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Rohan Mudkavi BlackoutCONTENT 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Syncopal causes 3. Non-syncopal causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING BLACKOUT 1. Epilepsy 2. HOCM 3. Subclavian Steal Syndrome 5. QUIZ NUMBER 2CONTENT 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Syncopal causes 3. Non-syncopal causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING BLACKOUT 1. Epilepsy 2. HOCM 3. Subclavian Steal Syndrome 5. QUIZ NUMBER 2How to split the differential Syncope – blackout due to a lack of blood supply to the brain (Greek, syn – together, kopein – to cut) Non syncopal – any cause which is not due to a lack of blood supplySyncopal Remember: ‘Harry plummeted really badly’ causes Heart Postural Reflex Blood vessels • Aortic stenosis • Drugs eg antihypertensives • Vasovagal • Vertebrobasilar • Cardiomyopathy • Dehydration syncope insufficiency • Masisve PE • Autonomic dysfunction • Carotid sinus • Subclavian steal • Baroreceptor dysfunction hypersensitivity syndrome (hypertensive patients) • Aortic dissection Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press.Non syncopal causes • Intoxication (alcohol, sedatives) • Head trauma • Hypoglycaemia • Seizure • Narcolepsy Remember: ‘Not This’ Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press.CONTENT 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Syncopal causes 3. Non-syncopal causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING BLACKOUT 1. Epilepsy 2. HOCM 3. Subclavian Steal Syndrome 5. QUIZ NUMBER 2HISTORY T AKING HISTORY OF PRESENTING COMPLAINT PAST MEDICAL HISTORY DRUG HISTORY FAMILY HISTORY SOCIAL HISTORY Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press.HPC Before During After • Was there a trigger? • How long were they • How quickly did they • Was there any out? recover? preceding • Did they move symptoms? (convulsions)? • Did they bite their tongue? Were they incontinent?PMH 1. Diabetes – hypoglycaemia, autonomic dysfunction 2. Cardiac illnesses – arrythmias or HOCM 3. Epilepsy – seizures 4. Psychiatric illnesses –non-epileptic seizures, panic attacks 5. Anaemia – hypoxiaDHX Drugs causing Drugs causing seizures Drugs causing hypoglycaemia orthostatic hypotension • Insulin • Anticonvulsant • Antihypertensives • sulphonylureas medications • Vasodilators (gliclazide) withdrawal • TCAs • Fluoroquinolone • Steroid cessation antibioticsFHX 1. Cardiovascular disease – any cardiac or cerebrovascular differentials 2. Sudden cardiac death – HOCM, channelopathies such as brugada syndrome, long QT syndrome. 3. Epilepsy – seizures 4. Diabetes – hypoglycaemia or autonomic dysfunction.SHx 1. Alcohol – intoxication is a non-syncopal cause of blackout 2. Stimulant drugs – cocaine and amphetamines can cause tachyarrhythmiasCONTENT 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Syncopal causes 3. Non-syncopal causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING BLACKOUT 1. Epilepsy 2. HOCM 3. Subclavian Steal Syndrome 5. QUIZ NUMBER 21. Which of the following is not a syncopal cause of blackout? 1. Aortic dissection 2. Atrial fibrillation 3. Vasovagal 4. Seizures 5. Orthostatic hypotension2. Which of the following is not usually associated with blackout? 1. Narcolepsy 2. HOCM 3. Aortic stenosis 4. Dehydration 5. StrokeNT Contributor (2018). Stroke 4: immediate treatment of acute stroke and TIAs | Nursing Times. [online] Nursing Times. Available at: https://www.nursingtimes.net/clinical- archive/neurology/stroke-4-immediate-treatment-of-acute-stroke-and-tias-15-01-2018/.3. Which of the following is the most common cause of blackout in elderly patients? 1. Arrythmias 2. Aortic stenosis 3. Seizures 4. Postural hypotension from medications 5. Subclavian steal syndrome4. Which of the following drugs would not cause blackout through postural hypotension? 1. Ramipril 2. Nifedipine 3. Gliclazide 4. Tamsulosin 5. Bisoprolol5. Patient X attends your clinic. He has been suffering a 3 month history of dizziness, vertigo and blurred vision and recently had a collapse triggered by head turning. PMH of angina. What is the most likely diagnosis? 