CLINICAL APPROACH TO FITS AND FAINTS

1. CLINICAL APPROACH TO FITS AND FAINTS HSAJB

2. OBJECTIVES • Know how to approach a patient with seizure/fits • Know how to approach a patient with syncope • Differentiate between fits and faints, and make a provisional diagnosis • Recognize the different type of seizure • Initiate the correct therapy for fits or faints • Know when and how to stop the anti-epileptic drugs

3. Approach to fits and faints

4. HISTORY • Ask the witness • Before the attack • General sense of the patient's state of health and hydration on the day of the event • Patient's appearance before the event (whether eyes were open or shut) • Posture immediately before loss of consciousness • Any warning? • Epileptic aura or cardiac pre-syncope • Prodromal symptoms (eg, seeing sparks, tunnel vision, nausea, sweating or feeling warm/hot, muffled hearing, or a feeling of lightheadedness) in the moments just before the attack-syncope

5. HISTORY • Before the attack • What sort of circumstances it occur? • While watching TV, sleep deprivation, alcohol withdrawal, drug misuse - epilepsy • Change in position, loud noises, jumping into water, phlebotomy, "emotional” stress, prolonged standing or dehydration, low salt intake, raised intrathoracic pressure (e.g., during coughing), and carotid sinus stimulation-syncope • Can the patient prevent the attacks? • Any family history of similar attacks? (Cardiac disease/epilepsy) • Current medication that may have contributed to TLoC (for example, diuretics, antihistamines-causes prolonged QT interval)

7. HISTORY • During the attack • Any loss of awareness? Is it a loss of consciousness (LOC) or fall to the ground without LOC? how the patient fell • Any injury? Loses of postural tone with LOC and little or no wounding-syncope. Head injury, shoulder dislocation, and severe lateral tongue biting-epilepsy. • Does the patient move? Stiff or floppy? Exact details of movements(e.g. (strange behavior, focal rhythmic movement-twitching, jerking, thrashing, automatisms of the face & extremities, expiratory groan or cry)

8. HISTORY • During the attack • Any incontinence?(epilepsy, but can occur also in syncope) • Any change of complexion? Cyanosis-epilepsy? Pale-syncope? Red-arrhythmia / temporal lobe seizure? • Did he bite side of his tongue? (epilepsy) • Associated symptoms- palpitations, sweats, pallor, chest pain, dyspnoea • How long does the attack last?(onset to regaining consciousness) • Details of any previous TLoC, including number and frequency • If a drop attack, is the patient always sleepy?(Narcolepsy)

9. HISTORY • After the attack • Were they sleepy, confused, or alert? • How long did they take to recover completely • Rapid recovery(eye-contact re-established in few seconds) without neurological deficits, with fatigue, nausea, pallor, and persisting diaphoresis-epilepsy • Weakness down one side during the recovery period

10. HISTORY • Past medical history • IHD • Arrhythmia • History of implanted defibrillator (ICD) or pacemaker • Epilepsy • Drug compliance

11. PHYSICAL EXAMINATION • Vital signs • Lying and standing blood pressure • Cardiovascular examination • Pulse-rate & rhythm • Palpate for ICD or pacemaker • Neurological examination • GCS, neurocutaneous stigmata, meningism, focal neurological deficit, raised ICP, UMNL • Venepuncture track marks, tatoo • Suggestive of IVDU with drug intoxication

12. INVESTIGATIONS • GM stat-hypoglycaemia • Haemoglobin levels -anaemia or bleeding • Buse/Creat-Sodium level(hyponatremia) • Calcium level-hypocalcemia • LFT • TFT-hyperthyroidism • Urine and blood toxicology • Trop-T, Cardiac enzyme

13. INVESTIGATIONS • Repeat 12-lead ECG and obtain and examine previous ECG recordings • Cardiac arrhythmias may present as syncope or seizures and may be life threatening, so correct diagnosis is important, particularly since a number of AEDs can affect cardiac conduction. • Red flag • 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 • any ST segment or T wave abnormalities

14. INVESTIGATIONS • Echocardiography is useful only at the presence of a positive cardiac history or an abnormal ECG

15. INVESTIGATIONS • EEG • Helpful to support a diagnosis of epilepsy in people in whom seizures are considered likely • Help in classification of seizures by demonstrating focal or generalized epileptic abnormalities • Because of its low sensitivity, EEG should not be used to exclude the diagnosis of epilepsy • possibility of a false-positive result

16. INVESTIGATIONS • Neuroimaging • used to identify structural abnormalities that cause certain epilepsies • MRI • Imaging modality of choice • It identifies abnormalities capable of causing epilepsy that are not apparent on CT scanning (such as focal cortical dysplasia, cavernoma, mesial temporal sclerosis) • Scanning may not be necessary in people in whom a clear diagnosis of genetic generalized epilepsy has been made • Important in those : • Who develop epilepsy before the age of 2 years or in adulthood • Who have any suggestion of a focal onset on history, examination or EEG (unless clear evidence of benign focal epilepsy) • In whom seizures continue in spite of first-line medication

17. INVESTIGATIONS • CT SCAN • Where MRI scanning is contraindicated (e.g. in people with cardiac pacemakers), it may be necessary to rely on a CT scan. • Appropriate for initial imaging to aid management in the situation where the patient presents acutely with seizures. • Urgent imaging is indicated in those in whom a focal intracranial lesion is suspected, for example • Those in whom recovery is delayed, • People with a recent history of head trauma, • Those with new or progressive focal neurological signs • Those with new focal onset seizures • In people with persistent altered mental state • Malignancy • Immunocompromised • HIV infection • Fever • Alcoholism • Bleeding diathesis.

