwise and expedite transport. |
13. Interpreting glucose with the whole patient
| Glucose finding | Symptoms and signs | High-priority questions |
|---|---|---|
| Low | Sweating, tremor, hunger, palpitations, anxiety, weakness, confusion or seizure. | Insulin or sulfonylurea? Last meal? Exercise? Alcohol? Kidney disease? Previous episodes? |
| Normal | Persistent altered consciousness, focal deficit, fever, pain or respiratory distress. | What other reversible cause is present? Hypoxia? Stroke? Sepsis? Trauma? Poison? |
| High | Thirst, polyuria, dry mouth, dehydration, nausea, abdominal pain, deep breathing or fruity breath. | Known diabetes? Missed insulin? Infection? Vomiting? Ketones? Pregnancy? SGLT2 inhibitor? |
| Rapidly changing | Symptoms fluctuate after food, insulin, glucagon, IV dextrose or fluids. | When was the last treatment and what was the repeat trend? |
14. A quick bedside interpretation sequence
- Read the value and unit twice.
- Look at the patient: airway, breathing, circulation, disability and exposure.
- Ask whether the result explains the presentation or is merely an associated finding.
- Check the quality of the sample and repeat if unexpected, without delaying emergency treatment.
- Identify the likely cause and the risk of recurrence.
- Treat within scope and local protocol, reassess the response and document the trend.
Never interpret a glucose number without the patient’s condition and the direction of change.
15. Hypoglycaemia: definition and levels
Hypoglycaemia is a glucose concentration below the level needed for safe function. The commonly taught action threshold is <70 mg/dL (3.9 mmol/L). A value below 54 mg/dL (3.0 mmol/L) is clinically serious because neuroglycopenic symptoms and impaired self-treatment are more likely. Symptoms may occur at a higher level if glucose falls rapidly, and people with repeated lows may have few warning symptoms.
| Level | Typical presentation | EMT priority |
|---|---|---|
| Early or mild | Hunger, sweating, tremor, palpitations, anxiety, tingling or irritability. | Check glucose, give fast carbohydrate only if alert and able to swallow, then recheck. |
| Moderate | Weakness, blurred vision, headache, poor coordination, unusual behaviour or confusion. | Protect from injury, reassess airway and swallowing, treat promptly and arrange clinical review. |
| Severe | Seizure, inability to cooperate, coma, collapse or inability to swallow safely. | ABC care, nothing by mouth, emergency glucose rescue per protocol and urgent transport. |
| Recurrent | Repeated low readings after temporary improvement. | Suspect long-acting insulin, sulfonylurea, renal failure, sepsis or inadequate intake; observe and transport. |
16. Symptoms of low glucose
Adrenergic warning symptoms: sweating, tremor, palpitations, tachycardia, hunger, pallor, anxiety, irritability and tingling.
Neuroglycopenic symptoms: headache, dizziness, poor concentration, slurred speech, visual change, weakness, confusion, abnormal behaviour, drowsiness, seizure and coma.
Do not wait for the full pattern. A person may present as “drunk,” aggressive, sleepy, clumsy or aphasic. Beta-blockers, autonomic neuropathy and recurrent hypoglycaemia can blunt the warning signs.
17. Causes and risk factors for hypoglycaemia
| Cause | Examples and questions | Why recurrence matters |
|---|---|---|
| Medication mismatch | Too much insulin, wrong dose, wrong timing, sulfonylurea, duplicated dose or pump error. | Long-acting medicines can cause a second fall after initial rescue. |
| Reduced intake | Missed meal, vomiting, fasting, swallowing difficulty or food insecurity. | Oral glucose may be temporary without a meal or observation. |
| Exertion | Unexpected exercise, heavy work or prolonged sport. | Glucose may fall later, including overnight. |
| Alcohol | Alcohol after little food, especially with diabetes medicines. | Alcohol can impair judgement and hepatic glucose release. |
| Organ failure | Renal or hepatic failure reduces drug clearance and glucose production. | Longer observation and specialist care may be needed. |
| Critical illness | Sepsis, adrenal insufficiency, malnutrition or severe infection. | Treat the underlying illness; glucose rescue alone is not definitive care. |
18. Conscious patient who can swallow: the 15–15 approach
For an alert patient with a low reading who can protect the airway and swallow safely, many diabetes protocols use the 15–15 rule: give about 15 g of fast-acting carbohydrate, wait 15 minutes and recheck. If still below the action threshold, repeat according to protocol. Once recovered, provide a longer-acting snack or meal containing carbohydrate and, when appropriate, protein. The exact amount is age- and protocol-dependent.
