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

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

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 FitFaint Trigger Rare (flashing lights, hyperventilation) Common (upright, bathroom, blood, needles, exertion) Prodrome Common (typical aura: epigastric, déjà vu etc) Almost always (nausea, sweating, palpitations, light- headedness, visual darkening) Onset May be suddenGradual (often minutes) Duration 1-2 minutes1-30 seconds Convulsive jerks Common (prolonged)Common (brief) Incontinence CommonUncommon Lateral tongue bite CommonRare Colour Pale (simple partial seizure) Red, blue (tonic clonic seizures) Very pale Post-ictal recovery Slow (confused)Rapid (quickly oriented) Post-ictal confusion Common (e.g. wakes in ambulance) Rare (e.g. wakes on the floor)

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. 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

18. NEADEpilepsy InducibleCommonRare OnsetGradualSudden DurationProlonged, hoursShort, 1-3 mins Breathing and colour Stays pink, keeps breathing Apnoeic and cyanosed Retained consciousness CommonUncommon Pelvic thrustingCommonRare Fighting, may injure others CommonRare Eyes closedCommonLess common Resists eye openingCommonRare Occurs only in company CommonRare Lateral tongue biteRareCommon IncontinenceRare (with experience) Common Post ictal confusionRarecommon

19. What else could it be?

20. Diagnostic scheme