18. How to differentiate between fits and faints

19. CLINICIANS “ART OF LISTENING” IS VITAL -time-consuming -a challenge during a time limited consultation

21. FEATURES NOT SUGGESTIVE OF EPILEPSY • Prodromal symptoms that on other occasions have been abolished by sitting or lying down • Sweating before the episode • Prolonged standing that appeared to precipitate TLoC • Pallor during the episode

22. SYNCOPE

23. DEFINITION • A sudden loss of consciousness resulting from decreased cerebral blood flow, usually with prompt recovery during a period of seconds to minutes. • The underlying mechanism is transient global cerebral hypoperfusion • Syncope is almost ten times commoner than epilepsy in particular when considering the elderly population.

24. CAUSES OF SYNCOPE

27. CARDIAC vs NON CARDIAC SYNCOPE • A screening rule suggestive of a cardiac etiology based on • History of exertional syncope • TLOC has occurred after exercise, it could suggest a reflex syncope, and if during exercise, a cardiomyopathy or an intracardiac conduction defect. • Family history of cardiac disease • Abnormal physical examinations findings • Abnormal ECG findings

28. WHEN TO REFER FOR URGENT CVS ASSESSMENT • Red flags • TLoC who also has any of the following: • ECG abnormality • Heart failure (history or physical signs) • TLoC during exertion • Family history of sudden cardiac death in people aged younger than 40 years • Inherited cardiac condition • New or unexplained breathlessness • Heart murmur • Consider referring within 24 hours • Anyone aged older than 65 years who has experienced TLoC without prodromal symptoms

29. SPECIALIST CARDIOVASCULAR ASSESSMENT AND DIAGNOSIS

30. SPECIALIST CARDIOVASCULAR ASSESSMENT AND DIAGNOSIS

31. SPECIALIST CARDIOVASCULAR ASSESSMENT AND DIAGNOSIS Criteria to determine type of ambulatory ECG • For people who have: • TLoC at least several times a week, offer Holter monitoring (up to 48 hours if necessary). • TLoC every 1–2 weeks, offer an external event recorder. • TLoC infrequently (less than once every 2 weeks), offer an implantable event recorder. • A Holter monitor should not usually be offered unless there is evidence of a conduction abnormality on the 12-lead ECG

32. SPECIALIST CARDIOVASCULAR ASSESSMENT AND DIAGNOSIS • SUSPECTED NEURALLY MEDIATED (VASOVAGAL SYNCOPE)

33. SPECIALIST CARDIOVASCULAR ASSESSMENT AND DIAGNOSIS • SUSPECTED NEURALLY MEDIATED (CAROTID SINUS SYNCOPE)

35. DIAGNOSE UNCOMPLICATED FAINT (UNCOMPLICATED VASOVAGAL SYNCOPE) • The 3 'P's • No features that suggest an alternative diagnosis • (note that brief seizure activity can occur during uncomplicated faints and is not necessarily diagnostic of epilepsy) • Posture – prolonged standing, or similar episodes that have been prevented by lying down • Provoking factors (such as pain or a medical procedure) • Prodromal symptoms (such as sweating or feeling warm/hot before TLoC).

36. DIAGNOSE SITUATIONAL SYNCOPE • No features from the initial assessment that suggest an alternative diagnosis • Syncope is clearly and consistently provoked by straining during micturition (usually while standing) or by coughing or swallowing

37. MANAGEMENT OF UNCOMPLICATED FAINT OR SITUATIONAL SYNCOPE • If there is nothing in the initial assessment to raise clinical or social concern, no further immediate management required • Advice • Reassure the person that their prognosis is good • Explain the mechanisms causing their syncope • Advise people on possible trigger events and strategies to avoid them • To keep a record of their symptoms, when they occur and what they were doing at the time to help understand trigger events • To consult their GP if they experience further TLoC, particularly if this differs from their recent episode

38. DIAGNOSE ORTHOSTATIC HYPOTENSION • To measure lying and standing blood pressure – repeat measurements while standing for 3 minutes • When to suspect orthostatic hypotension • There are no features from the initial assessment that suggest an alternative diagnosis and the history is typical • Consider likely causes, including drug therapy • Advice • Explain the mechanisms causing their syncope • Discuss and review possible causes, especially drug therapy • Discuss the prognostic implications and treatment options available • Advise people what to do if they experience another TLoC

