Patient explanation:

Gold standard case presentation

Syncope

Syncope is the sudden temporary reversible loss of consciousness associated with postural tone and it relates to a loss of blood supply to the brain causing the patient to fall to the floor.  It is part of the TLOC or transient loss of consciousness spectrum

Causes of syncope:

• epilepsy related seizures
• cardiac arrhythmias blockages (more common elderly)
• orthostatic hypotension (more common elderly)
• psychogenic collapses – stress-related dissociative events
• narcolepsy
• simple faint (<75%) – more common in in teenagers and in young people

Key information comes from the history and it can take quite a while. It is important that we hear about every aspect of the patient’s most recent event and ensure to ask all of the following questions:

• eye witness account
  • what did they look like
  • what happened
  • what were they doing
  • what happened afterwards
  • what the patient was feeling when they started to have this event
• what medications were they on
• did you lose consciousness
• did you come around rapidly

If there are six blackouts, then the above must be asked for each of those six events.

• what is different
• what is the same?

Other key pieces of information to ask in an extended history:

• previous cardiac history
• previous neurological history
• family history
  • family history of sudden death onto the age of 40

When thinking about a diagnosis of faint consider the Three P’s:

• Postural – was the patient standing up?
• Provoking Factors – can you think about somebody else who would faint in that circumstances
• Prodrome – is there a warning / start to feel sick / start to feel hot/sweaty /start to feel that blood draining

When considering cardiac, most patients will have a cardiac history. When considering epilepsy factors to consider:

• tongue-biting but particularly tongue-biting at the side, not at the tip and odd head-turning during the blackout
• the patient does something strange while they’re unconsciousness but they have no memory of it.
• odd postures
• prolonged limb jerking
• a little bit of shaking (up to 50% of faints will have a bit of shaking)
• confusion for at least e.g. 15-minutes
• déjà vu or jamais vu
• urinary incontinence – can happen as frequently with syncope as it does with epilepsy.

If there is very frequent fainting, consider an uncommon autonomic problem, postural orthostatic tachycardia syndrome with lots of systemic autonomic features such as bowel disturbance, bladder disturbance, migraines, Raynaud’s.

Investigations:

Examination:

• listen for aortic stenosis
• lying and standing blood pressure
• if over 60-years and they’ve not had a recent stroke, we should do a carotid sinus massage with an ECG

Investigations

• 12-lead electrocardiogram (significant sinus bradycardia; significant AV block, alternating right and left bundle branch block, and significant tachyarrhythmias)
• pacemaker check if present
• baseline bloods including renal function, liver, bone profile and thyroid function
• cardiac – 24-hour / 7-day cardiac monitor (choose the rhythm monitoring according to the frequency of the patient’s blackouts); 24-hour blood pressure monitoring;  echocardiogram; reveal device
• neurological – CT/MRI brain; EEG; sleep-study with EEG

Management

Orthostatic hypertension:

• patient education – understanding what are the sort of things that going to make it worse
• reducing the exacerbating factors (standing for long periods of time when it’s very hot, suddenly getting up, standing passing water, eating lunch, food, drinking alcohol, and so forth)
• building up fitness, adding more salt to the diet as long as they don’t have high blood pressure, drinking more fluids, and possibly using compression clothing
• stopping medications (most commonly ACE inhibitors and beta-blockers and angiotensin receptor blockers)

Fainting:

• lots of studies that are being done that really have proven that not a lot of medications make a difference
• beta-blockers – no evidence
• SSRIs, – no evidence
• Fludrocortisones – some evidence that 100 mcg – 200 mcg a day may reduce the amount of fainting.

Neurological

• many treatment strategies
• atonic seizures are very, very rare (if a patient falls to the floor and isn’t moving, it is very unlikely to be epilepsy)
• TIAs never cause syncope without other neurological features.
• Subclavian steal never causes syncope without other neurological features
• cataplexy is rare and it’s always associated with narcolepsy, therefore excessive daytime somnolence
• psychogenic pseudosyncope or dissociative syncope stress-related collapses, often very frequent

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