Blackouts and Faints
Definition & DDx
Syncope = transient loss of consciousness due to global cerebral hypoperfusion
Reflex syncope: Cardiac Syncope
- Vasovagal (emotion/pain/stress) Structural
- Situational (GI/cough/micturition) - Aortic stenosis
- Carotid sinus syncope - Ischaemic cardiomyopathy
Orthostatic syncope - Hypertrophic Obstructive
- 1º autonomic failure (PD/LBD) Cardiomyopathy (HOCM)
- 2º autonomic failure (DM - Cardiac tamponade
neuropathy/amyloidosis/uraemia) Electrical
- Drug induced - Tachyarrhythmias (SVT/VT/VF)
(diuretics/alcohol/vasodilators) - Bradyarrhythmias (sick sinus
- Volume depletion syndrome/AVN block)
(haemorrhage/diarrhoea) - Inherited channelopathies e.g.,
Brugada syndrome
Symptoms & Complications
Cardiac Syncope Vasovagal syncope
Pre-collapse – rare in cardiac syncope - Clear trigger e.g., long stand
- Lightheaded - Narrowing vision
- Palpitations - Sweating/nausea
- Chest pain - Have time to lower to floor
- SOB
- Exertional syncope = red flag Seizures (not classified as syncope, but can
During collapse cause blackouts)
- Pallor - Lateral tongue biting
- Abrupt onset - Urinary incontinence
- Unlikely seizure activity/tongue - Long post-ictal period
biting/urinary incontinence - Residual focal neurological deficit
After collapse - Seizure activity (tonic-clonic or
- Rapid recovery focal)
Investigations
Obtain collateral history if collapse was witnessed
- ECG +/- 24hr tape/loop recorder
- U&Es (electrolyte abnormalities precipitating arrhythmias)
- TTE for structural causes of cardiac syncope
- Postural BP
Patients with typical features of syncope, no postural drop and normal ECG
- No further investigations
Treatment/Management & Side effects
- Unexplained syncope = 6mths off driving and inform DVLA
- Advice showers over baths
,Fits/Seizures (Non-Epileptic)
Anatomy & Risks - Benzos given to reduce risk
Alcohol withdrawal seizures Febrile convulsions (see paeds)
- Hx alcohol excess who suddenly
stop drinking e.g., after hospital Definition & DDx
admission Most are self-limiting, but prolonged can
- Peak 36hrs after last drink be life-threatenin
Symptoms & Complications
Pseudo-seizures (Psychogenic non-
epileptic seizures)
- Pelvic thrusting Treatment/Management & Side effects
- Family member with epilepsy Acute management
- Crying after seizure - Check airway and apply O2 if
- Don’t occur when alone appropriate
- Gradual onset - Recovery position
- Hx MH problems/personality - Benzos in prolonged seizures
disorder o Rectal diazepam after
True epileptic seizures 10mins
- Tongue biting o 10-20mg in adults
- Post-ictal high prolactin
Side effects of anti-epileptic drugs
Generally: Sodium valproate
- Teratogenic, caution if considering - Anaemia/haemorrhage/
pregnancy hyponatraemia
o Breastfeeding safe (except - Weight gain/confusion /gastric
barbiturates) irritation/tremor
- Interactions with contraceptives, - P450 enzyme inhibitor
warfarin, P450 medications - Do not use in females of
Specific drugs: reproductive age
Topiramate - Alopecia/hepatitis/ pancreatitis/
- Cognitive impairment/ thrombocytopenia
confusion/mood changes Phenytoin
- Muscle spasm/ tremor/weight loss - Constipation/anorexia/gingival
- Abdo pain/ N&V/ nephrolithiasis hypertrophy
Levetiracetam - Hirsutism/insomnia/rash/tremor
- Caution for QT prolongation - Acne/dizziness/ataxia
Carbamazepine - P450 inducer
- Ataxia/fatigue/blurred - Megaloblastic anaemia
vision/diplopia - Peripheral neuropathy
- Hyponatraemia/blood - Osteomalacia/lymphadenopathy
disorders/skin problems Lamotrigine
- P450 inducer - Arthralgia/headache/
- Dizziness/ataxia/drowsiness dizziness/ataxia/blurred vision
- Leukopenia/ agranulocytosis - Insomnia/rash/tremor/diarrhoea
- SIADH - SJS
- Can worsen myoclonic seizures
,Epilepsy
Definition & DDx
DVLA Guidance
Car/motorbike licence (Group 1); Reapply Bus/coach/lorry licence (Group 2); Reapply
after: after:
- 6mths for 1-off seizure - 5yrs for 1-off seizure if no anti-
- 1yr for ≥1 seizure epileptics taken in that time
- Seizure after changing - 10yrs seizure-free after ≥1 seizure,
meds/changing back >6mths ago during which no anti-epileptics
taken
Anatomy & Risks
Focal seizures (start in specific area, on Generalised seizures (involve both sides of
