Case 24 - Transient Loss Of Consciousness

Question 1

What are the differentials for a sudden collapse and loss of consciousness?

Answer 1

Vasovagal syncope 
Cardiogenic syncope 
Seizure 
Situational syncope e.g micturition or cough 
Carotid sinus syncope

Question 2

What are the 3 ‘P’s of vasovagal syncope?

Answer 2

Posture - prolonged standing
Provoking factors - evoked by strong emotion e.g, fear, pain
Prodromal symptoms - e.g, nausea, pallor, feeling hot and sweaty precede the episode

Question 3

What is the pathophysiology of vasovagal syncope?

Answer 3

Reflex bradycardia
Peripheral vasodilation
Leads to lack of cerebral blood supply
Patient becomes unconscious (roughly 2 mins)
Brief clonic jerking of the limbs may occur
Recovery is rapid afterwards

Question 4

What is cardiogenic syncope?

Answer 4

Where syncope is accompanied by an arrhythmic cause e.g complete heart block

Question 5

What is a stokes-Adams attack?

Answer 5

Transient arrhythmias (e.g, bradycardia due to complete hearblack) causes a decrease in cardiac output and loss of consciousness

Patient falls to ground often with no warning, and is pale with a slow or absent pulse. Recovery is within seconds

Question 6

What are the different types of situational syncope?

Answer 6

Cough syncope - syncope after paroxysm of coughing
Effort syncope - syncope on exercise
Micturition syncope - syncope during or after micturition. Mostly men at night

Question 7

What is carotid sinus syncope?

Answer 7

Where turning of the head or shaving can lead to brief loss of consciousness

Question 8

What is epilepsy?

Answer 8

A disease where part of the brain has a recurrent tendency to spontaneous, intermittent abnormal electrical activity

People have recurrent and unpredictable seizures

Question 9

What are the causes of epilepsy?

Answer 9

Idiopathic (2/3rds are unknown)
Structure cause - cortical scaring, space occupying lesion
Autoimmune cause - tuberous sclerosis, sarcoidosis, lupus
Non epileptic causes - trauma, stroke, haemorrhage
Metabolic disturbances - hypoxia, sodium/calcium/glucose imbalance

Question 10

What are the preceding symptoms of an epileptic seizure?

Answer 10

Aura symptoms - strange feeling in gut, feeling of deja vu, visual or olfactory symptoms

Prodomal symptoms lasting hours/days can rarely precede the seizure where the patient notices a change in mood/behaviour

Question 11

What is a Jacksonian March?

Answer 11

Where jerking movements start in one muscle group and spread to others

This is typical of an epileptic seizure

Question 12

What are the post ictal symptoms of an epileptic seizure

Answer 12

State of drowsiness, myalgia, headache and amnesia (can last up to 2-3 mins)
Sore tongue (due to biting during seizure)
Temporary weakness in arms/legs which can last up to 2 days

Question 13

What is todds palsy?

Answer 13

Temporary weakness in the arms/legs after a focal seizure in the motor cortex which can last up to 2 days

Question 14

What are the two classes of seizures?

Answer 14

Partial seizures - limited to one hemisphere of the brain, or a single lobe of the brain

Primary generalised seizures - involves entire cortex

Question 15

What are the two types of partial seizure

Answer 15

Simple partial seizure - where patient remains conscious

Complex partial seizure - where patient has impaired consciousness during seizure

Question 16

What is a secondary generalised seizure?

Answer 16

Where a seizure starts off as a partial seizure (in one part of the brain) and then spreads to the entire cortex becoming a generalised seizure

Question 17

What are the different types of primary generalised seizures?

Answer 17

Tonic-clonic seizures - where patient muscles become stiff tense up and then the muscles start to jerk
Atonic seizures - where there is a sudden loss of muscle tone and muscles become floppy
Myoclonic seizures - short muscle twitches but may in a short amount of time
Absence seizures - where patients lose consciousness and then quickly regain consciousness. The only outward sign being that the patient is ‘spaced out’

Question 18

What is status epilepticus?

How is it treated?

Answer 18

If a seizure lasts longer than 5 mins
Or if it is ongoing without returning to normal
Usually tonic-clonic type seizure

This is a medical emergency - requires benzodiazepines
Treated with IV lorazepam

Question 19

What is the mechanism of action of benzodiazepines?

Answer 19

Enhances the GABA inhibitory pathway

Question 20

What investigations would you do in a patient with transient loss of consciousness?

Answer 20

Full cardiovascular and neurological exam
Bloods - FBC, U&Es, calcium, glucose, troponin
ECG
EEG
Lying and standing BP
CT head for first seizure - to check for brain abnormalities
Echocardiogram if heart involvement suspected

Question 21

Where should patients presenting with a 1st seizure be referred to?

Answer 21

Neurology

First seizure clinic

Question 22

When would you start an epileptic patient on medication?

Answer 22

If the patient has more than 2 fits

Treat with one medication at a time ONLY

Question 23

What advice would you give someone who has just been diagnosed with epilepsy?

Answer 23

Stop driving - inform the DVLA
Avoid dangerous work or leisure activities 
Avoid swimming (alone especially)
Take care when bathing to avoid risk of drowning

Question 24

How would you treat a status epileptisus in the community?

Answer 24

Buccal midazolam
OR
Rectal diazepam

Question 25

What is the treatment for simple and complex focal seizure with or without secondary generalisation?

Answer 25

1st line - Carbamazepine OR lamotrigine

Question 26

What is the treatment for tonic-clonic generalised seizures?

Answer 26

1st line - Sodium valproate

2nd line - lamotrigine

Question 27

What is the treatment for absence seizures?

Answer 27

1st line - sodium valproate OR ethosuximide

2nd line - lamotrigine

Question 28

What is the treatment for myoclonic seizures

Answer 28

1st line - sodium valproate

2nd line - topiramate

Question 29

What are the important considerations for treatment women with epilepsy?

Answer 29

Women of child bearing age should avoid sodium valproate as it can be tertrogenic (use lamotrigine instead)
Many antiepileptic drugs can interfere with the combined contraceptive pill - advice progesterone only pills or progesterone only implant, also advice alternative contraception e.g, condoms

Question 30

What are the rules with epilepsy and driving?

Answer 30

If a driver has a seizure they must stop driving immediately and inform the DVLA
Patients who have first unprovoked epileptic seizure must not drive for 6 months, and then driving may be resumed, provided the patient has been assessed by a specialist as fit to drive
Patients with established epilepsy may drive as long as they have been seizure free for at least a year
DVLA also advises patients should not drive during medication changes or withdrawal of treatment for 6 months

Question 31

What is a non epileptic attack disorder?

Answer 31

Loss of consciousness but with no electrical abnormality
Patient can be conscious with bilateral limb shaking
Patient has characteristic back arching or pelvic thrust movement