SYNCOPE / SEIZURE

Question List

1. What were you doing before you passed out?

2. Did you get any warning symptoms before you collapsed?

3. What is your memory of the first thing after the event?

4. Were you incontinent with bowels or bladder?

5. How do you feel now? Do you have any sore muscles?

6. How have you been feeling over the last few days, before today's collapse?

7. Take me through the whole event and what you saw.

8. Were his eyes open or closed?

9. What was his colour like when this happened?

10. How long did the jerking last?

11. How soon did he come around?

12. Have you had any other episodes of lapses in consciousness, or staring episodes, or jerking
episodes in the past?

13. Did you have fever-related seizures or meningitis as a child?

14. Any history of head injury or stroke?

15. Any history of cancer or weakness with immunity?

16. Any diagnosis of learning disability?

17. What do you work as?

18. Do you drive? If so, what type of vehicles?

19. Do you drink alcohol or use any illicit drugs?

20. Any fevers?

21. Any problems with seeing bright light?

22. Any weakness in arms or legs?

MANAGEMENT
There are four important questions for any patient with a likely diagnosis of seizure:
1. Is this really a seizure?
2. Is this the first ever seizure?
3. Is it a provoked or an unprovoked seizure?
4. What instructions will I give to my patient?
 In a patient with first fit, who has a normal neurological status, i.e. normal CT head and a normal
neurological examination after the seizure, the risk of seizure recurrence is low. Ideally, a normal
EEG would support this.

1. Electrocardiogram (ECG)

2. Urea and electrolytes (U&Es)

3. Plasma glucose

4. Full blood count including blood film

5. Computed tomography (CT) head

6. Bone panel

7. Serum magnesium

8. Risk-stratify patient regarding seizure recurrence

9. Refer to neurologist/epileptologist as an outpatient

10. Arrange outpatient electroencephalogram (EEG)

11. Arrange outpatient MRI scan

12. Advise patient to inform DVLA

13. Discuss occupational hazards

14. Discuss dangerous sports

Anti-epileptic drug (AED) therapy should be initiated on the recommendation of a

specialist, after having been discussed with the patient and his family/carers.

AED therapy can be commenced after first seizure if:

- The patient has neurological deficit
- The EEG shows unequivocal epileptic activity
- The patient/family considers the risk of another seizure is unacceptable
- Brain imaging shows structural abnormality

Significant predictors of seizure recurrence [1] are:

- Number of seizures
- Presence of a neurological disorder
- Abnormal EEG

Both the Multicentre trial for early Epilepsy and Single Seizures (MESS) and First Seizure
Trial Group study have looked into early treatment of first fit with AED and there is no
improvement in the long-term outcome in the low risk group [1,2]. Also, there is no
effect on mortality due to Sudden Unexpected Death in Epilepsy (SUDEP) [3]. Therefore,
AED therapy is generally recommended after second seizure in the low risk group.

Key Points
 The diagnosis of seizures is mainly based on the clinical history
 Sometimes eye-witnesses say the patient has had a fit; junior doctors need to tease out
the history to arrive at a seizure diagnosis
 Establish if there was any triggering or precipitating factor, e.g. alcohol, flickering of
lights, drugs
 Distinguish between provoked seizures (due to head injury, stroke, CNS infections) and
unprovoked seizure (where no cause is identified) which, in turn, has an implication on
the prognosis and management
 Junior doctors can forget to mention the implications that diagnosis of seizure has on
driving, occupation and dangerous sports

References
1. Kim LG, Johnson TL, Marson AG et al. Prediction of risk of seizure recurrence after a
single seizure and early epilepsy: further results from the MESS trial. Lancet Neurol
2006;5:317-322.
2. Musicco M, Beghi E, Solari A, et al. Treatment of first tonic-clonic seizure does not
improve the prognosis of epilepsy. First Seizure Trial Group (FIRST Group). Neurology
1997;49:991-998.
3. Shinnar S, O’Dell C, Berg AT. Mortality following a first unprovoked seizure in
children: A prospective study. Neurology 2005;64:880–882.

Questions (20)

1.  Have you had any flu-like symptoms or any fever recently?
2.  Before the seizure, did you experience anything unusual? By this I mean any specific
warning. Any palpitations or clamminess? Any hunger or sweating? Any light-
headedness or chest tightness?
3.  Can you describe what happened to you before, during, and after the seizure?

4.  In the morning, whilst having breakfast or brushing your teeth, have you ever found your
arm uncontrollably jerking?
5.  Have you ever had seizures like this before? If not, have you or other people noticed
uncontrolled jerks of your arms or legs, or moments when you are absent?
6.  Do you drink or take recreational drugs? Did you take anything last night?
7.  Are you ever short of sleep?

8.  Do you take any regular medications? Or have you been prescribed any new medications
recently?
9.  Have you travelled abroad recently?
10.  What do you do for a living?
11.  Did you have a normal birth and development? Did you have any periods of
developmental stress?
12.  Did you or any siblings suffer from febrile seizures when you were young? If so, do you
know what they were like?
13.  Is there any family history of seizures or other medical conditions such as diabetes or
other genetic conditions?
14.  Have you had any head injuries, brain infections or tumours?
15.  Have you had any other symptoms such as rashes, problems with your vision, taste,
smell, hearing or coordination recently?
16.  Have you had any headaches, or vomiting?

17.  I understand you witnessed what happened. Can you describe what happened before,
during and after the seizure?
18.  Were her arms moving and legs moving symmetrically? By that I mean were they
moving about the same on each side, or was one side moving more than the other?
19.  Did she move her head? If so, to which side?
20.  Were her eyes open or closed? If they were open, did you notice which way they were
moving?
Iulia Dulgheru
Junior Clinical Fellow

January 2016 – December 2016 - General Surgery (Romania)

January2017 – March 2018 - General Surgery (FY1) LDH
March 2018 – March 2019 - Trauma and Orthopaedics (SHO) LDH
March 2019 – present - General Medicine (FY1) LDH