1. Subclavian steal syndrome 2. Aortic stenosis 3. Postural hypotension 4. Vertebrobasilar insufficiency 5. HypoglycaemiaCONTENT 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Syncopal causes 3. Non-syncopal causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING BLACKOUT 1. Epilepsy 2. HOCM 3. Subclavian Steal Syndrome 5. QUIZ NUMBER 2EpilepsyWhat is Epilepsy? Epilepsy = condition in which patients have repeated seizures 1 seizure = not epilepsy (10% of population) 2+ seizures – epilepsyCAUSES/ RISK FACTORS Acquired Congenital 1. Head trauma 1. Tuberous sclerosis - hamartomas 2. Stroke or brain haemorrhage 2. Sturge Weber – vascular disorder 3. Hypoxic brain injury 3. Vascular malformations – AVMs, 4. Brain infections – meningitis, carvernomas encephalitis, abscess 4. Abnormalities of cortical 5. Brain tumours development 6. Neurodegenerative disease such as ADAbnormalities of cortical development’SYMPTOMS AND SIGNS • Multiple different types of seizures • All are ‘stereotyped’ • Exact symptoms can indicate type of seizureType of seizure Symptoms Generalised tonic clonic Muscle tensing then jerking incontinence and tongue biting common Temporal Automatisms, mneomimic, auras Frontal Focal clonic, Jacksonian march, Versive, Posturing Focal Parietal Somatosensory – tingling, shock, pain Occipital Visual - flashing lights, spots, simple patterns Absence Stop, stare off into space, then abruptly returns to normal Atonic Brief lapse in muscle tone, found in Lennox- Gastaut syndrome Myoclonic Sudden and brief muscle contractions, found in juvenile myoclonic epilepsy Infantile spasms Aka West syndrome, clusters of full body spasmsDIAGNOSIS • Clinical diagnosis – video from relatives • EEG – note can be normal outside of seizure • MRI – to look for structural pathologyTREA TMENT • Conservative • Seizure diary • Cut down alcohol- increases frequency and SUDEP • Stop driving until seizure free for 12 months • Medical • Anticonvulsant medications • Surgical • Vagal nerve stimulation • Resection of lesion • Corpus callosotomy (Lennox Gastaut) • Hemispherectomy (Sturge Weber)Type of seizure Symptoms Generalised tonic-clonic • First line - Sodium valproate • Second line – lamotrigine or levetiracetam • First line – lamotrigine or leviteracetam • Second line – carbamazepine, oxcarbazepine, zonisamide Focal Absence • First line – Ethosuximide • Second line – sodium valproate, lamotrigine or leviteracetam Atonic • First line - Sodium valproate • Second line – lamotrigine Myoclonic • First line – sodium valproate • Second line – lamotrigine, leviteracetam or topiramate Infantile spasms • Prednisolone • VigabatrinCOMPLICA TIONS • Status epilepticus • Lorazepam 4mg à repeat after 10 minutes à phenytoin or phenobarbital • SUDEP • Could be due to arrythmias, pulmonary oedema, post-ictal generalised EEG suppressionCONTENT 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Syncopal causes 3. Non-syncopal causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING BLACKOUT 1. Epilepsy 2. HOCM 3. Subclavian Steal Syndrome 5. QUIZ NUMBER 2HOCMWHA T IS HOCM? • Autosomal dominant condition with hypertrophy of the cardiac muscle tissue • to outflow obstruction.cts the septum of the heart, leadingCAUSES/ RISK FACTORS • Adolescents and above – sarcomeric protein mutation (troponin, tropomyosin) • Pre-pubertal and below – mitochondrial gene mutationsSYMPTOMS AND SIGNS Symptoms – relatively unspecific: Signs: • Syncope • Ejection systolic murmur • Palpitations • Loudest at lower left sternal border • Chest pain • Can have palpable thrill • Fourth heart soundDIAGNOSIS • Ecg – Left ventricular hypertrophy • Echocardiogram – assymetrical septal hypertrophy, SAM of anterior leaflet mitral valve • Genetic testingTREA TMENT What you should do: What you shouldn’t do: 1. Surgical myomectomy (removing part of the 1. NO ACE INHIBITORS OR obstructing heart muscle) NITRATES! 