Case 24- LOC

Question 1

Ictal phases

Answer 1

When the seizure is occurring

1-3 minutes

Question 2

Post ictal phase

Answer 2

Confusion, altered consciousness
Residual neurological symptoms eg. Todd’s paralysis
Minutes to hours

Question 3

Provoked seizures

Answer 3

Secondary to acute conditions

Question 4

Unprovoked (epileptic) seizures

Answer 4

A condition of irregular electrical activity in the brain caused by hyperexcitability of neutrons

Question 5

Focal (partial) seizure

Answer 5

Develop from one hemisphere of the brain

Question 6

Generalised seizures

Answer 6

Develop from neurological networks in both cerebral hemispheres

Either generalised motor seizures (tonic-clonic, myoclonic etc.), or absence seizures (no muscle involvement)

Question 7

Tongue biting

Answer 7

Syncopal attack- tip of tongue

Seizure- lateral edges of tongue

Question 8

Investigations for a first seizure

Answer 8

History (collateral), A-E, 12 lead ECG, blood glucose, OBS, urine (infection?)
Bloods- FBC UE LFT CK (6 hours) prolactin (15 minutes after T-c) tox screen cultures
Imaging and specialist tests- CT head, lumbar puncture and CSF analysis EEG

Question 9

Commonest causes of reduced GCS

Answer 9

Hypomatraemia (may also see seizures)
Hypoxia
Hypoglycaemia

Question 10

Difference between syncope and seizure

Answer 10

May get muscle twitching in syncope, but post ictal confusion won’t be present (noticeable after a grand mal seizure), neither would bladder/bowel incontinence, may have pre epilepsy aura eg. Strange sensations, deja vu, smells etc.

Question 11

Features of syncope

Answer 11

Prodrome
Vasovagal- nausea, pallor, diaphoresis, light headed ness, hyperventilation
Orthostatic- light headed ness, nausea, dizziness
Cardiac- usually no prodrome, often sudden fall (unless palpitations or pain)

Rapid onset LOC, complete loss of muscle tone, spontaneous recovery, myoclonic movements are possible

Question 12

Pre syncopal symptoms (PPP) for vasovagal syncope

Answer 12

Position- stood up
Provocation- strong emotion, distress, dehydration, low BP etc.
Prodrome- light headedness, nausea etc.

If PPP not present, think cardiogenic syncope

Question 13

Important note

Answer 13

People with diagnosed epilepsy can have episodes of syncope eg. Vasovagal and cardiogenic syncope

Not always a seizure/ epilepsy related every time they lose consciousness

Question 14

Risks of seizure after being seizure free for a years

Answer 14

Inter current illness eg. UTI, chest infection
Missing medication
New medication interaction eg. Amitriptyline, tramadol
Alcohol excess/ binge
Recreational drugs
Metabolic disturbance eg, . Hyponatraemia, hypoglycaemia
Broken sleep, fatigue, jet lag
GI disturbance (impaired uptake and absorbency of AED)