Transient Loss Of Consciousness

Question 0

What trend does TLOC show as you get older

Answer 0

It is more common amongst the older

Question 1

Describe transient loss of consciousness

Answer 1

Spontaneous Loss of consciousness with complete recovery

Includes blackout and syncope

Question 2

What clinical challenges does TLOC pose

Answer 2

Main witness unconscious 
Eyewitness accounts unreliable 
Unpredictable 
Occasionally life threatening 
Driving restrictions

Question 3

What are the risks of TLOC

Answer 3

Can be the first symptom of fatal arrhythmia

Can lead to sudden death (most common death in America &similar in Europe )

May result in injuries to patients or others as result of accidents

Question 4

What are the differential diagnoses for TLOC

Answer 4

Neurally mediated syncope 
              Vasovagal 
               Situational (cough/micturation) 
                 Carotid sinus hypersensitivity 
Cardiac syncope 
Neurological 
                Epilepsy 
                  Sleep disorders 
                     Raised ICP
Orthostatic hypotension 
                Drugs 
                 Neurodegenerative disorders 
Metabolic disorders
Psychogenic non epileptic seizures

Question 5

What are the four aspects of history taking for TLOC

Answer 5

What happened before the attack?
What happened during the attack ? (Eyewitnesses)
What happened after the attack?
How frequent are the attacks?

Question 6

Important history taking features before the attack

Answer 6

Any warnings or auras?
Does anything provoke the attacks?
Any associated symptoms?
Can the attacks be prevented?
In what circumstance did the attacks occur?

Question 7

Important history taking features during the attacks?

Answer 7

Was consciousness actually lost
Duration
Change in complexion 
Verbal/ tactile responsiveness 
Movements 
Injuries 
Pulse 
Any injuries sustained?

Question 8

What are the important history feature to ascertain after an attack?

Answer 8

Recovery (rapid or prolonged)?
Confused or sleepy?
The duration?
How much does the patient remember 
Muscle pain( debatable)

Question 9

How common is Vasovagal syncope?

Answer 9

0. 5% of the population per year (women>men)

1: 200 a&e referrals (75000)

Question 10

Describe common features of simple syncope

Answer 10

Convulsive movements common
Lack of post-ictal confusion
Hearing people around you before you can respond is common
Reccurance of blackout on regaining upright posture

Question 11

Describe micturation syncope

Answer 11

Syncope after or during urination
Often when men have a large prostate 
Tensing to urinate causes stimulation of Vagal nerve 
Slows down heart 
Bradycardia 
Pelvic venous plexus has a role

Question 12

Define cardiac syncope

Answer 12

Temporary but sudden reeducation in blood supply and hence oxygen to the brain as a result of cardiovascular conditions

Question 13

Describe the mechanisms for cardiac syncope

Answer 13

Temporary but sudden reduction in blood supply triggers syncope, caused by either vasodilation (bradycardia), hypotension (tachycardia) or arrhythmia (valvular disease)

Onset is relatively rapid and recovery from LOC is spontaneous, complete and usually prompt

Question 14

Describe the main clinical features of epilepsy (history)

Answer 14

Description of an aura
Brief
Prolonged post ictal confusion
Head Turning or posturing of body
Stiffening of body and myoclonus jerking
Abnormal behavior of which patients do not remember
Severe tongue biting

Question 15

Name four features useful in differential diagnosis if NEAD from epilepsy

Answer 15

Scant description from patient
Frequent or long seizures
Different types of seizures
Crying during recovery

Question 16

4 common features of NEAD

Answer 16

Gradual onset
Sinusoidal and asynchronous arm and leg movements
Prolonged Antonia, rhythmic pelvic thrusting, side to side head movements
Post ictal crying , high anxiety in carers