Funny turns… what could it be?

1. Funny turns… what could it be? Martin Sadler

2. It’s all in the history… Single most important “tool” in funny turns is a corollary history Funny turns

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

19. What else could it be?

20. Diagnostic scheme