Transient Loss of Consciousness Flashcards by James Turner

What are the 3 causes / categories of syncope?

Reflex syncope / “vasovagal”
Orthostatic hypotension
Cardiogenic syncope

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What types of seizures are there?

Focal / “partial”
1. without impairement of consciousness “simple partial”
2. with impairement of consciousness “complex partial”
Generalized
- Tonic-clonic “grand mal”
- Abscence seizures “petit mal”
- Myoclonic
- Atonic
- Infantile spasms

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What can look like epilepsy but isn’t?

Syncope (various kinds)
Non-epileptic attack disorder
- Requires psychotherapy
- Characteristic pelvic thrusting
- Slumping attack (looks like syncope)
- Lack of post-ictal confusion (sometimes, not always)
- See later card

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What is the definition of syncope?

Loss of consciousness
Which is transient
And caused by global hypoperfusion (as opposed to focal e.g. TIA)
- Rapid onset
- Short duration
- Spontaneous / complete recovery

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What might a patient experience before an episode of syncope?

There may be a trigger
- seeing blood (vasovagal)
- tight shirt collar (carotid sinus)
- post-exercise (situational)
- position change (orthostatic hypotension)
Prodromal symptoms / warnings e.g. in vasovagal syncope:
- visual changes
  - loss
  - dimming
- sweating
- light-headedness
- tinnitus
- nausea
- limb weakness
Can be remembered as 3 Ps: Position, provoking, prodrome

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What characteristics do patients with syncope exhibit during an episode?

Motor: flaccidity (hypoperfusion) or jerking limbs
Duration: generally less than a minute / <30 seconds
Colour: patients can go blue (suggesting cardiogenic cause) or pale

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What happens to patients after an episode of syncope?

Full recovery in under a minute (in seizures there is often post-ictal confusion)
May have relieving factors e.g. orthostatic hypotension; lying back down

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What are the 3 types of reflex / neurally mediated syncope?

What should you ask about?

What investigations are there to differentiate?

Vasovagal
- ‘simple faint’
- most common type of syncope
- common in young people
- often after an emotional response
  - fear, anxiety or disgust
- may also happen due to prolonged standing.
Situational
- syncope occurs consistently after a specific trigger e.g:
  - Post-micturition (the most common
  - Post-cough
  - Post-swallow
  - Post-defecation
  - Post-prandial
  - Post-exercise (note - during exercise is more alarming for cardiac cause)
Carotid sinus
- syncope after mechanical manipulation of the carotid sinus
- can happen accidentally whilst shaving, wearing a tight shirt collar or even head movement

Ask about:

triggers
warning symptoms
position

Investigate with

full history
a tilt-table test
lying - standing BP
Carotid sinus massage (requires specialist!!)

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What is orthostatic hypotension?

What should you ask about?

What are the investigations for it?

Unsteadiness or LOC on standing from lying in those with inadequate vasomotor reflexes.
It is defined as a fall in systolic BP of 20mmHg+ or a fall of diastolic BP by 10mmHg+ when an individual assumes a standing position
or a similar fall in BP within 3 minutes of upright tilt-table testing to at least 60°

Ask about:

warning symptoms / prodrome (may be prolonged in delayed postural syncope - a drop in BP that occurs after 3 minutes not at once)
position
drug history
- diuretics
- alcohol
- TCA
- anti-hypertensive medications
- anti-psychotics
cause for hypovolaemia (check GI bleed)
PMH
- DM
- uraemia
- spinal cord lesions

Investigate with

a tilt-table test
lying - standing BP

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What are the 4 main causes of orthostatic hypotension?

Secondary to drugs
- diuretics
- alcohol
- TCA
- anti-hypertensive medications
- anti-psychotics
Hypovolaemia
- check sinister underlying cause e.g. GI bleed
Primary ANS failure
- PD
- LB Dementia
Secondary ANS failure
- DM
- Uraemia
- Spinal cord lesions

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What are the cardiac causes of syncope?

Arrythmias
1. Bradyarrythmias (more likely)
  - sick sinus syndrome
  - 2nd degree heart block
  - 3rd degree heart block
2. Tachyarrythmias
  - SVT
    - Atrial flutter
    - Atrial fibrillation
    - Junctional
  - Ventricular (most likely out of the tachyarrythmias)
Structural ie outflow tract obstruction
- Valvular (AS)
- Cardiomyopathy (HOCM)
- Cardiac mass (atrial myxoma)
- Pericardial disease (constrictive pericarditis)
- Non-cardiac causes
  - PE
  - Aortic dissection

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What questions should you ask if you suspect cardiac cause of syncope?

