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Transient loss of consciousness Flashcards

1
Q

What are the ‘big three’ for a differential diagnosis of TLOC?

A
  1. Epileptic seizure
  2. Syncope
  3. Psychogenic nonepilpetic seziure
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2
Q

Define a seizure

A

Clinical manfestation of abnormal and excessive discharge of cerebral neurones

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3
Q

Causes of a seizure

A

May be due to epilepsy, may be the first seizure, may be an acute symptomatic seizure

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4
Q

Define epilepsy

A

a tendency to experience recurrent unprovoked epileptic seizures

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5
Q

two important factors which cause different clinical manifestations of a seizure

A

where the seizure arises from

where the seizure spreads to

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6
Q

What is a focal onset of an epileptic seizure?

A
  • Simple, partial seziure [aura]
  • Complex partial seziures
  • Secondary generalized tonic clonic seziures [GTCS]

Structural cause

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7
Q

Focal onset is one, what is the other type of onset for ES? How do they present?

A

Generalized tonic clonic seizures [GTCS]
Moyclonic jerks
Absences

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8
Q

Causes of generalized onset seizures

A

Idiopathic/genetic cause
family history
Early morning seizures, worse with sleep deprivation or alcohol, photosensitivity

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9
Q

What does an absence seizure look like on an EEG?

A

slides

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10
Q

When is the only time you should talk about ‘absence seizures’?

A

Only if you mean a clinical absence seizure associated with a 3 second spike and wave on the EEG.

Otherwise, use ‘loss of awareness’ or ‘vacant spell’.

Lots of seizures can cause somebody to briefly lose awareness, not just absence seizures.

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11
Q

What is the technical term for syncope?

A

Transient global cerebral hypoperfusion

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12
Q

Three main causes for a syncope

A

Reflex [nuerally mediated]:

  • VASOVAGAL
  • situational
  • carotid sinus hypersensitivity

Cardiogenic

Orthostatic hypotension
- drugs, autonomic failure

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13
Q

Cause for cardiac syncope

A
  1. Condiitons that predispose to transient tachyarrhythmias
  2. Bradyarhythmias
  3. Cardiac ischaemia
  4. Structural heart disease
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14
Q

What would a cardiac syncope look like on an ECG?

A

slides

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15
Q

What would Wolff-Parkinson-White look like on an ECG?

A

slides

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16
Q

What would Brugada syndrome look like on an ECG?

A

slides

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17
Q

What is Brugada syndrome?

A

look up

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18
Q

Arrythmogenic right ventricular dysplasia on ECG

A

slides

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19
Q

learning point 2: what do conditions that give rise to transient tachyarrhythmias look like on an ECG?

What can these conditions cause?

What should you ALWAYS do on a patient with TLOC?

A

Have an abnormal ECG between events

These conditions cause sudden death in young people

Do an ECG in pts with TLOC

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20
Q

Which type of heart block have a high risk of progression to asystole?

A

Complete [3rd degree] heart block

Moritz type II 2nd degree heart block

incomplete trifascicular block

  • RBBB
  • LAD
  • 1st degree heart block
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21
Q

how does acute ischaemia cause syncope?

A

Causes syncope due to arrhythmia, output failure or acute mitral regurgitation

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22
Q

What can previous MI cause to the heart?

A

Can cause scar related VT

23
Q

Which two conditions can cause cardiac syncope by cardiac outflow obstruction during exertion?

A

Aortic stenosis

Hypertrophic cardiomyopathy

24
Q

What can cardiac syncope look like?

25
Q

Learning point 3: what is the most important Ix to do in the first seizure clinic?

A blackout during exercise is what until proven otherwise?

A

ECG is the most important Ix in the first seizure clinic.

A blackout occurring during exercise is cardiogenic until proven otherwise

26
Q

What is PNES also known as?

A

Psychogenic non-epileptic seizure:

  • ‘pseudo-seizures’
  • ‘non-epileptic attack disorder’
  • ‘dissociative seizures’
27
Q

Define PNES

A

Episodes of movement, sensation or experience that resemble epileptic seizures, but without ictal cerebral discharges

Physical manifestations of psychological distress

Associated with comorbid psychopathology and with childhood sexual abuse

28
Q

Differential Dx of TLOC

A

Rare but important:

  1. Hypoglycaemia
  2. Acute hydrocephalus
29
Q

Should vascular causes be a DDx of TLOC? what about migraine? W

A

No, look up why.

Slides suggest it is to do with the reticulating activating system.

30
Q

Learning point 4: should TIA be a DDx for TLOC?

A

[almost] never a DDx for TLOC

31
Q

how do we make a Dx w/o a video of the event of syncope?

A

History is essential

32
Q

Main important questions in the history from the patient’s account

A

What were the circumstances of the event?
What do they recall beforehand?
What is the next thing they remember?
Did the attack cause injury or incontinence?

33
Q

What should you do if there was a witness?

A

Phone them up, then ask:

  • in what circumstances did the event occur?
  • what were the first signs of the attack?
  • what exactly happened during the attack? loss of consciousness/stiffening trunk/hands, eyes opened/closed, cyanosis/noisy breathing/vocalisation
  • how long did the event last?
  • what immediately happened after the event?
34
Q

What are other useful history features?

35
Q

PMH questions

36
Q

DH questions

A

anti-depressants [psychological comorbid.], tramadol

37
Q

SH questions

A

evidence of psychological comorbid
alcohol and drugs
driving

38
Q

FH questions

A

seizures, sudden cardiac death, evidence of psychological comorbid.

39
Q

Learning point 5: if you haven;t made a Dx end of history, are you likely to make one at all?

A

no, unlikely

40
Q

Characteristics of a GTCS [circumstances, prodrome, wtiness, duration, post-ictal phase, other phenomena, other events, PMH, DH, SH, FH]

41
Q

Characteristics of a syncope

42
Q

Characteristics of PNS

43
Q

Important when to do generla and neuro examination?

A

In acute seizures

44
Q

Why examination is important in the acute setting?

45
Q

most important ECG all pts with TLOC should have?

A

12 lead ECG!

46
Q

When should neuroimaging be used?

A

Ct useful in acute assessment seizures
CT not indicated in syncope [unless acute hydrocephlus suspected]
Pts with epilepsy should have neuroimaging, unless they have a Dx of genetic generalized epilepsy
MRI is the Ix of choice

Abnormalities on imaging are found in about 30% of pts with epilepsy

47
Q

When is an EEG useful?

A

Useful in the Dx and classification of epilepsy

48
Q

When is a EEG not useful? [why it’s known as one of the most abused Ix]

49
Q

how to record an event ECG?

50
Q

Percentage of pts referred to specialist epilepsy clinic with refractory seizures that don’t have epilepsy

51
Q

Most commonly made mistakes when Dx epilepsy

A

Incomplete history, lack of witness account
Misinterpretation of syncope, myoclonic jerks
Misinterpretation of EEG-changes

52
Q

What are the consequences of misdiagnoses?

A

100% treated with anticonvulsants
39% unemployed
41% barred from driving

53
Q

Is all jerking epilepsy/

54
Q

Which circumsrtances should psychogenic seizures be thought of?

A

Setting pt with presumed status or refractory epilepsy

Neurology (13 decks)

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