Collapse Flashcards
Differential Diagnosis of Collapse
1- Epilepsy 2- Syncope 3- Psychogenic Attacks 4- TIA / stroke 5- Migraine 6- narcolepsy 7- Hypoglycaemia 8- Hypersomnolence/OSA 9- Infection 10- Inner ear Pathology / BPPV
What are the 3 types of Syncope
1- Neurally mediated reflex
- vasovagal : tunnel vision / lightheaded , brief
- carotid sinus syncope: stimulated baroreceptors causing bradycardia& decrease BP
- situational syncope : cough or micturition , giving blood
- Valsalva : causes drop in bP
2- Cardiac
- arrhythmias : heart block , tachycardia , decrease in CO
- Valvular disease
- Cardiomyopathies
- Shunts
3- Perfusion
- Orthostatic Hypertension
- Hypovolaemia
- Autonomic Failure
What types of Psychogenic attacks can cause collapse
1- Panic attacks / hyperventilation
2- night terrors
3- breath holding
4- Non-epileptical dissociative/functional event
How to Diagnose Blackouts
1- History
- any witnesses before , during or after ( usually get good history for before and after )
2- Examination
- CVS : HR , BP
- General
- Neurological
3- Investigations
- ECG / Holter monitor
- Carotid sinus massage
- tilt table
- ECHO
- MRI head
- EEG
61 yr man , active went to gym in the morning.
- briefly light headed
- woke in casualty dazed , injured face , bitten side of tongue , not incontinent of urine
- admitted ; sore but oriented
PMH : Hypertension 5 years (enalapril) , uncomplicated anteroseptal MI 2 years ago
Examination normal
ECG : Prolongation of PR interval , right bundle branch block , left anterior fascicular block = Trifasicular block
What is the likely Diagnosis ?
What is the treatment ?
Cardiac Syncope
Treatment : Pace maker
What has to be done for all unexplained blackouts
ECG to rule out Cardiac syncope
When to consider Cardiac Syncope
1- Treatment resistant epilepsy
2- Sleep-related seizures
3- normal EEG
Vasovagal vs Cardiac syncope presentation
Vasovagal Trigger : Common prodrome: common ( nausea) onset: gradual Fatigue : minutes to hours
Cardiac Trigger: uncommon prodrome : uncommon or brief Onset: sudden Fatigue : none
What are hints it could be Cardiac syncope ( risk factors )
Syncope with heart disease
- previous MI
- congestive heart failure
- abnormal ECG
16 year old girl collapsed while swimming
Prolonged QT interval
What is the diagnosis?
What is the treatment
Prolonged QT is a risk factor for Torsades de pointes
Treatment : Magnesium sulphate
Young female collapsed while swimming is usually due to what ?
Long QT syndrome due to torsades de pointes
27 yr man with nocturnal seizures
- assaulted 2019 with metal pipe to front of head & lost consciousness
- episodes for years but worse after injury
- going and coming out of sleep
- unable to move
- sense of dread or nearby presence
- breathing becomes shallow
- tired next day and has headache
Girlfriend states
- man is moaning
- jerks a bit
- Lucid and can recall seizures
- not much snoring
- heavy alcohol past and occasional smoker
FMH : similar problems
What is the likely diagnosis
a) Dissociative/non-epileptic attack
b) Frontal lobe epilepsy with nocturnal seizures
c) Narcolepsy
d) obstructive sleep apnoea
e) sleep paralysis
Sleep paralysis
What is sleep paralysis
Period of inability to voluntarily move either Hypnagogic ( at sleep onset ) or Hypnapompic ( upon waking up or in morning )
Sleep paralysis could be associated with what conditions
Nacrolepsy or Cataplexy syndrome
What exacerbates Sleep paralysis
Stress, excessive sleepiness , irregular sleep/wake cycle , jet lag
Presentation of Sleep paralysis
1- Isolated or frequent episodes
2- Associated with hallucinatory experiences
- sense presence
- pressure on chest with SOB or suffocation
- Floating or Flying out of body experience
What is the cause of Sleep Paralysis
Dissociated manifesto of REM sleep
When Asleep during REM stage the body is paralyzed with exception of eye muscles. If suddenly aroused while in middle of REM , REM atonia ( sleep paralysis ) could happen before it’s switched off and you are awake
What diseases can cause REM disorders
Parkinson’s disease
15 yr girl with marked hypersomnolence after H1N1 vaccination
- previously fit and well
- Seasonal flu and swine vaccination 2015
- Following spring, loses awareness multiple times during the day , nocturnal sleep not disrupted, legs giving away and occasionally dropping objects
- Emotionally distraught , devastating affect on day to day function
- no medication
Examination normal
MRI brain normal
Overnight SaO2 normal
EEG shows slowing during wakefulness and increased fast activity during REM sleep
What is likely diagnosis
a) Dissociative/non-epileptic attack
b) Frontal love epilepsy
c) Kleine-Levin syndrome
d) Narcolepsy
e) OSA
f) REM sleep behavioural disorder
d) Narcolepsy
What is Narcolepsy & what is the Cause ( Different types )
One of the primary hypersomnia syndromes.
