Makindo Medical Notes

NICE is very helpful about this

Ask the person who has had the suspected TLOC, and any witnesses, to describe what happened before, during and after the event. Try to contact by telephone witnesses who are not present. Record details about:

• circumstances of the event: at a birthday party in a restaurant
• person's posture immediately before loss of consciousness: sitting
• prodromal symptoms (such as sweating or feeling warm/hot); some nausea
• appearance (for example, whether eyes were open or shut) and colour of the person during the event: pale and then normal colour after
• presence or absence of movement during the event (for example, limb-jerking and its duration): few jerks at the onset
• any tongue-biting (record whether the side or the tip of the tongue was bitten): none
• injury occurring during the event (record site and severity): none
• duration of the event (onset to regaining consciousness): seconds to a minute
• presence or absence of confusion during the recovery period: no was able to get up with help and mobilise to the ambulance
• weakness down one side during the recovery period: no

He jerked the diagnosis is seizure

Not so fast. A few jerks are very common with vasovagal syncope. Some may even be incontinent. A seizure would expect sustained rhythmical jerking for at least 20-30 seconds.

Luckily you have an excellent history and description - what if it happened and only the waiter was there.

See Answer

You would ask the patient for permission and ring the restaurant and speak to the waiter and any other witnesses.

What other general info would you get

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• details of any previous TLoC, including number and frequency
• the person's medical history and any family history of cardiac disease (for example, personal history of heart disease and family history of sudden cardiac death)
• current medication that may have contributed to TLoC (for example, diuretics)
• vital signs (for example, pulse rate, respiratory rate and temperature) – repeat if clinically indicated
• lying and standing blood pressure if clinically appropriate
• other cardiovascular and neurological signs.

What test would you get next

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Record a 12-lead electrocardiogram (ECG) using automated interpretation. Treat as a red flag if any of the following abnormalities are reported on the ECG printout: conduction abnormality (for example, complete right or left bundle branch block or any degree of heart block) evidence of a long or short QT interval, or any ST segment or T wave abnormalities.

What are some rare but important ECG findings to spot

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• Inappropriate persistent bradycardia.
• Inappropriate persistent tachycardia - VT/SVT/AF
• Any heart block
• Any ventricular arrhythmia (including ventricular ectopic beats).
• Long QT (corrected QT > 450 ms)
• Short QT (corrected QT < 350 ms) intervals.
• Brugada syndrome.
• Ventricular pre-excitation (part of Wolff-Parkinson-White syndrome).
• Left or right ventricular hypertrophy.
• Abnormal T wave inversion.
• Pathological Q waves.
• Any Atrial arrhythmia (sustained)
• Paced rhythm.

What other tests may be considered

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suspected cardiac arrhythmic: Consider 7-day tape which hopefully will help capture any arrhythmia

List

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What

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Red flags for Cardiology review

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• Significant ECG abnormality (see above)
• Heart failure (history or physical signs)
• TLoC during or immediately following exertion
• Family history of sudden cardiac death in people aged younger than 40 years and/or an inherited cardiac condition
• New or unexplained breathlessness
• A heart murmur

Guidance suggests cardiology review in 24 hours. Take senior advice.

Red flags for Seizure Clinical Referral

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• A bitten tongue
• Head-turning to one side during TLoC
• No memory of abnormal behaviour that was witnessed before, during or after TLoC
• Unusual posturing
• Prolonged limb-jerking
• Confusion following the event
• Prodromal déjà vu, or jamais vu
• Prolonged recovery
• Structural brain disease

  Are there any clues that help diagnose vasovagal

  See Answer
  • No features that suggest an alternative diagnosis
  • Brief jerks may be seen with VVS
  • The 3 Ps
  • Posture: prolonged standing, or even sitting. VVS never when lying down.
  • Provoking factors (pain or a medical procedure or situational)
  • Prodromal symptoms (sweating or feeling warm/hot before)
  • Quickly resolves on lying down with instant full recovery
  • Pallor during the episode

  Can you

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  List

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References

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