one side of brain) brain at onset)
- Without impaired consciousness = - Absence (petit mal)
simple - Tonic-clonic (grand
- With impaired consciousness = mal)/tonic/clonic
complex - Myoclonic
- Evolving to bilateral, convulsive - Atonic
seizure = 2º generalised
Can be associated with: DDx
- CP - Syncope
- Mitochondrial disease - TIA
- Tuberous sclerosis - Migraines
- Panic disorder
Localising lobes
Temporal lobe Frontal lobe (motor)
- Rising epigastric sensation - Post-ictal weakness
- Déjà vu - Jacksonian march (clonic
- Automatisms e.g., lip movements travelling proximally)
smacking/grabbing/plucking - Head/leg movements
Parietal lobe (sensory) - Posturing
- Paraesthesia Occipital lobe (visual)
- Floaters/flashers
Complications Investigations
- Status epilepticus (≥5mins) - Neuro exam
- Psychiatric (increased risk - EEG
depression/suicide) - CT/MRI
- Sudden unexpected death in
epilepsy Symptoms & Complications
o Excessive electrical activity General
inducing a cardiac - Tongue biting
arrhythmias and death - Urine incontinence
- Postictal drowsiness ~15mins
, Focal Generalised
- Focal simple/aware - Absence
o Retain consciousness o Brief pauses <10s
o Only focal symptoms - Tonic-clonic
o Absent post-ictal symptoms o LOC
- Focal complex/impaired aware o Stiffening and jerking of
o Lose consciousness limbs
o Post-aura o Post-ictal confusion
o Temporal lobe - Myoclonic
o Post-ictal confusion o Sudden jerks of
- 2º generalised limb/trunk/face
o Focal seizure experienced - Atonic
first o Sudden loss of muscle tone
o Evolves into generalised o Causing pt to fall
o Typically tonic-clonic o Consciousness retained
Treatment/Management & Side effects
Anti-epileptics normally started following a second seizure (prescribed by brand)
- Focal = Lamotrigine/Levetiracetam (Keppra); Carbamazepine (2nd line)
- Generalised
o Absence = Ethosuximide (1st line); 2nd line see tonic-clonic
o Tonic-clonic = Sodium valproate (men); Lamotrigine/Levetiracetam (women)
o Myoclonic = Sodium valproate (men); levetiracetam (women)
o Atonic = Sodium valproate (men); lamotrigine (women)
- Other
o Phenytoin no longer 1st line due to side effect profile
Definition & DDx
Syncope = transient loss of consciousness due to global cerebral hypoperfusion
Reflex syncope: Cardiac Syncope
- Vasovagal (emotion/pain/stress) Structural
- Situational (GI/cough/micturition) - Aortic stenosis
- Carotid sinus syncope - Ischaemic cardiomyopathy
Orthostatic syncope - Hypertrophic Obstructive
- 1º autonomic failure (PD/LBD) Cardiomyopathy (HOCM)
- 2º autonomic failure (DM - Cardiac tamponade
neuropathy/amyloidosis/uraemia) Electrical
- Drug induced - Tachyarrhythmias (SVT/VT/VF)
(diuretics/alcohol/vasodilators) - Bradyarrhythmias (sick sinus
- Volume depletion syndrome/AVN block)
(haemorrhage/diarrhoea) - Inherited channelopathies e.g.,
Brugada syndrome
Symptoms & Complications
Cardiac Syncope Vasovagal syncope
Pre-collapse – rare in cardiac syncope - Clear trigger e.g., long stand
- Lightheaded - Narrowing vision
- Palpitations - Sweating/nausea
- Chest pain - Have time to lower to floor
- SOB
- Exertional syncope = red flag Seizures (not classified as syncope, but can
During collapse cause blackouts)
- Pallor - Lateral tongue biting
- Abrupt onset - Urinary incontinence
- Unlikely seizure activity/tongue - Long post-ictal period
biting/urinary incontinence - Residual focal neurological deficit
After collapse - Seizure activity (tonic-clonic or
- Rapid recovery focal)
Investigations
Obtain collateral history if collapse was witnessed
- ECG +/- 24hr tape/loop recorder
- U&Es (electrolyte abnormalities precipitating arrhythmias)
- TTE for structural causes of cardiac syncope
- Postural BP
Patients with typical features of syncope, no postural drop and normal ECG
- No further investigations
Treatment/Management & Side effects
- Unexplained syncope = 6mths off driving and inform DVLA
- Advice showers over baths
,Fits/Seizures (Non-Epileptic)
Anatomy & Risks - Benzos given to reduce risk
Alcohol withdrawal seizures Febrile convulsions (see paeds)
- Hx alcohol excess who suddenly
stop drinking e.g., after hospital Definition & DDx
admission Most are self-limiting, but prolonged can
- Peak 36hrs after last drink be life-threatenin
Symptoms & Complications