| Fast carbohydrate option | Teaching point |
|---|---|
| Glucose tablets or glucose gel | Use the label to provide the required carbohydrate amount. |
| About 120 mL (½ cup) of ordinary fruit juice or non-diet soda | Use a measured portion; diet drinks do not contain enough sugar. |
| Sugar, honey or syrup | Use a measured amount if glucose products are unavailable and swallowing is safe. |
| Follow-up snack or meal | Prevents another fall when the next meal is not soon or the cause is prolonged. |
Never give food, drink, tablets or gel by mouth to a patient with reduced consciousness, active seizure, vomiting with poor airway protection or inability to swallow on command. Aspiration can be fatal.
19. Severe hypoglycaemia: ABCDE response
- Airway: open and protect the airway; suction if necessary and prepare for advanced support according to scope.
- Breathing: assess rate, effort and oxygenation; give oxygen when indicated by the patient’s condition and local protocol.
- Circulation: check pulse, perfusion and blood pressure; obtain IV or intraosseous access only if trained and authorised.
- Disability: check glucose, pupils, seizure activity and level of consciousness; look for trauma from a fall.
- Exposure and cause: search for insulin pens, tablets, pump, alcohol, infection, medical alert jewellery or a medication list.
- Rescue glucose: administer IV dextrose, buccal glucose or glucagon only as authorised by local protocol and scope. Do not delay transport while repeatedly attempting an unsafe oral intervention.
- Reassess: repeat glucose and neurological status, then monitor for recurrence during transport.
20. Glucagon and IV dextrose: safety principles
| Intervention | When considered | Safety principle |
|---|---|---|
| IV dextrose | Severe hypoglycaemia when IV access and authorised protocol are available. | Use the prescribed concentration and dose; check patency because extravasation can injure tissue. |
| Glucagon | Severe low glucose when the patient cannot swallow and IV access is delayed or unavailable, if supplied and authorised. | Position safely because vomiting may occur; call for emergency medical care and reassess. |
| Oral glucose | Alert, cooperative patient with intact swallowing. | Stay with the patient; do not leave tablets unattended in a confused person. |
| No intervention yet | Uncertain reading, but the patient is symptomatic or deteriorating. | Repeat promptly while supporting ABCs; a reasonable repeat must never become an excuse to withhold indicated rescue. |
Medication administration must follow the Uganda facility or ambulance standing orders, concentration labels, patient age and scope of practice. This educational page does not replace authorisation or supervised skills training.
21. Reassessment after treating a low
| Reassessment | What to record | Escalate when |
|---|---|---|
| Clinical response | Alertness, speech, coordination, behaviour, seizure activity and ability to eat. | No improvement, worsening consciousness, new focal deficit or recurrent symptoms. |
| Repeat glucose | Time, value, unit and method after the intervention. | Still below threshold, falling again or result conflicts with the examination. |
| Cause and duration | Medication, meal, exercise, alcohol, renal disease and previous episodes. | Long-acting insulin/sulfonylurea, intentional overdose, pregnancy or serious illness. |
| Disposition | Transport, observation, responsible adult and receiving clinician. | Severe episode, uncertain cause, unreliable follow-up or unsafe home environment. |
22. Hypoglycaemia in special groups
- Children: use age-, weight- and protocol-specific carbohydrate or medication doses; young children may need less than 15 g and have limited symptom reporting.
- Neonates: follow neonatal hypoglycaemia policy and feeding/IV glucose pathway; do not apply adult thresholds without supervision.
- Pregnancy: glucose needs and treatment targets differ; severe or recurrent lows require urgent obstetric and medical review.
- Older adults: falls, confusion and stroke-like symptoms may be the only clues; renal impairment can prolong medication effects.
- Renal or hepatic failure: expect delayed clearance and recurrent lows even after an apparently successful rescue.
- People who live alone: ask who can supervise eating, medication and transport; do not equate recovery with safety.
