Blackouts

Question 1

How can you differentiate between a fall an a collapse?

Answer 1

Ask the patient if they remember falling and if they remember hitting the ground. If yes, it is a fall. If no, it is a collapse.

Question 2

What features suggest syncope?

Answer 2

Triggering factor, distinct prodrome, ‘convulsion’ after LoC and less than 15 seconds, short duration, quick recovery, ongoing lethargy but no confusion.

Question 3

What features suggest seizures?

Answer 3

Aura, automatisms, convulsions at onset of LoC, longer duration, post-ictal phase, tongue biting, incontinence.

Question 4

What are the four big causes of blackouts and hoe do they typically present?

Answer 4

1. Syncope - light headedness, nausea, tunnel vision
2. Seizure - fit, tongue/urine, post-ictal
3. Stroke/TIA - unilateral weakness/sensory loss, speech, face
4. Cardiogenic - palpitations

Question 5

What is the pathophysiology of vasovagal syncope?

Answer 5

Reflex bradycardia and peripheral vasodilation provoked by emotion, pain, or standing too long.

Question 6

What symptoms typically precede vasovagal syncope?

Answer 6

Nausea, pallor, sweating, narrowing of visual fields.

Question 7

How long does vasovagal syncope last and how quickly do people recover?

Answer 7

1. <2 minutes

2. Rapid recovery

Question 8

What is this a presentation of?

Vasovagal syncope symptoms but brought on by exercise (cardiac), or during/after urination (mostly in men, at night).

Answer 8

Situational syncope - cough/effort/micturition

Question 9

What is this describing?
Hypersensitive baroreceptors cause excessive reflex bradycardia +/- vasodilation on minimal stimulation (e.g. head turning/shaving).

Answer 9

Carotid sinus syncope

Question 10

What is this a presentation of?
Attacks when asleep/lying down, aura, identifiable triggers, altered breathing, cyanosis, tonic-clonic movements, incontinence of urine, tongue-biting, prolonged post-ictal drowsiness, confusion, amnesia.

Answer 10

Epilepsy

Question 11

What is this a presentation of?

Unilateral weakness, sensory loss, slurred speech, facial asymmetry.

Answer 11

Stroke/TIA

Question 12

What is this a presentation of?
Patient falls to the ground often with no warning except for palpitations, injuries common, pale, slow/absent pulse, recovery in seconds.

Answer 12

Stokes-Adams attack

Question 13

What is the cause of a Stokes-Adams attack?

Answer 13

Transient arrhythmias cause reduction in CO and LoC.

Question 14

What is this a presentation of?

Tremor, hunger, perspiration, rare in non-diabetics.

Answer 14

Hypoglycaemia

Question 15

What are the causes of hypoglycaemia?

Answer 15

Poorly controlled diabetes, alcohol, liver failure, adrenal insufficiency, insulinoma.

Question 16

What is this a presentation of?
Unsteadiness or LoC on standing from lying in those with inadequate vasomotor reflexes, elderly, autonomic neuropathy, antihypertensive medications, overdiuresis.

Answer 16

Orthostatic hypotension

Question 17

What is this a presentation of?

Hyperventilation, tremor, sweating, tachycardia, paraesthesia, light-headedness, no LoC.

Answer 17

Anxiety attack

Question 18

What is this a presentation of?

Sudden fall to the ground without LoC, mostly benign and due to leg weakness.

Answer 18

Drop attack

Question 19

What is this a presentation of?

Gradual onset, prolonged, abrupt termination, closed eyes, resistance to eye opening, dyssynchronous blackout.

Answer 19

Factitious blackout (Munchausen’s)

Question 20

What is it important to ask someone who has just had a blackout?

Answer 20

1. Lose awareness? Injury themselves? Stiff/floppy? Movements?
2. Incontinence? Complexion change? Tongue biting? Other symptoms?
3. How long? When did it start? More/less frequent? Anyone in family get them? History of birth injury/CNS infections?

Question 21

What should you ask about before a blackout?

Answer 21

1. Any warning? Aura/pre-syncope?
2. In what circumstances do attacks occur?
3. Can the patient prevent them?

Question 22

What should you ask about after a blackout?

Answer 22

1. How much does the patient remember?
2. Muscle ache?
3. Confusion/sleepiness?
4. Injuries sustained?

Question 23

What are the typical initial syncope investigations?

Answer 23

1. Cardiac assessment - ECG
2. Metabolic assessment - calcium, U&Es, magnesium, glucose
3. ABG, low PaO2 suggests hyperventilation