funny turns… what could it be? martin sadler. funny turns it’s all in the history… single most...
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Funny turns… what could it be?
Martin Sadler
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Funny turns
It’s all in the history…
Single most important “tool” in funny turns is a corollary history
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History 1
18 year old woman out with friends In nightclub Flashing lights Feels funny and goes into toilets Has “fit” according to friends Has wet herself
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History 2
37 year old man With his son in A&E (son injured foot) Sitting next to son near trolley Seen to slump his head onto the trolley Jerks his limbs Told he has had a fit by the nurse
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Tips
Faints are far more common than fits A collapse in a bathroom is a faint until proven otherwise Jerks of the limbs are common in faints 50% of people who collapse with a full bladder wet
themselves A bitten tongue down the side is very suggestive of a
seizure Multiple stereotyped TIAs are rare If a patient sees both sides of their body shaking it is not
a fit
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FeaturesFit Faint
Trigger Rare (flashing lights, hyperventilation)
Common (upright, bathroom, blood, needles, exertion)
Prodrome Common (typical aura: epigastric, déjà vu etc)
Almost always (nausea, sweating, palpitations, light-headedness, visual darkening)
Onset May be sudden Gradual (often minutes)
Duration 1-2 minutes 1-30 seconds
Convulsive jerks Common (prolonged) Common (brief)
Incontinence Common Uncommon
Lateral tongue bite Common Rare
Colour Pale (simple partial seizure)Red, blue (tonic clonic seizures)
Very pale
Post-ictal recovery Slow (confused) Rapid (quickly oriented)
Post-ictal confusion Common (e.g. wakes in ambulance)
Rare (e.g. wakes on the floor)
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Types of syncope
Reflex (vasovagal) syncope… a faint Common healthy people
Cardiac syncope… important Any posture (eg ARV in bed) During exercise …urgent cardiac referral
Tachyarrhythmias Palps between and during attacks
Bradyarrythmias Carotid hypersensitivity (10-20% of over 60s) Do not massage neck unless fully paid up insurance!
Valsalvas Trumpeters (up north) Cough
Micturition
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Investigations
ECG Look at PR & QT
BP usually normal in clinic
Tilt table testing Sensitive (up to 90%) Specific (up to 70%) for syncopal tendency
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Management
Tell patient to lie down at onset of symptoms Rise slowly Desensitisation for “triggers” B blockers Salt, fludrocortisone, SSRI Dual chamber pacing! (for malignant fainting)
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Collapses continued
Reflex (vasovagal) syncope Carotid sinus syncope Cardiac syncope
W-P-W Long QT
Romano-Ward Lange-Neilsen Acquired
Bradyarrhythmias Structural cardiac disease
Autonomic failure (orthostatic syncope)
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Orthostatic syncope
Autonomic dysfunction Upright Colour normal Heart rate unchanged No sweating
Old age, DM, alcohol, amyloid Drugs (eg in PD) MSA
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Diagnosis
Lying and standing BP Consider tilt table and valsalva Exclude anaemia and hyponatraemia
Treatment Remove drugs Aviod provoking situations Head up tilt at night Fludrocortisone (50-200ug/d)
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Yet more…
Toxic/metabolic/infectious causes Respiratory syncope
Cough Hyperventilation Breath holding (children)
CNS syncope Raised intracranial pressure Autonomic dysreflexia Concussive convulsions
Psychogenic attacks
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And more…
TIAs TGA Startle disorders Migraine
Retinal Basilar artery Migraine syncope Migraine-epilepsy syndrome Migraine coma
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NEAD
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NEAD
50% of patients admitted with status epilepticus Female (8:1) Previous abnormal illness behaviour Childhood physical/sexual abuse Begin after age 10 Resistance to treatment No significant underlying brain damage to
account for frequent seizures
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NEAD 2
EEGs normal during and between attacks No prolactin rise Telemetry often helpful
Outcome variable
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NEAD Epilepsy
Inducible Common Rare
Onset Gradual Sudden
Duration Prolonged, hours Short, 1-3 mins
Breathing and colour
Stays pink, keeps breathing
Apnoeic and cyanosed
Retained consciousness
Common Uncommon
Pelvic thrusting Common Rare
Fighting, may injure others
Common Rare
Eyes closed Common Less common
Resists eye opening Common Rare
Occurs only in company
Common Rare
Lateral tongue bite Rare Common
Incontinence Rare (with experience)
Common
Post ictal confusion Rare common
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What else could it be?
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Diagnostic scheme