23. Hyperglycaemia: recognition
Hyperglycaemia may be chronic, stress-related or the first sign of diabetes. Common features include thirst, frequent urination, dry mouth, fatigue, blurred vision, weight loss, dehydration, nausea and weakness. Severe illness may produce abdominal pain, vomiting, fruity breath, deep rapid breathing, drowsiness or coma.
| Finding | What it may suggest | EMT action |
|---|---|---|
| Thirst and polyuria | Osmotic diuresis from hyperglycaemia. | Assess hydration, pulse, blood pressure, mental status and urine output. |
| Vomiting and abdominal pain | DKA, infection, pregnancy-related illness or another abdominal emergency. | Do not label it “just diabetes”; assess airway and expedite transport. |
| Deep, laboured breathing | Compensatory Kussmaul breathing from metabolic acidosis. | Urgent transport, oxygenation assessment and continuous reassessment. |
| Altered mental status | Severe dehydration, HHS, DKA, sepsis, stroke or toxic/metabolic disease. | ABCs and broad differential diagnosis; obtain glucose and other tests as available. |
| Fever or infection symptoms | Infection can precipitate DKA/HHS and may be the underlying emergency. | Search for source, monitor temperature and notify the receiving team. |
24. Diabetic ketoacidosis (DKA)
DKA develops when effective insulin is insufficient. Cells cannot use glucose normally, so fat breakdown produces ketones and metabolic acidosis. It is common in type 1 diabetes but can occur in type 2 diabetes, during infection, trauma, myocardial infarction, pregnancy or medication interruption. DKA is a life-threatening emergency.
| Domain | Typical clues | Why it matters |
|---|---|---|
| History | Known diabetes, missed insulin, new diabetes, infection, vomiting or SGLT2-inhibitor use. | Euglycaemic DKA can occur with only modest glucose elevation. |
| Fluid loss | Thirst, polyuria, dry mucosa, tachycardia, hypotension and poor skin turgor. | Osmotic diuresis causes dehydration and reduced perfusion. |
| Gastrointestinal | Nausea, vomiting and diffuse abdominal pain. | May mimic an acute abdomen; do not give oral fluids to an unsafe airway. |
| Respiration | Deep, rapid Kussmaul breathing and possibly fruity breath. | Reflects compensation for acidosis; fatigue can precede respiratory failure. |
| Neurology | Headache, drowsiness, confusion or coma. | Severe dehydration, acidosis, electrolyte disturbance or cerebral complications. |
25. Hyperosmolar hyperglycaemic state (HHS)
HHS is marked by very high glucose, profound hyperosmolarity and dehydration, usually with little or no significant ketoacidosis. It is often seen in older adults with type 2 diabetes, but anyone can be affected. Confusion, focal deficits, seizures and coma may occur. A meter result that is “HI” or extremely high is an emergency even when the patient is not yet vomiting.
| Feature | DKA | HHS |
|---|---|---|
| Onset | Hours to days; may be rapid. | Often days to weeks, with progressive dehydration. |
| Ketones/acidosis | Prominent ketones and metabolic acidosis. | Minimal ketones or acidosis compared with DKA. |
| Glucose | High, but can be lower in euglycaemic DKA. | Usually extremely high; the meter may read HI. |
| Neurological findings | Variable; drowsiness or coma in severe disease. | Prominent confusion, focal deficits, seizures or coma are common. |
| EMT priority | ABCs, cautious fluids and urgent transport under protocol. | ABCs, perfusion assessment, cautious fluids and urgent transport; avoid delay for a “better” number. |
26. Pre-hospital approach to suspected DKA or HHS
- Recognise the pattern early and request advanced support or medical control when available.
- Assess airway, breathing and circulation; place an unconscious but breathing patient in a safe lateral position unless spinal precautions or another condition prevents it.
- Monitor oxygen saturation, respiratory effort, pulse, blood pressure, temperature, mental status and cardiac rhythm if available.
- Obtain capillary glucose and ketones if the service has an approved device; repeat unexpected results.
- Establish IV access and give isotonic fluid only under local protocol, considering age, pregnancy, renal failure, heart failure and shock.
- Do not administer insulin in the field unless specifically authorised, trained and supplied under a written protocol; insulin without potassium and fluid assessment can be dangerous.
- Keep the patient NPO when vomiting, confused or at aspiration risk. Treat nausea and pain only within protocol.
- Transport urgently to a facility able to perform electrolytes, blood gas, ketones, renal tests and definitive treatment. Send the glucose trend and all interventions.
