24. Introduction to TLoC

Question 1

what does transient loss of consciousness mean

Answer 1

just mean blackouts: fits, faints and funny turns

paroxysmal disorders of consciousness

Question 2

what is syncope

Answer 2

• loss of consciousness caused by lack of cerebral blood supply (lie down so that the heart is at the same level as the brain to re-establish the blood flow)

Question 3

what kind of motor activity can be associated with syncope

Answer 3

 Twitching of limbs
 Stiffening and jerking
 Tongue biting and incontinence can occur

Question 4

Give me the main classifications of blackouts:

Answer 4

- syncope
vasovagal  
cardiogenic (arythmie or obstructive cardiomyopathy) 
- neurological causes 
provoked (next question)  and unprovoked  (epilepsy)
-psychogenic causes 
non epileptic attack disorder (NEAD)
- rarer causes 
o	Migrainous events 
o	Vestibular disorder 
o	Cerebrovascular events (TIA) 
o	Sleep disorders

Question 5

Name some things that can cause a provoked neurological seizure

Answer 5

alcohol
cocaine
prescription meds such as tramadol

Question 6

Name some characteristics which would make you think that the patient has non-epileptic attack disorder- NEAD rather than epilepsy

Answer 6

o NAD on EEG and this is what distinguishes
o Pelvic thrusting and back arching is very classical and distinguish from epilepsy
o Slump and lie still which raises suspicion of syncope but the blood pressure and EEG activity remains normal which again makes you think this is more psychogenic

Question 7

when taking a TLoC history what things do you need to ask about what happened before the TLoC

Answer 7

o What were you doing?
 Any potential trigger?: Sleep deprivation, stress, light sensitivity, alcohol use
o Did you get any warning?
 Aura
 Dizziness = loss of balance
 Vertigo = sensation of movement (room spinning)
 Prodromal symptoms -> fever, rash, sweating
 Focal epilepsy -> may suggest where the seizure arises

Question 8

when taking a TLoC history what things do you need to ask in terms of what happened during the episode

Answer 8

o	Collateral Hx
o	How long did it go on for?
o	Did they seem stiff or floppy?
o	Appearance
	Colour
	Were their eyes open or shut
o	Characteristics:
	Tonic seizure : <1-minute, abrupt, generalised muscle stiffening with rapid recover: 
	Generalised tonic-clonic seizure: Generalised stiffening with subsequent rhythmic jerking of limbs, urinary incontinence, tongue biting
	Absence seizure: Behavioural arrest
	Atonic seizure: Loss of muscle tone
	Myoclonic seizure: Brief, ‘shock-like’ involuntary single or multiple jerks

Question 9

when taking a TLoC history what things do you need to ask in terms of what happened after the TLoC

Answer 9

o How did you feel when you came round?
 Post-ictal phenomena -> drowsiness, headaches, amnesia, confusion
• Generalised tonic and/or clonic seizures
o Tongue biting?
o Incontinence?
o Injury?
Have there been episodes in the past?

Question 10

what are some triggers of a vasovagal syncope

Answer 10

Pain, illness, emotion, dehydration, standing for a prolonged period

Question 11

what are some triggers of a seizure

Answer 11

Sleep deprivation, drugs, alcohol

Question 12

what are some prodrome features of a vasovagal syncope

Answer 12

Feeling faint/pre-syncope, nausea, tinnitus, vision dimming

Question 13

what are some prodrome features of a seizure

Answer 13

focal onset ( not always present) 
auras

Question 14

what is the typical duration of unconsciousness in;

• vasovagal syncope
• seizure

Answer 14

vasovagal less than a minute

seizure more like 1-2 minutes

Question 15

describe the convulsions in;

• vasovagal syncope
• seizure

Answer 15

• vasovagal syncope : may occur as brief myoclonic jerks

- seizure: usual, tonic-clonic

Question 16

what colour to people tend to go in

• vasovagal syncope
• seizure

Answer 16

• vasovagal syncope : pale and grey

- seizure : flushed/cyanosed, may be pale

Question 17

what injuries can people pick up in

• vasovagal syncope
• seizure

Answer 17

• vasovagal syncope : uncommon

- seizure : Lateral tongue biting, headache, generalised myalgia, back pain, shoulder fracture

Question 18

describe the recovery time in;

• vasovagal syncope
• seizure

Answer 18

• vasovagal syncope : rapid with no confusion
• seizure: Gradual, over 30 mins
  Patient if often confused, agitated, sometimes aggressive

Question 19

when investigating TLoC what examinations do you need to carry out

Answer 19

• Cardiac
• Neurological
• Mental state
• Oral mucosa  lateral tongue biting
• Identification of any seizure related injuries

Question 20

what are the main differentials for TLoC

Answer 20

•	Vasovagal syncope
•	Seizures 
•	Panic attacks with hyperventilation
•	NEAD
•	Migraine
•	Medication, alcohol or drug intoxication
•	Sleep disorders
•	Movement disorders
•	Delirium or dementia
•	Children:
o	Febrile convulsions
o	Breath-holding attacks
o	Night terrors

Question 21

what are the red flags with TLoC

Answer 21

• MI
• Arrhythmias
• TIA
• Occult haemorrhage
• Aortic dissection
• Cardiac tamponade
• Severe hypoglycaemia
• Addison’s disease
• Massive PE