FH of sudden death. Omitting this may miss a potentially fatal disease such as a familial channelopathy (e.g. long QT syndrome, Brugada syndrome) or cardiomyopathy (e.g. hypertrophic cardiomyopathy) which requires treatment
Cardiac symptoms (breathlessness, chest pain, oedema)
Prodrome (lack of this in cardiogenic syncope)
Onset around exercise (during is more worrying)
PMH of any heart problems, MI, pacemakers
DH including diuretics

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What investigations should be done for a patient with suspected cardiogenic syncope?

ECG – looking for:
- Ischaemic heart disease – pathological q-waves
- Long QT interval
- Wolff-Parkinson-White syndrome
Longer term ECG monitoring- to capture an association between syncope and the arrhythmia (this is the only way to definitively diagnose arrhythmic syncope)
- Ambulatory ECG monitoring
- External and implantable loop recorders
Echocardiography – looking for:
- Heart failure
- Cardiomyopathies
- Valvular disease
- Non-cardiac disease – e.g. pulmonary hypertension

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An absence of prodromal symptoms makes you more likely to consider this as a cause of TLoC

cardiogenic syncope

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What are the 5 Ps and Cs to remember questions in a syncope vs seizure history?

5 Ps:

Precipitant (vasovagal)
Prodrome (orthostatic, vasovagal, absence of → cardiogenic)
Position (orthostatic)
Palpitations (cardiogenic)
Post-event phenomena (confusion/disorientation is more common after epileptic seizures)

5 Cs

Colour (blue is more likely transient loss of respiratory muscle action in a tonic seizure, pale more likely systemic hypoperfusion ie syncope)
Convulsions (happens in both syncope and seizures but tonic phase is characteristic)
Continence (incontinence is more likely in seizures)
Cardiac problems (points to cardiogenic syncope)
Cardiac death family history (cardiogenic syncope)

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What kind of prodromal symptoms are more likely before an epileptic fit?

Most commonly found in focal (partial) seizures without loss of consciousness (simple):

déjà vu
strange smells
strange tastes
strange feeling
intense joy / fear
tingling in arms and legs
rising feeling in the belly

What defines a focal seizure without loss of consciousness/awareness?

“simple partial”

Awareness is unimpaired
Focal symptoms e.g.
- stiffness / twitcing in limbs
- rising in belly
- deja vu
- strange smells
- intense emotions
- localising features to certain lobes (see separate card)
no post-ictal symptoms
can spread to become generalised (which is then called secondary tonic-clonic)
- therefore, these seizures are sometimes called ‘warnings’ or ‘auras’

What defines a focal seizure with loss of consciousness/awareness?

“complex partial”

Patient has a loss of awareness +/- consciousness
- e.g. they may have their eyes open but be unresponsive
Can follow“simple” focal seizure
Most commonly the temporal lobe
- post-ictal confusion makes temporal involvement more likely
Random body movements, characteristically:
- lip-smacking
- rubbing hands
- random noises
- fiddling
- picking clothes
- moving arms
Patient will have no memory of it

What defines a tonic-clonic seizure?

“grand-mal”

It is a generalized motor seizure: electronic activity is spread all over the brain, and movements are involved
Loss of consciousness
+/- Tonic phase - during which patient goes stiff / rigid / may fall to floor
+/- Clonic phase - during which
- patient’s limbs jerk
- incontinence
- tongue biting
- difficulty breathing
  - can make them blue
Post-ictal drowsiness / confusion

What defines an absence seizure?

“petit-mal”

Generalised seizure type
Childhood onset
Presents with
- “Day-dreaming look”
- eylid fluttering
- pausing in the middle of speaking, then picking up where they left off
Usually short duration (10secs)

What defines a myoclonic seizure?

Generalized seizure type
“movement” of “muscle”:
- a spasm or twitch or jerk
- one part of body or whole body
Often soon after waking
Conscious / aware throughout
Often very short duration (5 secs)

What are some provoking causes for seizures?

(the 1/3 that aren’t idiopathic!)

Consider NEAD (non-epileptic attack disorder)
Structural:
- Stroke
- SOL
- Cortical scarring
- febrile convulsions
Provoking causes:
- Withdrawal
  - alcohol
  - benzos
- Infection
  - meningitis
  - encephalitis
- Raised ICP
- Drugs
  - Cocaine
  - TCAs
- haemorrhage
- liver disease
Metabolic:
- Hypoxia
- ↑↓Na+
- ↓Ca2+
- ↓glucose

What are some localizing features of focal seizures?

ie. which part of the brain will produce which symptoms?

Temporal Lobe (most common in focal seizures):

automatisms:
- Primative oral - lip smacking, random noises
- Primative manual - grabbing, hand rubbing, fiddling, picking at clothes, moving arms
dysphasia
hallucinations
- smell
- taste
- sound
deja vu / jamias vu
emotional disturbance
- anger
- de-realisation
- anxiety
- panic / terror

Frontal Lobe:

subtle behaviour changes
dysphagia / speech arrest
Motor:
- peddling
- post-ictal Todd’s palsy = weakness 24hrs after seizure

Parietal Lobe:

Sensory disturbances
- tingling
- numbness
- pain (rare
Motor (if spread to pre-central gyrus)

Occipital Lobe:

Visual phenomena
- stripes
- dots
- flashes

What is first-line AEDs for epilepsy in a woman of childbearing age?