27. Glucose and altered mental status
Hypoglycaemia is a reversible stroke and coma mimic, but a low result should not stop the examination. After glucose is corrected, reassess speech, facial symmetry, limb power, pupils, gait and orientation. Persistent focal deficits may indicate stroke or intracranial disease. If consciousness does not improve, widen the differential: hypoxia, seizure/postictal state, poisoning, sepsis, head injury, electrolyte disturbance, hypothermia and endocrine illness.
| Step | Question |
|---|---|
| Before treatment | Was the patient last known well? Any facial droop, arm drift, speech change, trauma or seizure? |
| During treatment | Is the airway protected? Is the patient improving after glucose, or deteriorating? |
| After treatment | Has the neurological deficit resolved? What is the repeat glucose? Is stroke activation still indicated? |
| Handover | Give exact onset, glucose values, treatment times and residual findings. |
28. Glucose and seizures
- Protect the patient from injury; do not restrain forcefully or place objects in the mouth.
- Time the seizure and check breathing after the convulsion stops.
- Check glucose early in a first seizure, prolonged seizure, recurrent seizure or unexplained postictal state.
- If low, treat according to the severe-hypoglycaemia pathway while managing airway and oxygenation.
- After recovery, investigate medication adherence, insulin/sulfonylurea exposure, alcohol, infection, pregnancy and other seizure causes.
29. Glucose in trauma, poisoning and sepsis
| Presentation | Why check glucose | Additional priorities |
|---|---|---|
| Trauma or collapse | Low glucose may cause the fall; stress hyperglycaemia may accompany serious injury. | Control haemorrhage, protect spine when indicated, assess head injury and do not anchor on glucose. |
| Suspected poisoning | Insulin, sulfonylurea, alcohol and some toxins cause hypoglycaemia. | Preserve containers, establish time and amount, call poison/medical control and observe for recurrence. |
| Sepsis | Severe infection can cause either low or high glucose and poor perfusion. | Temperature, perfusion, mental status, oxygenation, source control and urgent transport. |
| Unknown collapse | It is a fast, reversible test that can alter immediate care. | Run a complete primary and secondary survey regardless of the result. |
30. Pregnancy and glucose emergencies
Pregnancy changes insulin sensitivity and can make vomiting, dehydration and DKA progress quickly. Ask about gestational or pre-existing diabetes, insulin, oral medicines, fetal movement and gestational age. Treat maternal ABC threats first, avoid oral intake when unsafe, monitor both mother and fetus when equipment and protocol allow, and transport early with obstetric notification. Do not assume a pregnant patient with abdominal pain and high glucose has “ordinary morning sickness.”
31. Documentation and handover template
| Record | Example |
|---|---|
| Indication and symptoms | Confused, sweating and weak; known type 1 diabetes. |
| Time, site and method | 14:20; right middle-finger capillary sample; meter model if required. |
| Value and unit | 3.1 mmol/L (56 mg/dL), not “3.1” alone. |
| Quality checks | Strip in date, finger washed/dry, repeat performed when indicated. |
| Intervention | 15 g oral glucose while alert; no oral intake if consciousness declined. |
| Response | 14:35: 4.4 mmol/L, oriented to person and place, still weak. |
| Disposition | Transported for assessment because sulfonylurea dose was uncertain; receiving clinician notified. |
32. Clinical scenarios for EMT practice
Scenario 1 – conscious low: A 22-year-old with type 1 diabetes is sweaty, shaky and able to swallow. CBG is 3.2 mmol/L. Give fast carbohydrate under protocol, recheck after the recommended interval, provide a longer-acting snack when safe, investigate insulin/meal mismatch and do not leave until a safe plan is arranged.
Scenario 2 – severe low: A patient is found unresponsive beside insulin supplies; CBG is 2.1 mmol/L. Protect the airway, nothing by mouth, administer authorised rescue glucose, treat injuries, repeat the glucose and transport urgently because the cause and duration are uncertain.
Scenario 3 – DKA pattern: A young adult has polyuria, vomiting, abdominal pain, fruity breath and deep breathing; CBG is 22 mmol/L. Treat as a time-critical hyperglycaemic crisis, monitor ABCs, avoid unsupervised insulin and notify the receiving facility.