2. No heavy exercise 2. Heart transplant 3. No heavy lifting 3. Alcohol septal ablation (via a catheter) 4. Avoid dehydration 4. Beta blockers 5. Implantable cardioverter defibrillator ‘SHABI’COMPLICA TIONS 1. Arrythmias 2. Heart failure 3. Mitral regurgitation 4. Sudden cardiac deathCONTENT 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Syncopal causes 3. Non-syncopal causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING BLACKOUT 1. Epilepsy 2. HOCM 3. Subclavian Steal Syndrome 5. QUIZ NUMBER 2What is Subclavian Steal Syndrome? • Sorigins of subclavian artery proximal to vertebral artery • Means arm doesn’t get enough blood supply • So get retrograde blood flow in vertebral artery, depleting posterior cerebral circulation supplyCAUSES/ RISK FACTORS • Age • Smoking • Alcohol • Poor diet • Sedentary lifestyle • hyperlipidaemia • Hypertension • DiabetesSYMPTOMS AND SIGNS Loss of blood supply to the Loss of blood supply to the arm: posterior cerebral circulation: 1. Arm claudication 1. Vertigo 1. Pain 2. Diplopia 2. Paraesthesia 3. Visual loss 4. SyncopeDIAGNOSIS 1. Initial investigation – duplex ultrasound 2. Definitive diagnosis – CT/MR angiography STAGING: 1. Pre-subclavian steal – reduced anterograde flow 2. Intermittent alternating flow – anterograde flow in diastolic phase, retrograde flow in systolic 3. Advanced disease – permanent retrograde flowTREA TMENT Conservative: 1. Control modifiable risk factors Medical: 1. Antiplatelet therapy 2. Statins Surgical: 1. Percutaneous angioplasty +/- stenting – smaller or more proximal occlusions 2. Bypass techniques – longer or distal occlusions .COMPLICA TIONS • No specific complications • Syncope/ visual problems à falls à head injuryCONTENT 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Syncopal causes 3. Non-syncopal causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING BLACKOUT 1. Epilepsy 2. HOCM 3. Subclavian Steal Syndrome 5. QUIZ NUMBER 21. Which of the following is not a typical feature of temporal lobe seizures? 1. Automatisms 2. Mneomimic 3. Doing strange things on autopilot 4. Versive movements 5. Auras2. Which of the following disorders can increase seizure risk by causing hamartomas to develop in the brain 1. Neurofibromatosis 2. Sturge Weber Syndrome 3. Sotos syndrome 4. Tuberous sclerosis 5. Lissencephaly3. Which of the following is not true with regards to epilepsy complications 1. A seizure lasting more than 5 minutes is status epilepticus 2. Phenytoin is the first line treatment for status epilepticus 3. Alcohol increases the risk of SUDEP 4. Buccal midazolam can be used in the community for status epilepticus 5. SUDEP could in part be due to arrythmias4. What is the most common type of mutation causing HOCM in pre-pubertal patients 1. BRAF mutations 2. TSC1 mutations 3. Mitochondrial gene mutations 4. Androgen receptor mutations 5. Sarcomere protein mutations5. Which of the following signs is not typically seen in HOCM? 1. Fourth heart sound 2. Ejection systolic murmur 3. Collapsing pulse 4. Palpable thrill 5. Murmur loudest at the left lower sternal border6. Which of the following drugs should be avoided in HOCM? 1. B-blockers 2. Calcium channel blockers 3. Lisinopril 4. Aspirin 5. Doxazocin7. Which of the following is the cause of subclavian steal syndrome? 1. Atherosclerosis in the vertebral artery 2. Atherosclerosis in the aorta proximal to the internal carotid artery 3. Atherosclerosis in the subclavian artery proximal to the vertebral artery 4. Atherosclerosis in the subclavian artery distal to the vertebral artery 5. Atherosclerosis cutting off the vertebral artery8. Which of the following neurological symptoms is less likely in subclavian steal syndrome? 1. Dizziness 2. Speech difficulties 3. Vision loss 4. Vertigo 5. Arm painTHANK YOU!REFERENCES 1. Oxford ; New York: Oxford University Press.-Smith, J. (2015). Oxford cases in medicine and surgery. 2. Anon, (n.d.). Zero To Finals – Tools for Medical School. [online] Available at: https://zerotofinals.com. 3. NT Contributor (2018). Stroke 4: immediate treatment of acute stroke and TIAs | Nursing Times. 4-immediate-treatment-of-acute-stroke-and-tias-15-01-2018/.mes.net/clinical-archive/neurology/stroke- 4. [online] Available at: https://geekymedics.com/syncope/.tion, Causes, History Taking | Geeky Medics.