Blackouts, Fits, Faints, Funny Turns

Question 1

What are 5 differentials for blackouts?

Answer 1

1) Vasovagal syncope.
2) Cardiac syncope.
3) Non-epileptic attacks.
4) Intermittent hydrocephalus (rare).
5) Migraine (if no loss of awareness).

Question 2

What questions should you ask when taking a history from someone complaining of blackouts?

Answer 2

Trigger?
Prodrome - what happened immediately before the event?
Attack - what happened during the event?
Recovery - what happened immediately after?
PMH - have they had similar attacks previously?

Question 3

What investigations should you do in a patient who presents with blackouts?

Answer 3

12-lead ECG is very important - look for prolonged corrected QT interval.
Brain imaging.
EEG.
Video telemetry.
Heart scan.
Tilt table test.

Question 4

What is one of the most valuable things you can do when taking a history from someone presenting with blackouts?

Answer 4

Ask about and obtain an eye witness account.

Question 5

Why should you be cautious interpreting the results of an EEG?

Answer 5

EEG’s have high false positive rates leading to over-diagnosis.

Question 6

What is epilepsy?

Answer 6

Recurrent seizures

Question 7

What is focal epilepsy?

Answer 7

Abnormal electrical activity in localised area of the brain

Question 8

Describe a focal aware seizure.

Answer 8

Focal aware seizures aka. aura, simple partial seizure.

Symptoms depend on the site of the focus e.g. limb jerking (frontal lobe), paraesthesia (parietal lobe), speech arrest.

Question 9

Focal seizures: what lobe of the brain would be affected if a patient had limb jerking?

Answer 9

Frontal Lobe

Question 10

Focal seizures: what lobe of the brain would be affected if a patient had paraesthesia?

Answer 10

Parietal Lobe

Question 11

Name 2 types of seizure that can result from the spread of a focal seizure.

Answer 11

1) Focal impaired awareness seizure (complex partial seizure).
2) Focal to bilateral tonic-clonic seizure (secondary generalised tonic clonic).

Question 12

Name 3 types of generalised seizure.

Answer 12

1) Absence
2) Myoclonic
3) Primary Generalised Tonic Clonic

Question 13

Give 3 signs/symptoms of a stereotypical seizure.

Answer 13

Patient will struggle to describe the event.
Duration 1-3 minutes.
Tonic-clonic phase.
Vocalisations.
Eyes/mouth open.
Post-event amnesia.

Question 14

Describe the triggers, prodrome, attack, duration and recovery of an epileptic seizure.

Answer 14

Triggers: sleep deprivation, early morning, alcohol withdrawal, photosensitivity, medication non-compliace
Prodrome: aura, deja vu, olfactory/gustatory aura.
Attack: tonic clonic.
Duration: 30-120 seconds.
Recovery: confusion, headache, amnesia, prolonged recovery.

Question 15

What is syncope?

Answer 15

A transient loss of consciousness, loss of postural tone e.g. fainting.

Question 16

Describe the triggers, prodrome, attack, duration and recovery of syncope.

Answer 16

Triggers: prolonged standing, hot, pain, venepuncture.
Prodrome: pale, sweating, visual clouding, muffled hearing.
Attack: reduced body tone.
Duration: 5-30 seconds.
Recovery: quick.

Question 17

What are the 3 P’s suggestive of syncope?

Answer 17

Position e.g. standing.
Precipitating factors e.g. venepuncture, pain, nervous, hot.
Prodromal signs: sweating, pale, visual clouding etc.

Question 18

What is a non-epileptic attack disorder (NEAD)?

Answer 18

NEAD resembles an epileptic seizure but without the abnormal electrical discharge, often has a psychological cause e.g. panic attacks.

Question 19

What are the main features of a NEAD?

Answer 19

Triggers: situational.
Attack: arms flexing and extending, pelvic thrusting, back arching, wax and wane, eyes closed, gaze aversion, may lie completely still.
Duration: variable, can be prolonged.
Recovery: may be tearful.
NB. may have a history of other functional disorders.

Question 20

What criteria can be found in the Dissociative fit

Answer 20

“young for age”, situational seizures(Can be specific), falling down stairs, resisting eye opening, O2 sats, down-going plantars

Question 21

What is status epilepticus?

Answer 21

5/more minutes of either continuous seizure activity or repetitive seizures without regaining consciousness. (It is a medical emergency!!!)

Question 22

What is the immediate treatment for someone with status epilepticus?

Answer 22

Benzodiazepines e.g. Lorazepam.
(A->E, IV access, eventually call senior anaesthetics –>HDU/ITU)