Scenario 4 – stroke mimic: A person has slurred speech and right-arm weakness; CBG is 2.9 mmol/L. Treat the low, repeat the neurological examination and preserve the stroke pathway if deficits persist or the last-known-well time is concerning.
Scenario 5 – recurrent sulfonylurea low: A patient improves after glucose but becomes sweaty again 40 minutes later. Ask about glibenclamide or another sulfonylurea, repeat glucose, continue observation and transport for prolonged monitoring.
33. Common mistakes to avoid
- Reading mg/dL as mmol/L or omitting the unit during handover.
- Giving oral glucose to a patient who cannot swallow safely.
- Using an expired strip, a strip from another meter or a contaminated finger.
- Squeezing the finger aggressively or testing through wet alcohol.
- Sharing lancets, finger-stick devices or an uncleaned meter.
- Assuming a high glucose proves DKA or that a normal glucose rules out serious illness.
- Repeating a reading endlessly while delaying airway support or transport.
- Discharging a patient after one normal repeat when a long-acting medicine, pregnancy, renal failure, overdose or unreliable follow-up is present.
- Failing to repeat the neurological examination after correcting a low glucose.
34. EMT blood-glucose checklist
| Before the puncture | During the test | After the result |
|---|---|---|
| ABC threats addressed | Correct strip and meter | Read value and unit aloud |
| Consent or best-interest decision | Hand hygiene and gloves | Match number to symptoms and perfusion |
| Correct patient identified | Clean, dry side of finger | Treat within scope and protocol |
| Strip expiry/storage checked | Single-use lancet | Repeat at the correct interval |
| Sharps container ready | Natural blood drop, no forceful squeezing | Document, hand over and transport when indicated |
35. Revision questions
- Define capillary blood glucose and distinguish it from a laboratory plasma glucose.
- Convert 54 mg/dL to mmol/L.
- Why can hypoglycaemia present as confusion, aggression or seizure?
- List five indications for an EMT glucose check.
- Why must the alcohol on a finger dry before puncture?
- Why is the side of the finger preferred to the central pad?
- List four causes of an inaccurate capillary reading.
- What does a “LO” meter message require you to do first?
- State the 15–15 approach and its swallowing-safety limitation.
- What are the adrenergic symptoms of hypoglycaemia?
- What are the neuroglycopenic symptoms?
- Why can sulfonylurea-associated hypoglycaemia recur?
- What is the first priority for an unconscious patient with a low reading?
- Why should oral glucose be withheld during an active seizure?
- Name four features that suggest DKA.
- How can HHS differ from DKA?
- Why can a person with DKA have a modest glucose value?
- What questions identify a possible insulin dosing error?
- Why is a normal glucose not enough to rule out stroke?
- When is venous confirmation particularly important?
- What information belongs in the glucose handover?
- Why is a repeat reading a trend rather than a complete diagnosis?
- How should a child’s treatment differ from the adult 15 g teaching example?
- Why can pregnancy accelerate concern about vomiting and hyperglycaemia?
- What safety steps prevent hepatitis B transmission during glucose monitoring?
36. Key takeaways
- Check glucose early in unexplained altered mental status, seizure, collapse and suspected diabetes emergencies.
- Always state the value, unit, time and patient condition.
- For an alert patient who can swallow, fast carbohydrate and a repeat reading are common first-line actions for low glucose; follow local protocol.
- For reduced consciousness, protect the airway and never give anything by mouth.
- High glucose plus dehydration, vomiting, abdominal pain, deep breathing or altered mental status is a time-critical emergency.
- Use single-use lancets, clean equipment and careful technique every time.
- Reassess after every intervention and transport when the cause, recurrence risk or follow-up is uncertain.
37. References and further reading
- Blood Glucose – supplied teaching slides (SlideShare).
- CDC: Treatment of Low Blood Sugar (Hypoglycemia).
- CDC: Low Blood Sugar (Hypoglycemia).
- CDC: Diabetic Ketoacidosis.
- CDC: Considerations for Blood Glucose Monitoring and Insulin Administration.
- American Diabetes Association: DKA—Signs, Symptoms and Treatment.
- World Health Organization: Guidelines on Drawing Blood.
Scope note: This lesson supports EMT learning and examination preparation. Follow current Uganda Ministry of Health, ambulance service, facility and medical-control protocols for glucose thresholds, paediatric and pregnancy care, medication concentrations, IV therapy and transport decisions.