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    Add as FriendFunny turns… what could it be?

    by: Rogers

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    1 : Funny turns… what could it be? Martin Sadler
    2 : Funny turns It’s all in the history… Single most important “tool” in funny turns is a corollary history
    3 : 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
    4 : 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
    5 : 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
    6 : Features
    7 : 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
    8 : 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
    9 : 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)
    10 : 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)
    11 : Orthostatic syncope Autonomic dysfunction Upright Colour normal Heart rate unchanged No sweating Old age, DM, alcohol, amyloid Drugs (eg in PD) MSA
    12 : 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)
    13 : Yet more… Toxic/metabolic/infectious causes Respiratory syncope ? Cough Hyperventilation Breath holding (children) CNS syncope Raised intracranial pressure Autonomic dysreflexia Concussive convulsions Psychogenic attacks
    14 : And more… TIAs TGA Startle disorders Migraine Retinal Basilar artery Migraine syncope Migraine-epilepsy syndrome Migraine coma
    15 : NEAD
    16 : 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
    17 : NEAD 2 EEGs normal during and between attacks No prolactin rise Telemetry often helpful Outcome variable
    18 :
    19 : What else could it be?
    20 : Diagnostic scheme

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