Disturbance & Transient Loss of Consciousness Pathway (for patients over 16 years of age)

 Fall Loss of consciousness No  Drop attack Please refer to the Summary of Product  Migraine Characteristics (SPC) of any drug considered. Yes  Psychogenic This pathway has been developed from published  Hypoglycaemia guidance in collaboration with local neurologists.  Dizziness This guidance is to assist GPs in decision making  Intoxication and is not intended to replace clinical judgement History including review of  Cataplexy medication/drugs/alcohol,  Anxiety/ examination, eye witness hyperventilation Queries – [email protected] account. Manage as clinically References – Blood pressure (+/- postural NICE CG109 Transient loss of consciousness in over 16s BP), pulse, ECG appropriate and screening blood tests Refer to Acute medical team IF:  Persistent focal neurology Immediate clinical concern?  Recent history of head/neck trauma Yes  Status epilepticus (continued seizures >30 minutes) No  Abnormal ECG (e.g. conduction abnormalities)

Suspected epilepsy Syncope Known epilepsy

 Seizure in immunosuppressed patient  Seizure with known drug use or alcohol dependency  Seizures patients with cancer diagnosis  Seizures following new medication initiation  Seizure clinically unwell patient eg symptoms of infection, meningism, dehydration  Crescendo seizures

Telephone epilepsy nurse specialist (if under service) or on-call neurology doctor

 Lateral tongue biting  Head turning to one side Neurally-mediated Cardiac syncope Orthostatic hypotension Other cause  Amnesia of event  Unusual posturing FBC, UE, TFT, HbA1C, ECG,  Prolonged limb jerking echo, BP if not already done Volume depletion  Confusion after event/ Drug-induced Refer urgently to cardiology IF: Underlying autonomic failure Patient deja vu Normal Dizziness > 80 years  New onset significant murmur ECG & old  Chest Pain suggestive of angina  Abnormal ECG / echo / echo + Lying and standing BP arrhythmia needing cardiology single or  Syncope during exercise where infrequent If symptoms persist clinical concern similar consider Advice & Consider Refer urgently to  New/unexplained breathlessness Guidance +/- e-referral to Refer to neurology episodes referral to  FHx or sudden cardiac death cardiology dizziness care of pathway See referral form for criteria 40 yrs old elderly  65 yrs old with no prodromal Reassure Consider medication trial* symptoms

Vasovagal faint Carotid-sinus syncope (pressure on Situational or exercise induced carotid artery causes syncope) Consider referring unexplained syncope Typical prodrome** Cough, sneeze, micturition, post-prandial, Emotional distress, fear, swallow, brass instrument playing, in patients >aged 60 years to cardiology instrumentation, blood phobia, exercise, weight-lifting for carotid sinus massage with ECG orthostatic stress monitoring Reassure  Advice on fluid (+/-) salt intake Consider carotid-sinus syncope in men >40 shaving,  Advice on counter-pressure manoeuvres*** extreme head turning or wearing tight fitting collar  Situational awareness  Avoidance / amelioration of situational triggers FBC, UE, TFT, HbA1C, ECG, BP if Recurrent episodes / persistent symptoms not already done

FBC, UE, TFT, HbA1C, ECG, BP Consider Advice & Guidance on e-referral OR referral to cardiology If tests normal, consider cardiology Advice & Guidance where clinically appropriate

* Orthostatic hypotension – Consider fludrocortisone (off-label indication): ** 3 Ps = Posture (e.g. prolonged standing); Provoking (e.g. pain or medical procedure); Prodromal (e.g. sweating, feeling warm/hot before TLoC) Initial dose: 50 to 100 micrograms once daily, increased to a usual *** Leg crossing, clenching fists, tensing arms and body maximum of 300 micrograms once daily. Advise all people who have experienced transient loss of consciousness that they must not Check sitting & standing BP weekly before each dose titration. drive while waiting for a specialist assessment. Depending on the outcome of the specialist Discontinue if blood pressure in either position increases assessment, advise that the person may then be obliged to report the event to the Driver and above 180/100 mmHg or is considered clinically significant. Vehicle Licensing Agency (DVLA). Refer to the full DVLA guidance. Contraindications, cautions, drug interactions and adverse effects are Group 1 includes cars and motorcycles as per systemic corticosteroid treatment. Avoid abrupt withdrawal – Group 2 includes large lorries and buses consider advice & guidance on eRS. Note any blood test monitoring required.

Health & Safety at work: Advise patients to ensure the safety of themselves and others at work. For full details of contraindications, cautions, drug interactions and adverse effects check BNF or summary of product characteristics

Produced by neurology STP group. Approved by Camden Clinical Cabinet July 2019 and Camden Medicines Management Committee August 2019. Review due August 2021