Perdita di coscienza

1. Perdita di coscienza

2. Telefonata Visitadomiciliare Consigliotelefonico 118 Gestionedomiciliare Informazioni a paziente e familairi Consigli a paziente e familiari Eventualimodificheterapie in atto Informazioni per MMG

5. Coma Final diagnosis in 500 patients admitted to hospital with “coma of unknown etiology” • Metabolic and other diffuse disorders 326 (65%) • Drug poisoning 149 • Anoxia or ischemia 87 • Hepatic encephalopathy17 • Encephalomyelitis and encephalitis 14 • Subarachnoid hemorrhage 13 • Endocrine disorders (including diabetes) 12 • Acid-base disorders 12 • Temperature regulation 9 • Uremic encephalopathy8 • Pulmonary disease 3 • Nutritional 1 • Nonspecific metabolic coma 1 • Psychiatric disorders 8 (2%) • Supratentorial mass lesions 101 (20%) • Intracerebral hematoma 44 • Subdural hematoma 26 • Cerebral infarct 9 • Brain tumor 7 • Brain abscess 6 • Epidural hematoma 4 • Thalamic infarct 2 • Pituitaryapoplexy 2 • Closed headinjury1 • Subtentorial lesions 65 (13%) • Brainstem infarct 40 • Pontine hemorrhage 11 • Cerebellar hemorrhage 5 • Cerebellar tumor 3 • Cerebellar infarct 2 • Brainstem demyelination 1 • Cerebellar abscess 1 • Posterior fossa subdural hemorrhage 1 • Basilar migraine 1

6. Conditions incorrectly diagnosed as syncope Disorders without impairment of consciousness • Cataplexy • Drop attacks • Falls • Functional (psychogenic pseudosyncope) • Anxiety Attacks and the Hyperventilation Syndrome • TIA of carotid origin

7. cataplessia • una rapida perdita del tono muscolare causata da manifestazioni emotive come riso, collera, eccitazione, sorpresa. Un attacco cataplettico può comportare solo una breve e parziale debolezza ma può anche causare una quasi completa perdita del controllo muscolare per alcuni minuti. Ciò può provocare una caduta, l'impossibilità di muoversi e di parlare, anche se il soggetto è cosciente o almeno parzialmente conscio di ciò che gli sta accadendo.www.narcolessia.it

8. Drop Attacks • This term is generally applied to falling spells that occur without warning and without loss of consciousness or postictal symptoms. The patient, usually elderly and more often female, suddenly falls down while walking or standing, rarely while stooping. The knees inexplicably buckle. There is no dizziness or impairment of consciousness, and the fall is usually forward, with scuffing of the knees and sometimes the nose. The patient, unless obese, is able to right herself and to rise immediately and go her way, quite embarrassed. There may be several attacks during a period of a few weeks and none thereafter.

9. Psychogenic pseudosyncope • Generalised anxiety disorder, panic disorder, somatisation disorder and major depression can present with apparent syncope, usually young; no known cardiac problems; frequent episodes of recurrent syncope

10. Psychogenic pseudosyncopeEpilepsy & BehaviorVolume 9, Issue 1, August 2006, Pages 106-110 • The diagnosis of psychogenic pseudosyncope required:(1) an activation procedure that triggered the habitual event; (2) a clinical event of loss of postural tone and limp, motionless unresponsiveness with eyes closed; (3) normal EEG before, during, and after the clinical event, that is, no epileptiform abnormalities, a normal α rhythm during unresponsiveness, and no suppression of background or slowing as is typically seen in syncope.

11. Anxiety Attacks and the Hyperventilation Syndrome • Probably the most important diagnostic considerations in unexplained faintness without syncope. The light-headedness of anxiety and hyperventilation are frequently described as a feeling of faintness, but a loss of consciousness does not follow • Such symptoms are not accompanied by facial pallor or relieved by recumbency.

12. Conditions incorrectly diagnosed as syncope Disorders with partial or complete LOC but without global cerebral hypoperfusion • Epilepsy • Metabolic disorders, including hypoglicemia, hypoxia, hyperventilation with hypocapnia • Intoxication • Vertebrobasilar TIA

13. Transient Cerebral Ischemic Attacks • Syncope is not one of the clinical presentations. In the case of attacks in the vertebrobasilar territory, an impairment of consciousness is a rare manifestation, but almost always in the context of additional signs of upper brainstem dysfunction. • The syncope of aortic arch occlusive (Takayasu) disease is, however, usually associated with TIAs, some elicited by effort or exercise.

14. Hypoglycemia In nondiabetics • Hypoglycemia may be an obscure cause of episodic weakness and very rarely of syncope. With progressive lowering of blood glucose, the clinical picture is one of hunger, trembling, flushed facies, sweating, confusion, and finally, after many minutes, seizures and coma. • The diagnosis depends largely on the history, the documentation of reduced blood glucose during an attack, and reproduction of the patient’s spontaneous attacks by an injection of insulin or hypoglycemia-inducing drugs (or ingestion of a high-carbohydrate meal in the case of reactive hypoglycemia).

15. Although a useful medical term to denote recurrent seizures, the words epilepsy and epileptic still have unpleasant connotations to the laity and should be used advisedly in dealing with patients.

16. Viewed in its many clinical contexts, the first solitary seizure or brief outburst of seizures may occur during the course of many medical illnesses. It indicates that the cerebral cortex has been affected by disease, either primarily or secondarily

17. The authors have erred in mistaking akinetic seizures for simple faints and vasovagal and cardiac faints for seizures. • Postictal confusion, incontinence, and a bitten tongue clearly bespeak seizure rather than syncope. • If blood is tested after the episode in question, elevation in creatinekinase (persistent for hours) and prolactin (for up to 10 min) may be helpful in the diagnosis of a convulsive seizure. • Absence attacks may be difficult to identify because of their brevity. Helpful maneuver are to have the patient hyperventilate in order to evoke an attack or to observe the patient counting aloud for 5 min. Those with frequent absence attacks will pause or skip one or two numbers.