39. UNEPLAINED CAUSE OF SYNCOPE If the cause of TLoC remains uncertain • If a person has persistent TLoC, consider psychogenic non-epileptic seizures (PNES) or psychogenic pseudosyncopeif, for example: • the nature of the events changes over time • there are multiple unexplained physical symptoms • there are unusually prolonged events • The distinction between epilepsy and non-epileptic seizures is complex; therefore, refer for neurological assessment if either PNES or psychogenic pseudosyncope is suspected • Advise people to try to record any future TLoC events • (for example, a video recording or a detailed witness account of the event), particularly if diagnosis is unclear or taking a history is difficult • If after further assessment the cause of TLoC remains uncertain or the person has not responded to treatment, consider other causes, including the possibility that more than one mechanism may co-exist (for example, ictal arrhythmias)

40. EPILEPSY

41. DEFINITIONS • Epileptic seizure is a transient occurrence of signs and/or symptoms due to abnormal excessive or enhanced synchronous neuronal activity in the brain.

42. DIAGNOSIS • Diagnosis of epilepsy depends on the occurrence of two nonprovoked seizures

43. RED FLAGS • Should be seen by the specialist within 2 weeks • Bitten tongue. • Head-turning to one side during TLoC. • No memory of abnormal behaviour that was witnessed before, during or after TLoC by someone else. • Unusual posturing. • Prolonged limb-jerking (note that brief seizure-like activity can often occur during uncomplicated faints). • Confusion following the event. • Prodromal déjà vu, or jamais vu • Consider that the episode may not be related to epilepsy if any of the following features are present. • Prodromal symptoms that on other occasions have been abolished by sitting or lying down. • Sweating before the episode. • Prolonged standing that appeared to precipitate the TLoC. • Pallor during the episode.

44. TO TREAT OR NOT TO TREAT AS EPILEPSY • Patients should not be treated if there is uncertainty about the diagnosis • The wisdom would be to “wait and see" for the next event • If further events are frequent and the diagnosis is still doubtful, video-EEG monitoring is helpful when trying to reproduce a T-LOC • When there is high risk of further seizures, medication may be started after a single seizure. • Development of epilepsy secondary to a cerebral tumour • Presence of active epileptic changes on EEG in people with genetic generalized epilepsy. • Seizures associated with cavernous haemangiomata -high risk of recurrence

45. TO TREAT OR NOT TO TREAT AS EPILEPSY • Trials of treatment should not normally be undertaken. • Rare exceptions occur in which the diagnosis is difficult to confirm • For example in elderly people living alone (provided there is a compatible history and cardiac causes have been ruled out) • In the case of focal seizures without loss of awareness, in which even ictal epileptic activity may not be apparent on scalp electrode EEG recordings.

46. TO TREAT OR NOT TO TREAT AS EPILEPSY • Nature of the seizures • The need to start treatment for seizures not causing loss of awareness may be less pressing than for other seizures, unless driving is an issue) • Timing of seizure • Tonic clonic seizures in sleep are associated with an increased risk of sudden unexpected death in epilepsy (SUDEP) • Other co-morbidities • The likelihood of pregnancy • The wishes of the patient

47. FACTORS THAT MAY LOWER SEIZURE THRESHOLD • Alcohol excess • Sleep deprivation • Fever/acute systemic illness • Hyponatremia/other metabolic disturbance • Abrupt withdrawal of antiepileptic drugs • Proconvulsant medication (includes much psychotropic medication as well as some recreational drugs)

48. COUNSELLING PEOPLE WITH EPILEPSY • Nature of epilepsy • Precipitating factors for seizures • Driving laws • Need to avoid potentially dangerous situations • Sudden unexpected death in epilepsy (SUDEP) • Need (or not) for medication • Adverse effects of medication • Interactions of medication with other drugs including oral contraceptive • Pregnancy and teratogenicity • Employment/leisure

49. SAFETY PRECAUTIONS IN EPILEPSY • Avoid unguarded heights • Avoid unguarded fires, radiators etc • Shower rather than bath where possible • Avoid swimming alone: an observer should always be alerted to the possibility of a seizure before swimming • When waiting for a train, wait at the back of the platform till the train pulls in • Avoid working with unguarded machinery

50. GENERAL PRINCIPLES OF PHARMACOLOGICAL TREATMENT OF EPILEPSY • Initial treatment should be a first-line drug appropriate for their epilepsy syndrome and seizure type(s). • Started at a low dosage and gradually increased until either the patient becomes seizure-free, or they develop adverse effects. • If the patient has ongoing seizures despite adequate doses of an appropriate AED for their seizure type or syndrome, the diagnosis should be reconsidered. • Is the diagnosis correct? Correct seizure type? • If yes, a second first-line drug appropriate for the epilepsy should be added • The dosage being gradually increased as before. • Once an appropriate dosage has been reached, the dosage of the AED used initially should be gradually tapered. • Only if at least two appropriate first-line drugs have failed independently to control the seizures should two or more drugs be prescribed concurrently.