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Medicine year 3 ANNA > Transient Loss of Consciousness > Flashcards

Transient Loss of Consciousness Flashcards

1
Q

What are the 3 causes / categories of syncope?

A
  1. Reflex syncope / “vasovagal”
  2. Orthostatic hypotension
  3. Cardiogenic syncope
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2
Q

What types of seizures are there?

A
  1. Focal / “partial”
    1. without impairement of consciousness “simple partial”
    2. with impairement of consciousness “complex partial”
  2. Generalized
    • Tonic-clonic “grand mal”
    • Abscence seizures “petit mal”
    • Myoclonic
    • Atonic
    • Infantile spasms
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3
Q

What can look like epilepsy but isn’t?

A
  1. Syncope (various kinds)
  2. 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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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
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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
  • Can be remembered as 3 Ps: Position, provoking, prodrome
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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
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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
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8
Q

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

What should you ask about?

What investigations are there to differentiate?

A
  1. 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.
  2. 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)
  3. 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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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
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10
Q

What are the 4 main causes of orthostatic hypotension?

A
  1. Secondary to drugs
    • diuretics
    • alcohol
    • TCA
    • anti-hypertensive medications
    • anti-psychotics
  2. Hypovolaemia
    • check sinister underlying cause e.g. GI bleed
  3. Primary ANS failure
    • PD
    • LB Dementia
  4. Secondary ANS failure
    • DM
    • Uraemia
    • Spinal cord lesions
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11
Q

What are the cardiac causes of syncope?

A
  1. 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)
  2. 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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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
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13
Q

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

A
  1. ECG – looking for:
    • Ischaemic heart disease – pathological q-waves
    • Long QT interval
    • Wolff-Parkinson-White syndrome
  2. 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
  3. Echocardiography – looking for:
    • Heart failure
    • Cardiomyopathies
    • Valvular disease
    • Non-cardiac disease – e.g. pulmonary hypertension
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14
Q

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

A

cardiogenic syncope

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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)
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16
Q

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

A

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
17
Q

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

“simple partial”

A
  • 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’
18
Q

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

“complex partial”

A
  • 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
19
Q

What defines a tonic-clonic seizure?

“grand-mal”

A
  • 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
20
Q

What defines an absence seizure?

“petit-mal”

A
  • 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)
21
Q

What defines a myoclonic seizure?

A
  • 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)
22
Q

What are some provoking causes for seizures?

(the 1/3 that aren’t idiopathic!)

A
  • 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
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
24
Q

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

A

Lamotrigine

25
Q

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

A
  • 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
26
Q

What are the common counselling points for carbamazepine?

A
  • 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
27
Q

What are the common counselling points for sodium valproate?

A
  • 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)
28
Q

What are the adverse effects of AEDs?

A
  • 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
29
Q

Which AEDs are tetrogenic?

A

Sodium valproate, topiramate and carbamazepine

30
Q

What is NEAD?

A

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
31
Q

What are the defining features of an attack of NEAD?

A
  • 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
32
Q

What are some risk factors for developing epilepsy?

A
  • Febrile convulsions as a child
  • FH of epilepsy
  • Developmental problems
  • Low birth weight
33
Q

What are some common triggers for epilepsy?

A
  • 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
34
Q

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

A
  • 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
35
Q
  1. When should you be worried about status epilepticus?
  2. What should the patient’s family do?
A
  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.
36
Q

What are the DVLA guidelines on driving with epilepsy?

A
  • For normal drivers, you must tell the DVLA
  • Not drive for 12 months after your last seizure
37
Q

Name some differentials for tLOC with jerking / twitching

A
  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
38
Q

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

A
  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

Medicine year 3 ANNA (30 decks)

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