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Jan 14, 2012

Fit or Faint: Funny turn, black out, giddiness, convulsions, syncope, loss of consciousness, vertigo




Above terms in heading are used very frequently without clear distinction from patients. However, their distinction is useful for treatment of patient. This distinction is done from history given by the patient; investigation and clinical examination are only to confirm the diagnosis. Therefore, history given by patient is very important.
Broadly, Giddiness and blackout are terms more often described for wide spectrum of conditions like vertigo, loss of balance, even presyncope.
Syncope and faint are same. Fit and convulsions are same.
Syncope is transient loss of consciousness with loss of postural tone (all muscles of body become flaccid),
Vertigo is equated Funny turn i.e. sensation of movement, problem with inner ear, here there is no loss of conciseness. Some time loss of balance, secondary brainstem problems can give vertigo, but there will other findings like double vision, slurring of speech, difficulty in swallowing in brainstem lesions.
Distinction between faint and fit is some time challenging, even after investigations. Some point given may help in diagnosis. Most important part of distinction is, history given by the patient.
Distinction between Faint or Fit

syncope
Convulsions or seizers
Symptoms before the event
Nausea lightheadedness, sweating
Confusion, hyperexcitabilty, noises heard
During i.e. unconscious period
Pallor
No pallor, tonic clonic movements, tongue biting, passing urine and defecation
After event
Nausea and lightheadedness present
Prolonged confusion,
headache,
paralysis of some body parts may be present.

Syncope is further divided into
1.      vascular
2.      cardiac
3.      psychogenic
Vascular causes (problems from blood vessels)
·         Vasovagal syncope
·         Carotid body hypersensitivity
·         Orthostatic hypotension
Vasovagal syncope :
Most common form of syncope, seen more common in young females  and also in old age middle age this form of syncope is less common
This occurs following prolonged standing in warm environment. Pain of prick  etc
Some patient develop syncope with some situation like passing urine, laughing, defecation, coughing
During event of syncope pallor with slow heart rate and hypotension are present. Most often prompt recovery is role unless patient is not able to lay down example sitting in dental chair
Treatement is to make patient lay down immediately in supine position, head of patient should be never above the level of rest of body. This done to augment flow of blood to brain with help of gravity as brain can not tolerate loss of blood supply.  Within 10 seconds of cessation of blood supply to brain patient becomes unconscious. If more then 3 to 4 minutes of cessation of blood supply to brain occurs then damage to brain occurs.
Giving supine position to all patient of loss of consciousness of any cause is very important part of treatement
Carotid body hypersensitivity
Carotids are blood vessels, which carry blood to brain. These vessels, have pressure sensitive receptors present in the neck, which control blood pressure. They send signal to brain to either increase or decrease heart rate and for vessels to dilate or to constrict. With increase in heart rate and vasoconstriction, blood pressure increases and vasodilatation and decreased heart rate, blood pressure decreases.
Some old individuals have highly sensitive pressure receptors, even with minimal external stimulation like saving, tight collars around the neck can activate these receptors to reduce blood receptors and induce decrease blood pressure and heart rate, induce syncope
For these patient if they have predominant decrease in heart rate as manifestation of syncope, then pacemaker implantation will help them as it works on demand mode to increase the heart rate if it falls below set limit like 50/min for example.
Orthostatic hypotension
On standing from supine position, relative decrease in blood supply to brain happens, due to shift of blood to lower limb by gravity. To overcome, compensatory mechanisms work and prevent this fall in Blood pressure. In some old individuals these compensatory mechanisms is not effective.
Blood pressure fall is predominate manifestation but heart rate is does not decrease, some time increases. This happen within 3 min of standing from supine position, unlike vasovagal syncope, which happens following prolong standing, with decrease in both heart rate and blood pressure.
Causes of ineffective compensatory mechanisms are
·         Diabetes which damage nerve cells
·         Parkinson’s disease (rigidity of limb movement, tremors of limb  due disease of the brain)
·         Blood pressure controlling drug like ACE inhitors  ramipril, enalapril, captopril, diuretics like frusamide, hydrchorothiazide,)
·         Decrease in volume of blood, secondary to blood loss or dehydration, following loose motion and excessive vomiting.
Treatement for these patient is avoid above mentioned drugs if any. Elastic stoking to be worn to leg to decrease accumulation of blood in lower limb. Advise patients not get up suddenly from supine position.

Cardiac cause of syncope (problems from heart)
Syncope secondary to cardiac cardiac cause can secondary to arrythymic in origin or secondary to obstruction of flow of blood
Syncope of flow obstruction occur on execration example HOCM, Aortic stenosis, pulmonary embolism (clot getting plugged in pulmonary artery lead decreased blood reaching the left heart)
Arrythymic cause of syncope is secondary slow heart rate and fast heart rate
Slow heart rate disease
·         sick sinus syndrome (sinus node pacemaker of heart if this stops firing impulses this leads to decreased heart rate)
·         AV node block (heart block): AV node is filter present in between atria and ventricles, this is supposed to allow only required number of impulses to ventricle. Disease of this node prevents impulse reaching the ventricle,  which leads to slow or absent ventricular  contractions
·         Fast heart rates (techycardias) these can originate from both ventricles or atria ventricular tachycardia is more dangerous than atrial ones. Syncope usually follows ventricular tachycardia, in case of atrial tachycardias rarely if syncope occurs that is only in the starting phase of atrial tachycardia then patient usually recovers although atrial tachycardia continues.
Treatement of syncope Out side hospital
·         Put the patient in supine position immediately.(this is most important step of immediate treatement)
·         If patient does not recover after putting in supine position  within   next minute then probably patient has some major issue, it is not syncope
·         Check weather patient has convulsion, if yes mostly patient is not having syncope patient needs medical attention call for medical help  in India some states have 108 phone number for ambulance services
·         find out weather has  patient cardiac arrest if yes start CPR if you are trained
·         in some countries automated external defibrillator are placed in public places take use them
investigation and treatement in hospital
your doctor will ask for ECG, Echocardiography, Head up tilt test, if seizer is supeted then CT scan EEG are done


To Know more on syncope read this http://www.learnonly.com/2012/03/syncope-understanding-made-simple.html