Transient Loss of Consciousness Flashcards
1
Q
What are the 3 causes / categories of syncope?
A
- Reflex syncope / “vasovagal”
- Orthostatic hypotension
- Cardiogenic syncope
2
Q
What types of seizures are there?
A
- Focal / “partial”
- without impairement of consciousness “simple partial”
- with impairement of consciousness “complex partial”
- Generalized
- Tonic-clonic “grand mal”
- Abscence seizures “petit mal”
- Myoclonic
- Atonic
- Infantile spasms
3
Q
What can look like epilepsy but isn’t?
A
- 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
4
Q
What is the definition of syncope?
A
- 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
5
Q
What might a patient experience before an episode of syncope?
A
- 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
- visual changes
- Can be remembered as 3 Ps: Position, provoking, prodrome
6
Q
What characteristics do patients with syncope exhibit during an episode?
A
- Motor: flaccidity (hypoperfusion) or jerking limbs
- Duration: generally less than a minute / <30 seconds
- Colour: patients can go blue (suggesting cardiogenic cause) or pale
7
Q
What happens to patients after an episode of syncope?
A
- 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
8
Q
What are the 3 types of reflex / neurally mediated syncope?
What should you ask about?
What investigations are there to differentiate?
A
-
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)
- syncope occurs consistently after a specific trigger e.g:
-
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!!)
9
Q
What is orthostatic hypotension?
What should you ask about?
What are the investigations for it?
A
- 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
10
Q
What are the 4 main causes of orthostatic hypotension?
A
- 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
11
Q
What are the cardiac causes of syncope?
A
- Arrythmias
- Bradyarrythmias (more likely)
- sick sinus syndrome
- 2nd degree heart block
- 3rd degree heart block
- Tachyarrythmias
- SVT
- Atrial flutter
- Atrial fibrillation
- Junctional
- Ventricular (most likely out of the tachyarrythmias)
- SVT
- Bradyarrythmias (more likely)
- Structural ie outflow tract obstruction
- Valvular (AS)
- Cardiomyopathy (HOCM)
- Cardiac mass (atrial myxoma)
- Pericardial disease (constrictive pericarditis)
- Non-cardiac causes
- PE
- Aortic dissection
12
Q
What questions should you ask if you suspect cardiac cause of syncope?
A
- 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
13
Q
What investigations should be done for a patient with suspected cardiogenic syncope?
A
-
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
14
Q
An absence of prodromal symptoms makes you more likely to consider this as a cause of TLoC
A
cardiogenic syncope
15
Q
What are the 5 Ps and Cs to remember questions in a syncope vs seizure history?
A
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)
23
Q
What are some localizing features of focal seizures?
ie. which part of the brain will produce which symptoms?
A
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
