TLOC

TLOC

1. Collapse

   • cardiac
     • MI + cardiac arrhythmias
   • blood pressure
     • Shock
       • cardiac, hypovolemia incl hemorrhagic incl ectopic preg, septic incl peritonitis, adrenal insufficiency
     • Syncope
       • 4 subtypes
         • arrhythmia related
           • transient comp of CO
         • cardiac
           • due to structural heart disease (or acute PE or aortic dissect)
         • orthostatic
           • b/c fail to maintain BP on assuming upright posture (can be caused by drugs)
         • reflex
           • vasodilat and/or bradycard in response to trigger (eg vasovagal or carotid sinus syncope)
       • result from global cerebral hypoperfusion; typically assoc w/a BP <60mmHg for >6sec
       • clin feats
         • preced by chest pain, palpit, dyspnea, light headed, or typical 'pre-syncopal' prodrome
         • LOC after stand up, prolonged standing, during exert, following unpleasant sight/pain, venepunt, micturition, cough, large meal
         • brief duration <1min
         • rapid return of clear-headedness
       • investigs: 24 hr EEG (so can catch); implantable loop recorder ; supine + erect carotid sinus massage (to check hypersens)
   • neuro
     • Stroke
     • seizure
       • Epilepsy
         • tendency to have recurrent seizures
           • convulsions = the motor signs of electrical discharges
         • phases
           • prodrome (rare) hrs-days. Change in behaviour
           • aura- part of seizure. pt aware. may be funny gut feeling, deja vu, strange smells, flashing lights
             • Implies partial seizure from temproal lobe
           • post-ictal: may be headache, confusion, myalgia, sore tongue, temporary weakness after focal seizure in motor ctx (Todd's palsy), temporary dysphasia after focal seizure in temporal lobe
         • causes
           • 2/3 idopathic
             • often FH
           • structural
             • cortical scarring (eg prev head inj), developmental, SOL, stroke, hippocampal sclerosis, vasc malforms
           • other
             • tuberous sclerosis, sarcoid, SLE, PAN
         • diagnosis
           • 1. are they really seizures? -get witness account -chee/tongue bit + slow recovery v suggestive -try not to diag incorrectly- syncope can have convulsions too 2. what type of seizure is it? -partial or generalized? ONSET KEY- if it begins w/focal, is partial however rapidly it generalizes 3. what triggers? -flicker lights, alch? can this be avoided? (TV induced seizures rarely req drugs) Also if 1st - really the 1st? -ask about prior odd behaviour -was it provoked (see non-epileptic cause) -admiss for 24h may be indicated
           • witness account
             • ?really seizures
           • partial or gen? onset key
           • what triggers
         • seizure classific
           • PARTIAL
             • focal onset, feats referable to a part of one hemisphere -often seen w/underlying structural disease
             • simple partial
               • awareness unimparied (focal motor, sens, autonomc or psychiatric symps)
               • awareness UNimpaired
               • focal symps
               • no post-icatl symps
               • like responsive kid w/twitchy mouth
             • complex partial
               • awareness IMpaired
               • may have AURA or impaired aware at onset
               • most commonly temporal lobe
               • post -ictal confusion (temporal); rapid recovery (frontal)
             • partial seizure w/secondary generalization
               • 2/3 of pts w/partials
               • starts focally, -> spreads -> generalized seizure which is typically convulsive
               • most common, onset teens/early 20s or later in life w/stroke (can be hippocamp or temporal lobe damage)
           • PRIMARY GENERALIZED
             • simultaneous onset of elect discharge throughout ctx (no localiz feats referable to only one hemis)
             • Absence
               • brief (<10s pauses); presents in childhood
                 • eg suddenly stops talking mid-sentence, then carries on where left off
             • Tonic -clonic
               • loss of consc, TONIC limbs stiffen + musc contract ; then CLONIC jerk
                 • may have one without the other
               • post ictal confusion + drowsiness
             • Myoclonic
               • sudden jerk of limb, face, or trunk
                 • pt may be thrown suddenly to ground or have disobedient limb
             • Atonic (akinetic)
               • sudden loss of musc tone causing a fall
               • no loss of consc
             • Infantile spasms
               • commonly assoc w/tuberous sclerosis
           • localizing features * (read note)
