Makindo Medical Notes

Related Subjects: |Transient Loss of Consciousness |Vasovagal Syncope |Syncope |Aortic Stenosis |First Seizure |Carotid Sinus Syncope

⚠️ Any sudden loss of consciousness without warning should be assumed to be due to a cardiac arrhythmia until proven otherwise. Transient loss of consciousness (TLOC) must be taken very seriously and assessed and investigated. 🚗 It can have implications for driving: patients must be advised to stop driving and inform the DVLA until a cause is established. See Driving advice topic.

📖 About

• 🧑‍⚕️ Common ED presentation, particularly in older adults.
• 🌓 Often described as “blackouts.”
• 🔍 Key to distinguish from seizure, TIA, or metabolic causes.

📝 Assessment

• History is key: Reconstruct the episode in detail; 👀 witness accounts invaluable (ask family/friends with consent).
• Before: 🧍 Position, activity, prodrome (💫 visual dimming, 🤢 nausea).
• During: Responsiveness, 💥 movements (jerks vs tonic–clonic), duration, colour, breathing.
• After: ⏱️ Time to recovery, 💤 confusion, headache, drowsiness.

🔎 Differentials

• 🩸 Vasovagal syncope: Triggered by standing, heat, meals, alcohol. Brief LOC, quick recovery. Minor jerks possible, incontinence rare.
• ❤️ Cardiac causes: Arrhythmia (brady/tachy), aortic stenosis, HOCM. Often exertional/no warning. May need ECG, echo, Holter/loop recorder, pacemaker.
• 💔 Silent MI / hypotension: Check ECG, troponin, echo.
• 🫁 Pulmonary embolism: Large PE can present with syncope. D-dimer ± CTPA.
• 🧠 Subarachnoid haemorrhage: Thunderclap headache + transient LOC. CT brain early.
• ⚡ Seizure: Lateral tongue bite 👅, incontinence, prolonged post-ictal drowsiness. Needs neuro referral, CT/MRI ± EEG.
• 👔 Carotid sinus syncope: Triggered by tight collars/head turning. Diagnose with carotid massage (caution!).
• 📉 Orthostatic hypotension: Drop in SBP >20 mmHg when standing. Common in elderly, worsened by 💊 diuretics, alpha-blockers, Parkinson’s meds.
• 🍭 Hypoglycaemia: Often in diabetics, Addison’s, or rarely insulinoma.

🧪 Investigations

• 🩸 Bloods: FBC, U&E, glucose, TFTs, bone profile.
• 📈 Cardiac: ECG, troponin, Holter (24–72h) or loop recorder, echo.
• 🫁 Thromboembolic: D-dimer ± CTPA if PE suspected.
• 🧠 Neurology: CT/MRI brain (SAH, seizure, structural cause). EEG if recurrent unexplained episodes.
• 🧬 Endocrine/metabolic: Glucose, cortisol (± Synacthen test if Addison’s suspected).

💊 Management

• 💊 Review meds: rationalise antihypertensives in frail, stop/reduce CCB, diuretics, alpha-blockers if contributory.
• 🚗 Driving advice: Stop until cause clarified; DVLA must be informed.
• Specific therapy:
  • ❤️ Cardiac: Pacemaker (brady), ablation (tachy).
  • 🧍 Vasovagal / orthostatic: Lifestyle (hydration 💧, slow posture changes). Fludrocortisone/midodrine if resistant.
  • ⚡ Seizure: Anticonvulsants if recurrent/unprovoked. Neuro referral.
  • 🚨 Acute causes: PE, MI, SAH → urgent specialist management.

💡 Clinical Pearl:
The most dangerous differential is arrhythmic cardiac syncope 🫀 — always exclude this first. 📚 Exam tip: “Sudden collapse, no prodrome, rapid recovery” → think cardiac syncope until proven otherwise.