Funny turns… what could it be?

Martin Sadler

Funny turns

It’s all in the history…

Single most important “tool” in funny turns is a corollary history

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

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

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

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)

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

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

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)

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)

Orthostatic syncope

Autonomic dysfunction Upright Colour normal Heart rate unchanged No sweating

Old age, DM, alcohol, amyloid Drugs (eg in PD) MSA

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)

Yet more…

Toxic/metabolic/infectious causes Respiratory syncope

Cough Hyperventilation Breath holding (children)

CNS syncope Raised intracranial pressure Autonomic dysreflexia Concussive convulsions

Psychogenic attacks

And more…

TIAs TGA Startle disorders Migraine

Retinal Basilar artery Migraine syncope Migraine-epilepsy syndrome Migraine coma

NEAD

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

NEAD 2

EEGs normal during and between attacks No prolactin rise Telemetry often helpful

Outcome variable

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

What else could it be?

Diagnostic scheme