Altered Level of Consciousness

Question 1

Red Flag Conditions for altered LOC:

Answer 1

Adrenal insufficiency, epilepsy, head injury, hyperglycaemia, hypoglycaemia, overdose, cardiac rhythm disturbance, stroke/TIA, SAH, Sepsis

Question 2

TLOC is:

Answer 2

A transient loss of consciousness. A spontaneous LOC with a complete recovery and no residual neurological deficit.

Question 3

Important history taking questions:

Answer 3

Posture immediatley prior, prodromal symptoms, appearance (eyes, coloure..), movement during the event (type and duration), tongue biting, injury, duration, confusion during recovery, weakness down one side during recovery, previous episodes.

Question 4

ECG Red Flags:

Answer 4

New conduction abnormalities (complete RBBB LBBB, or heart blocks), prolonged or shortened QTc, ST segment or T wave abnormalities (brugada syndrome, abnormal t wave inversion), pathological Q wave, paced, inappropriate persistent bradycardia, ventricular arrythmia, ventricular pre excitation syndrome (WPW), sustained atrial arrythmia, left or right ventricular hypertrophy.

Question 5

Uncomplicated Faint: (uncomplicated vasoagal syncope)

Answer 5

Nil alternative diagnosis is suggested, and they 3 P’s are present.
Posture - prolonged standing
Provoking - pain, medical, drugs, dehydration, alcohol, loss of fluids
Prodromal - sweating/warm prior to TLOC, dizzy, blurred vision, distortion of hearing.

Brief jerking may occur which can mimic an epileptic seizure. This would stop within seconds and normal brain circulation would restore.

Question 6

Situational Syncope:

Answer 6

Nil alternative diagnosis is suggested,
Clearly provoked by straining during micturition (often standing) or by coughing or swallowing.
During exercise (likely cardiac arrythmia)
Post excercise (likely vasovagal)

Question 7

Red Flags of TLOC:

Answer 7

New ECG abnormalities
Physical signs of heart failure
TLOC during exertion
Family hx of sudden death in under 40s
Inherited cardiac condition
New/unexplained breathlessness
Undiagnosed heart murmur
Over 65s with no prodromal symptoms

Question 8

Patients must legally notify DVLA if they have a TLOC whilst:

Answer 8

sitting or following coughing

Question 9

COMA is defined as:

Answer 9

GCS<8