             • Localizing features of partial (focal) seizures Temporal lobe -automatisms (w/no recollection of) -dysphasia (ictal or post ictal) -abdo rising sens (or pain +/-vomit) -memory phenomena (deja vu or jamais vu) -hippocampal involve- (emotional disturb, religiosity) -uncal involve- (hallucincations of smell or taste or dream like state) -delusional behaviour -bizzare story.. (see pg 495) Frontal lobe -motor feats (posturing, eye moves, peddling moves of legs) -jacksonian march- (spreading focal motor seiz but retain awareness) -motor arest -subtle behaviour disturbs -dysphasia or speech arrest -post ictal Todd's palsy Parietal lboe -sensory disturbs (rare) -motor symps Occiptial lobe&nbsp; -visual phenomena
         • complics
           • sudden unexpected death in epilepsy
             • more common in uncontrolled (maybe relat to nocturnal seizure-assoc apnea or asystole)
         • investigs
           • EEG
             • helps context for diag -&gt; don't do if likely syncope b/c false +ves only do emergency EEG if non-convulsive status epilepticus is the problem unprovoked inter-ictal EEG (ofte normal in ppl w/seizures; so often abnorm in ppl without) SO DO PROVOVOCATION (sleep depriv) + prolonged and /or video recording
           • other
             • further options: neurological resection- if single focus eg hippocampal sclerosis, small tumor vagal nerve stimulation
             • MRI
               • structural lesions
             • serum drug lvls
               • are they taking tablets?
             • PET
             • cog assess
             • ictal SPECT
         • management
           • involve pt!! essential for compliance
           • counselling
             • -after a seizure advise agisnt possible dangers (eg swimming, driving, heights) until diag estab'd then individual counselling after diag -&gt; employment, insurance, conception&nbsp; *driving- can't drive until seizure free &gt;1yr
           • drugs
             • probably start treatment after 2nd fit discuss w/pt- if low freq eg 1fit/2yr, don't drive, may choose no treat treat w/one drug by one doc, build up over months
             • depends on type of seizure.
               • Generalized tonic clonic- sodium valproate or lamotrigine
                 • 2nd line carbamazepine, topiramate
               • Absense: sodium valproate, lamotrigine, ethosuximide
               • tonic, atonic, myoclonic: sodium valproate or lamotrigine
                 • avoid carbemazepine
               • parital seizures +/- secondary gneralization: carbemazepine
                 • then sodium valproate, lamotrigine, oxcarbazepine, topiramate
       • disordered electrical activity affected whole brain
         • may be primary or secondary (resulting from focal that spreads)
           • if py doesnt' become secondary, partial seizures may cause altered consciousness without LOC
       • triggers
         • alcohol excess or withdrawal; recreational drug misuse
         • sleep depriv, physical/mental exhaustion
         • intercurrent infection
         • metabolic disturbance (low Na, low Mg, low Ca, uremia, liver failure)
         • non-compliance with meds, or drug interact
         • flickering lights
       • clin feats
         • preced by aura (smell, rising sens in abo, deja vu)
         • witness account of tonic-clinic limb moves
           • coarse and rhythmic
           • >30s (ask witness to demonstrate)
         • tongue/cheek inj
         • >5min confusion/drowsiness after
       • causes
         • epilep
         • non epilep
           • trauma, storke, hemorrhage, rasie dICP, alcohol or benzo withdrawal, metabolic disturbance (hypoxia, hypo/hyper natremia, hypocalcemia, hypo/hyper glucose, uremia), liver disease, infection, raised temp, drugs (TCAs, cocaine, tramadol, theophylline), pseudoseizures,&nbsp;
   • other
     • Diabetes (hypo or hyper)
       • hypoglycemia
         • may cause impari consc that resolves w/correction of blood glucose
         • most cases iatrogenic 9insulin or sulphonylurea)
         • other 'spontaneous' causes
           • alcohol, liver failure, insulinoma, adrenal insufficiency
     • PE

2. Dizziness, syncope and falls

   • orthostatic hypotension
     • any cause incl adverse drug reaction, cardioinhibitory syncope, autonomic neuropathy etc
   • psychiatric
     • anxiety
   • neuro
     • stroke, Parkinson's disease, myelopathy, MS
   • vestibular disorders [any]
   • metabolic

3. functional disorders (apparent TLOC)

   • 'pseudosezizure'
   • 'pseudosyncope'
   • atypical feats that may suggest pseudo
     • >5min episodes, eyes closed, numberous attacks/day, purposeful mves during, estab'd diag of other funct disorder

4. red flag

   • TLOC during exertion
   • severe heart disease
   • FH cardiac sudden death
   • previous or hi risk for ventric arryth
   • tachycardia
   • high risk ECG abnormality

5. history key!!!

   • listen and clarify
   • use witnesses
   • circumstances, prodrome, episode, recovery