2 Blackouts What do they mean? Take a detailed History Witness account Loss of consciousness?Loss of awareness?Something else? Sleep? Dizzy? Visual loss?NICE Guidelines
3 Loss of consciousness -Syncope Hot, lightheaded. Standing, grey out of vision and fading of hearing, floppy to floor, often pale. Rapid recovery ( if lying), brief <2mins. May twitch a bit. Re-faint on re-standing?, hearing back first.Clear provocation and a one off, examine, postural BP, ECG and safety advice.No clear provocation, recurrent. As above and consider bloods FBC, U+E, Glucose, 9am cortisol. If ECG abnormal or “red flags” refer to cardiology. If significant postural drop consider referral to syncope clinic ( or endocrine if results suggest Addison's)
4 Loss of consciousness- refer to cardiology? Red FlagsFamily history of sudden deathAge >65Chest pain, palpitations, exercise induced or sitting with light headed feeling or syncope.Prolonged recovery?Abnormal ECG ( QTc?), arrhythmia?, (heart block, WPW, LGL)Murmur, ischaemic heart disease or cardiac failureConsider echocardiogram and 24 hour tape
6 Loss of consciousness- Refer to Neurology Epilepsy?Possible status epilepticus ? 999, Neurology afterwards.At start :- Warning?, Automatisms? Posturing?Stiff, noisy breathing, odd colour ( desaturating), jerking, eyes often open, may deviate.Prolonged post ictal phase and confusionBite is usually side tongue, (wetting only means loss of consciousness).Mixed type of attacksStop and stare?Vacant with automatisms and or confusionMyoclonic jerksOdd blackouts ? Fits or not?
7 Loss of consciousness- No markers or witnesses Known heart disease refer to cardiologyOtherwise refer to Neurology
8 Loss of awareness- Refer to Neurology? ( or Peads if <16) Brief blanking+/- myoclonic jerksWith automatisms, confusion, refer to NeurologyCould it be psycogenic?
9 Remember Can have twitching with syncope Fits with headache and fever- encephalitis?More brain tumours present with fits than headacheAround half of people having one fit will get more. 1 in 100 or so will have a fitHigh level initial incorrect diagnosis- always be prepared to think again.Always remember safety ( including for syncope) and driving advice
10 Rotherham Neurology Outreach from Sheffield Although 4 consultants visiting we only make about 1 and a bit FTE ( Siân Price, Ralf Lindert, Siva Nair, Danute Kucinskiene ( locum)Specialist Nurses outreach from Sheffield too ( Epilepsy, MS, Parkinson’s ( separate from Elderly med), do clinics at Rotherham.Some specialty services and tests done in Sheffield. We have no Rotherham beds but see ward referrals.2 WW via SheffieldTHANK YOU