Case 24 - Transient Loss Of Consciousness Flashcards
What are the differentials for a sudden collapse and loss of consciousness?
Vasovagal syncope Cardiogenic syncope Seizure Situational syncope e.g micturition or cough Carotid sinus syncope
What are the 3 ‘P’s of vasovagal syncope?
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
What is the pathophysiology of vasovagal syncope?
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
What is cardiogenic syncope?
Where syncope is accompanied by an arrhythmic cause e.g complete heart block
What is a stokes-Adams attack?
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
What are the different types of situational syncope?
Cough syncope - syncope after paroxysm of coughing
Effort syncope - syncope on exercise
Micturition syncope - syncope during or after micturition. Mostly men at night
What is carotid sinus syncope?
Where turning of the head or shaving can lead to brief loss of consciousness
What is epilepsy?
A disease where part of the brain has a recurrent tendency to spontaneous, intermittent abnormal electrical activity
People have recurrent and unpredictable seizures
What are the causes of epilepsy?
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
What are the preceding symptoms of an epileptic seizure?
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
What is a Jacksonian March?
Where jerking movements start in one muscle group and spread to others
This is typical of an epileptic seizure
What are the post ictal symptoms of an epileptic seizure
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
What is todds palsy?
Temporary weakness in the arms/legs after a focal seizure in the motor cortex which can last up to 2 days
What are the two classes of seizures?
Partial seizures - limited to one hemisphere of the brain, or a single lobe of the brain
Primary generalised seizures - involves entire cortex
What are the two types of partial seizure
Simple partial seizure - where patient remains conscious
Complex partial seizure - where patient has impaired consciousness during seizure
What is a secondary generalised seizure?
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
What are the different types of primary generalised seizures?
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’
What is status epilepticus?
How is it treated?
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
What is the mechanism of action of benzodiazepines?
Enhances the GABA inhibitory pathway
What investigations would you do in a patient with transient loss of consciousness?
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
Where should patients presenting with a 1st seizure be referred to?
Neurology
First seizure clinic
When would you start an epileptic patient on medication?
If the patient has more than 2 fits
Treat with one medication at a time ONLY
What advice would you give someone who has just been diagnosed with epilepsy?
Stop driving - inform the DVLA Avoid dangerous work or leisure activities Avoid swimming (alone especially) Take care when bathing to avoid risk of drowning
How would you treat a status epileptisus in the community?
Buccal midazolam
OR
Rectal diazepam
