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Case History: UNFINISHED A 72-year-old man goes out to lunch with his extended family for his birthday. He has a glass of wine and a large meal in Frank and Benny's. While they are waiting for the birthday cake he complains of feeling nauseated and goes pale and slumps forward onto the table. He has a few jerks and then slips to the floor. His eyes were closed. His colour returns and he is able to sit up after 5 minutes. He is not incontinent. A paramedic arrives. His BP is 110/80 mmHg. He is on antihypertensives. he is brought to the ED. He was able to walk to the ambulance. He feels fine now and a bit embarrassed.
What are the differentials for TLOC
Vasovagal Syncope/Faint possibly exacerbated by meds
Syncope due to Aortic stenosis or HOCM
What facts do you need to determine
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.
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
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
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
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.
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)
What other tests may be considered
suspected cardiac arrhythmic: Consider 7-day tape which hopefully will help capture any arrhythmia
Red flags for Cardiology review
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
A bitten tongue
Head-turning to one side during TLoC
No memory of abnormal behaviour that was witnessed before, during or after TLoC
Confusion following the event
Prodromal déjà vu, or jamais vu
Structural brain disease
Are there any clues that help diagnose vasovagal
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
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