Pseudo-seizures (Psychogenic non-
epileptic seizures)
- Pelvic thrusting Treatment/Management & Side effects
- Family member with epilepsy Acute management
- Crying after seizure - Check airway and apply O2 if
- Don’t occur when alone appropriate
- Gradual onset - Recovery position
- Hx MH problems/personality - Benzos in prolonged seizures
disorder o Rectal diazepam after
True epileptic seizures 10mins
- Tongue biting o 10-20mg in adults
- Post-ictal high prolactin
Side effects of anti-epileptic drugs
Generally: Sodium valproate
- Teratogenic, caution if considering - Anaemia/haemorrhage/
pregnancy hyponatraemia
o Breastfeeding safe (except - Weight gain/confusion /gastric
barbiturates) irritation/tremor
- Interactions with contraceptives, - P450 enzyme inhibitor
warfarin, P450 medications - Do not use in females of
Specific drugs: reproductive age
Topiramate - Alopecia/hepatitis/ pancreatitis/
- Cognitive impairment/ thrombocytopenia
confusion/mood changes Phenytoin
- Muscle spasm/ tremor/weight loss - Constipation/anorexia/gingival
- Abdo pain/ N&V/ nephrolithiasis hypertrophy
Levetiracetam - Hirsutism/insomnia/rash/tremor
- Caution for QT prolongation - Acne/dizziness/ataxia
Carbamazepine - P450 inducer
- Ataxia/fatigue/blurred - Megaloblastic anaemia
vision/diplopia - Peripheral neuropathy
- Hyponatraemia/blood - Osteomalacia/lymphadenopathy
disorders/skin problems Lamotrigine
- P450 inducer - Arthralgia/headache/
- Dizziness/ataxia/drowsiness dizziness/ataxia/blurred vision
- Leukopenia/ agranulocytosis - Insomnia/rash/tremor/diarrhoea
- SIADH - SJS
- Can worsen myoclonic seizures
,Epilepsy
Definition & DDx
DVLA Guidance
Car/motorbike licence (Group 1); Reapply Bus/coach/lorry licence (Group 2); Reapply
after: after:
- 6mths for 1-off seizure - 5yrs for 1-off seizure if no anti-
- 1yr for ≥1 seizure epileptics taken in that time
- Seizure after changing - 10yrs seizure-free after ≥1 seizure,
meds/changing back >6mths ago during which no anti-epileptics
taken
Anatomy & Risks
Focal seizures (start in specific area, on Generalised seizures (involve both sides of
one side of brain) brain at onset)
- Without impaired consciousness = - Absence (petit mal)
simple - Tonic-clonic (grand
- With impaired consciousness = mal)/tonic/clonic
complex - Myoclonic
- Evolving to bilateral, convulsive - Atonic
seizure = 2º generalised
Can be associated with: DDx
- CP - Syncope
- Mitochondrial disease - TIA
- Tuberous sclerosis - Migraines
- Panic disorder
Localising lobes
Temporal lobe Frontal lobe (motor)
- Rising epigastric sensation - Post-ictal weakness
- Déjà vu - Jacksonian march (clonic
- Automatisms e.g., lip movements travelling proximally)
smacking/grabbing/plucking - Head/leg movements
Parietal lobe (sensory) - Posturing
- Paraesthesia Occipital lobe (visual)
- Floaters/flashers
Complications Investigations
- Status epilepticus (≥5mins) - Neuro exam
- Psychiatric (increased risk - EEG
depression/suicide) - CT/MRI
- Sudden unexpected death in
epilepsy Symptoms & Complications
o Excessive electrical activity General
inducing a cardiac - Tongue biting
arrhythmias and death - Urine incontinence
- Postictal drowsiness ~15mins
, Focal Generalised
- Focal simple/aware - Absence
o Retain consciousness o Brief pauses <10s
o Only focal symptoms - Tonic-clonic
o Absent post-ictal symptoms o LOC
- Focal complex/impaired aware o Stiffening and jerking of
o Lose consciousness limbs
o Post-aura o Post-ictal confusion
o Temporal lobe - Myoclonic
o Post-ictal confusion o Sudden jerks of
- 2º generalised limb/trunk/face
o Focal seizure experienced - Atonic
first o Sudden loss of muscle tone
o Evolves into generalised o Causing pt to fall
o Typically tonic-clonic o Consciousness retained
Treatment/Management & Side effects
Anti-epileptics normally started following a second seizure (prescribed by brand)
- Focal = Lamotrigine/Levetiracetam (Keppra); Carbamazepine (2nd line)
- Generalised
o Absence = Ethosuximide (1st line); 2nd line see tonic-clonic
o Tonic-clonic = Sodium valproate (men); Lamotrigine/Levetiracetam (women)
o Myoclonic = Sodium valproate (men); levetiracetam (women)
o Atonic = Sodium valproate (men); lamotrigine (women)
- Other
o Phenytoin no longer 1st line due to side effect profile