18. Epilessia: LG Regione Toscana • La diagnosi di crisi epilettica e di epilessia è prima di tutto clinica e, in assenza di un’osservazione diretta, si basa sulla storia del disturbo ictale riferito dal paziente o da un testimone. A volte può essere difficile stabilire una diagnosi corretta, poiché diverse condizioni possono simulare una crisi epilettica e, viceversa, il racconto di una crisi epilettica può essere simile a quello di un evento non epilettico (per esempio: sincope, aure emicraniche, crisi psicogene)

19. Epilessia: LG Regione Toscana • Nel sospetto di crisi epilettiche è indicato che i medici di medicina generale, i pediatri di famiglia, il personale dei mezzi di soccorso, i medici dell’emergenza territoriale e dell’accettazione ospedaliera raccolgano dal paziente e/o dai testimoni delle crisi le informazioni utili a una diagnosi differenziale precoce e alla definizione del tipo di disturbo

20. Epilessia: LG Regione Toscana Durante una crisi tonico-clonica generalizzata è indicato: • proteggere da eventuali lesioni della testa e del corpo, togliere occhiali e allontanare gli oggetti pericolosi • aiutare a respirare slacciando indumenti stretti • rimanere vicino, osservare, descrivere la crisi e la durata • non cercare di: rialzare la persona o modificarne la posizione, contenere le convulsioni, aprire la bocca a forza e introdurre qualcosa tra i denti, dare qualcosa da bere, praticare la respirazione artificiale

21. Epilessia: LG Regione Toscana Dopo una crisi tonico clonica-generalizzata è indicato: • posizionare la persona sul fianco (permette la fuoriuscita dalla bocca di saliva e vomito) • togliere dalla cavità orale eventuali impedimenti alla respirazione • restare accanto alla persona finché è confusa e proteggerla • non contenere e non somministrare farmaci se la crisi termina spontaneamente e, soprattutto, niente per bocca finché la persona non ha ripreso coscienza • rassicurare utilizzando calma, persuasione, gentilezza e sostegno psicologico

22. Epilessia: LG Regione Toscana • Le crisi di assenza e parziali non necessitano, in genere, di soccorsi speciali né della somministrazione difarmaci • Ricordareche: • le assenze sono brevi e basta rimanere accanto alla persona per controllare che si risolvano spontaneamente e per saper descrivere successivamente quanto avvenuto • in caso di crisi parziali complesse può essere necessario interagire con la persona allontanandola da luoghi pericolosi e proteggerla finché non ha ripreso coscienza o si avvisano situazioni di pericolo • non si deve gridare o scuotere la persona finché non si è ripresa

23. Epilessia: LG Regione Toscana Per lo più le crisi epilettiche cessano spontaneamente dopo pochi minuti e l’attivazione dell’emergenza è indicata solo se: • si tratta di una prima crisi tonico-clonica o la crisi si verifica in corso di un evento acuto (per esempio trauma cranico, stroke, malattia infettiva) definito o sospetto • la crisi convulsiva dura più a lungo del comune (2-3 minuti) • la persona tarda a riprendere conoscenza (>5 minuti) • le crisi si ripetono • la persona si è procurata lesioni • la persona respira con difficoltà o ha problemi circolatori

24. Epilessia: LG Regione Toscana • In caso di crisi epilettiche il ricovero ospedaliero non è quasi mai necessario, salvo che non si sospetti che le crisi siano sintomatiche di un danno cerebrale acuto e/o non vi siano altri motivi legati alla situazione clinica e sociale del paziente

25. Schematic presentation of the distribution of age and cumulative incidence of first episode of syncope in the general population

26. Syncope in paediatric patients • Reflex syncope represents the vast majority of the aetiology, but in rare cases syncope is the manifestation of lifethreatening cardiac arrhythmia or structural abnormalities. • Syncope should also be differentiated from epilepsy and psychogenic pseudosyncope, which are rare but important causes of T-LOC in paediatric patients. • Two specific conditions occur in early childhood: (1) Infantile reflex syncopal attacks (also called pallid breathholding spells or reflex anoxic seizures), elicited by a brief unpleasant stimulus, are caused by vagally mediated cardiac inhibition. (2) Apnoeic hypoxic T-LOC (also called cyanotic breath-holding spells), are characterized by an expiratory cessation of respiration during crying, leading to cyanosis and usually T-LOC.

28. Management of syncopein general practice • Syncope is a common phenomenon in general practice. Recurrent typical VVS is the most common diagnosis in this setting. The diagnosis is based upon a carefully taken medical history and the context of the event. Most of these typical common faints can be diagnosed by the patient’s general practitioner and need only reassurance. An active searching for alarming symptoms is recommended. • Alarming symptoms are: syncope during exertion, syncope in the lying position, absence of external factors, family history of SCD, or slow recovery from syncope. • If the diagnosis remains uncertain and there is potential risk of dangerous consequences then the patient should be referred to cardiologist, internist, neurologist, psychologist/psychiatrist as appropriate or to a specialized syncope facility if available.

29. Classification of syncope

30. Classification of syncope

31. Classification of syncope

32. Recommendations: diagnostic criteria with initial evaluation

33. The value of history for distinguishing seizure from syncope (adapted from Hoefnagels et al.5)