excessive sleepiness associated with cataplexy and other REM sleep phenomena ( sleep paralysis , hypnagogic hallucinations )
Cause:
Type 1 : hypocretin deficiency , always associated with cataplexy
Type 2 : 2+ SOREMPS on multiple sleep latency tests
Idiopathic hypersomnia : less than 2 SOREMPS
What is hypersomnolence
excessive sleepiness
What is cataplexy
sudden loss of muscle tone , causing weakness
What is SOREMPS
Sleep onset REM periods, REM periods that occur within 15 minutes of sleep onset
What is Klein-Levin Syndrome, presentation , onset , treatment , common in who?
Rare , usually in teenage years and more in males
Presents :
- persistent episodic hypersomnia
- cognitive or mood changes
- hyrerphagia
- hyper sexuality
Recurrent episodes > 10 years , individual episodes last from 1 week to 1 month
Symptoms spontaneously resolve
Onset usually follow viral infection
What is Obstructive Sleep Apnoea , presentation , risk factors and associated risk of developing conditions ?
Excessive daytime somnolence - falls asleep a lot
Present :
- wakes up gasping , choking or with sore/dry throat
- poor memory and concentration
- headaches
- nocturne
Associated with increased risk of of hypertension , stroke and CVS disease
Risk factors : Age, obesity , Males, retrognathia
What is retrognathia
Small chin
33 yr left-handed women with shaking episodes since age of 24
- up to 3 times a week
- occurs when falling asleep , especially if stressed
- left head, arm and leg aching , stiff, shaking for 10-30s
- appears awake but not fully , chewing side of mouth
- few minutes to recover
MRI brain normal
Inter-ictal EEG normal
ECG normal
Major events
- every 2-3 months
- especially if stressed , loss of consciousness and awareness
- feels head turn to one side
- wake up with people over her
- tongue bitten in middle
- incontinent of urine
What is the likely diagnosis
a) cardiac syncope
b) dissociative/functional disorder
c) epileptic seizure
d) panic disorder
e) vasovagal syncope
C) epileptic seizure
33 yr left-handed women with shaking episodes since age of 24
- up to 3 times a week
- occurs when falling asleep , especially if stressed
- left head, arm and leg aching , stiff, shaking for 10-30s
- eyes closed
- few minutes to recover
MRI brain normal
Inter-ictal EEG normal
ECG normal
Major events - every 2-3 months - especially if stressed , loss of consciousness and awareness - head shakes from side to side - back arching shout out - wake up with people over her - tongue bitten on tip - incontinent of urine - injured in past - on lamotrigine trial but no changes
What is the likely diagnosis
a) cardiac syncope
b) dissociative/functional disorder
c) epileptic seizure
d) panic disorder
e) vasovagal syncope
B) dissociate / functional disorder
Epileptic seizure Vs Psychogenic non-epileptic
Epileptic
- Onset : rarely situational or gradual
- stimuli : rarely
- purposeful movement : rarely
- Opisthotonus: very rare
- Bite tongue tip : rare
- Bite tongue middle : common
- Prolonged octal atonia : very rare
- Vocalization : very rare
- Reactivity: very rare
- Fluctuating in motor activity: very rare
- Asynchronous limb -movement : common
- eyelids commonly open
- mouth usually closed
- uncommon for convulsion to be > 2 minutes
- Cyanosis common
- incontinence may happen
Psychogenic -Onset : Situational and -gradual common -stimuli : occasionally -purposeful movement : occasionally -Opisthotonus : occasionally -Bite tongue tip : Occasional -Bite tongue middle : very rare -Prolonged octal atonia : occasional -Vocalization: occasional -Reactivity: occasional -Fluctuating in motor activity: common -Asynchronous limb movement : rare -Suttering /crying/ whispering : common closed eyelids & mouth -Convulsion > 2 minutes common - incontinence may happen
what is Opisthotonus
Back arching
What can mimic NEAD ( non epileptic attack disorder ) and give presentation & how to differentiate
Frontal lobe epilepsy
- patient remains conscious and have strange behaviour
- eye lids open
- Ictal grasping feature
- pelvic thrusting
- vocalization common
- Arise from sleep, brief
- quick tonic posturing
- can be hyper motor but less dramatic and disorganized than NEAD
Differentiate : Video EEG
- Normal octal EEG is common in FLE so Video EEG is needed
