2010 COSCIENZA Filippi

Perdita di coscienza
Telefonata
Visita
domiciliare
118
Consiglio
telefonico
Gestione
domiciliare
Informazioni a paziente e familairi
Consigli a paziente e familiari
Eventuali modifiche terapie in atto
Informazioni per MMG
Coma
Final diagnosis in 500 patients
admitted to hospital with “coma of unknown etiology”
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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%)
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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
Conditions incorrectly diagnosed
as syncope
Disorders without impairment of consciousness
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Cataplexy
Drop attacks
Falls
Functional (psychogenic pseudosyncope)
Anxiety Attacks and the Hyperventilation
Syndrome
• TIA of carotid origin
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
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.
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
Psychogenic pseudosyncope
Epilepsy & Behavior
Volume 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.
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.
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
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.
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).
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.
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
• 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
creatine kinase (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.
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)
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
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
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
Epilessia: LG Regione Toscana
• Le crisi di assenza e parziali non necessitano, in genere, di
soccorsi speciali né della somministrazione di farmaci
• Ricordare che:
– 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
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
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
Schematic presentation of the distribution of age and cumulative incidence of first
episode of syncope in the general population
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.
Management of syncope
in 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.
Classification of syncope
Classification of syncope
Classification of syncope
Recommendations: diagnostic criteria with initial evaluation
The value of history for distinguishing seizure from syncope (adapted from Hoefnagels
et al.5)