Falls & blackouts

Question 1

Outline vasovagal syncope

Answer 1

aka Neruocardiogenic syncope

• Reflex bradycardia +/- peripheral vasodilation [Low HR & BP]
  
  • Caused by stimulus ⇒ NTS activated ⇒ +parasym. (-symp)
• Occurs over seconds;
  
  1. Emotion/ pain/ fear/ standing for too long
  2. ⇒ Nausea, pallor, sweating & tunnel vision
  3. ⇒ Falls to ground, unconscious for 2min
     
     • Brief clonic jerking, incontinence
• Rapid recovery (unlike dysarhythmia)

Specific types

• Carotid sinus syncope - hypersensitive baroreceptors causing reflex bradycardia +/- vasodilation
• Situation syncope
  
  • Cough - after paroxysm of coughing
  • Effort - on exercise (cardiac origin)
  • Micturation - on/after micturation

Question 2

Define epilepsy and outline how it can cause a blackout

Answer 2

Epilepsy is a tendency for abnormal electrical activity causing seizures

1. Prodrome - hours/ days previous a ‘change’ is noticed
   
   • Aura - patient notices change
     
     • Strange feeling in the gut, deja vu, strange smells, flashing lights
     • Implies focal seizure from temporal lobe (normally)
2. Seizure occurs
3. Post-ictally
   
   • Headache, confusion, myalgia, sore tongue
   • Todd’s palsy - motor cortex seizure causing temp. weakness
   • Dysphasia following focal seizure in temporal lobe

Question 3

Outline Stokes-Adams attackes

Answer 3

Transient arrythmias causing low cardiac output & LOC

• Falls to the ground
  
  • No warning except palpitations
  • Pale
  • Slow/ absent pulse
• Recovery within seconds - flushes, pulse speeds up and consciousness regained

Question 4

Outline Drop attacks

Answer 4

Sudden weakness in legs - no warning, no LOC, no confusion after

Benign resolution after a few episodes

Question 5

Outline hypoglycaemia & blackouts

Answer 5

Tremor, hunger & perspiration herald light-headedness & LOC

Rare in non-diabetics

Question 6

Outline orthostatic hypotension & blackouts

Answer 6

Unsteadiness or LOC on standing from lying in those with inadequate vasomotor reflexes

• Elderly, autonomic neuropathy, antihypertensive medication, ocerdiuresis

Question 7

Outline Anxiety & blackouts

Answer 7

Hyperventilation, tremor, sweating, tachycardia

No LOC = panic attack

Question 8

Outline Factitious blackouts

Answer 8

Pseudoseizures - psychlogical defence mechanism?

Munchausen’s - fake.

Question 9

Outline all the differentials of a blackout

Answer 9

• Vasovagal syncope - reflex bradycardia +/- vasodilation
  
  • Normal neurocardiogenic
  • Situation syncope
  • Carotid sinus syncope
• Epilepsy - brain sensitivity to seizures
• Stokes-Adams - transient arrythmia
• Drop attacks - weak legs
• Hypoglycaemia - diabetics
• Orthostatic hypotension [postural hypotension] - standing up with poor vasomotor reflexes
• Anxiety
• Factitious - pseudoseizures, munchausen’s