Lamotrigine

What are 5 common AEDs and what types of seizures are they used in?

* Sodium valproate * first line for generalised/absence seizures * Carbemazepine, first line for: * focal seizures with + w/out secondary generalisation * primary generalised seizures * Lamotrigine * Seizure control in pregnancy / women of childbearing age * Phenytoin * status epilepticus where benzos aren't working * last-line seizure frequency control (others are preferred) * Topiramate * generalised or focal

What are the common counselling points for carbamazepine?

* Aim: reduce seizure frequency * Warn: * signs of severe hypersensitivity: * Blood toxicity: rashes, bruises, bleeding, ulcers, raised temperature * Liver toxicity: reduced appetite / abdo pain * contraception: * Some types may reduce the effectiveness of various hormonal contracepton types e.g. implant, patch, progestogen-only pill (the mini pill) * an alternative contraceptive method is recommended. * pregnancy: not advised

What are the common counselling points for sodium valproate?

* Aim: reduce frequency of seizures * Side effects: GI: * tummy upset * indigestion * can be improved by taking it with food * seek urgent medical attention if hypersensitivity symptoms occur (see carbamazepine) * Pregnancy: AVOID, see specialist (+folic acid)

What are the adverse effects of AEDs?

* Rare and serious: * Rash (Steven Johnson Syndrome - flu like symptoms progress to blistering red / purple rash) *carbemazepine, phenytoin* * Bone marrow suppression *carbemazepine* * Hepatic toxicity *valproate* * Neurotoxic * Dizziness * Incoordination * Drowsiness etc. * Metabolic * Weight gain *valproate* * Weight loss *topiramate* * Reproductive * Teratogenic * POS * Erectile dysfunction

Which AEDs are tetrogenic?

Sodium valproate, topiramate and carbamazepine

What is NEAD?

Non-Epileptic Attack Disorder * episodic disturbances of normal function and control that superficially resemble epileptic attacks but are **not** caused by **epileptic activity** in the brain and are thought to have a **psychological basis** * **Treatment** is not EADs, but **psychotherapy**

What are the defining features of an attack of NEAD?

* Eyes closed, difficult to open * Can be **aware** of what’s happening but may be **unable to respond** * Timing: * Attack tends to last **longer** * **Different lengths** each time - *epileptic seizures are stereotyped*, non-epileptic seizures are less predictable * Movements: * **Head** moves from **side to side** * **Pelvic thrusting** * **Or, slumping** (looks like syncope) * Otherwise can be very similar to epilepsy, requires specialist review

What are some risk factors for developing epilepsy?

* Febrile convulsions as a child * FH of epilepsy * Developmental problems * Low birth weight

What are some common **triggers** for epilepsy?

* Not taking epilepsy medicine as prescribed. * Feeling tired and not sleeping well. * Stress. * Alcohol and recreational drugs. * Flashing or flickering lights. * Monthly periods. * Missing meals. * Having an illness which causes a high temperature

How should you manage a patient with new-onset seizures?

* Refer to a neurologist for a consultation within 2 weeks * referral letter should include a detailed description of the seizure from a first-hand witness (ideally) * Advise patient not to drive and to avoid potentially dangerous work or leisure activities. * In particular, they should avoid **swimming**, and take care when **bathing** to avoid the risk of drowning (shower over bath) * Family: if they have another seizure: * How to manage it * Record details of it * Go to GP

1. When should you be worried about status epilepticus? 2. What should the patient's family do?

1. When a seizure has gone on for 5 minutes or more, or they have had 3 in an hour. 2. Call 999 and get patient to hospital. First aid for seizure.

What are the DVLA guidelines on driving with epilepsy?

* For normal drivers, you must **tell the DVLA** * **Not drive for 12 months** after your last seizure

Name some differentials for tLOC with jerking / twitching

1. Epilepsy 2. NEAD 3. Syncope 4. Metabolic * sepsis * type 2 respiratory failure * hypoglycaemia 5. Drug-related * withdrawal e.g. alcohol * overdose 6. Encephalopathy * e.g. benzo induced coma * encephalitis * malignant hypertension * eclampsia

What investigations are important in assessing a seizure patient to rule out organic caused of seizure?

1. History and Collateral History 2. FBC (evidence of systemic or CNS infection 3. Blood glucose (hypoglycaemia) 4. Electrolyte panel (low or high Na+, low Ca2+, uraemia) 5. EEG (but false negatives and positives) 6. CT / MRI head if SOL supsected