MINISTRY OF PUBLIC HEALTH OF UKRAINE ZAPORIZHZHIA STATE MEDICAL UNIVERSITY DEPARTMENT OF GENERAL PRACTICE – FAMILY MEDICINE AND INTERNAL DISEASES DEPARTMENT OF GENERAL PRACTICE – FAMILY MEDICINE, THERAPY, CARDIOLOGY AND NEUROLOGY OF THE POSTGRADUATE FACULTY TACTICS OF FAMILY DOCTORS IN CASE OF SYNCOPAL STATES STUDY GUIDE for the students of the specialty "Medicine" in the program of the educational discipline "General Practice - Family Medicine" Zaporizhzhia 2020 2 UDC 616.8-009.832-08(072) М 99 Аpproved by Central Methodical Council of Zaporizhzhia State Medical University as а study guide (Protocol № 3 of 27.02.2020) and recommended for use in the educational process Authors: N. S. Mykhailovska - Doctor of Medical Sciences, Professor, head of the Department of General practice – family medicine and internal diseases, Zaporizhzhia State Medical University; A. V. Grytsay - PhD, associated professor of the Department of General practice – family medicine and internal diseases, Zaporizhzhia State Medical University; І. S. Kachan - associated professor of the Department of Family medicine, therapy, cardiology and neurology of the Postgraduate faculty, Zaporizhzhia State Medical University. Readers: S. Y. Dotsenko – Doctor of Medical Sciences, Professor, Head of the Internal Medicine №3 Department, Zaporozhye State Medical University; S. M. Kiselev – Doctor of Medical Sciences, Professor, Professor of the Department of Internal diseases 1, Zaporizhzhia State Medical University. Mykhailovska N. S. M99 Tactics of family doctors in case of syncopal states = Тактика сімейного лікаря при синкопальних станах: study guide for the practical classes and individual work for 6th-years students of international faculty (speciality «General medicine»), discipline «General practice – family medicine» / N. S. Mykhailovska, A. V. Grytsay, I.S. Kachan. – Zaporizhzhia : ZSMU, 2020. – 166 p. The study guide for practical classes and independent work of students of the 6th year of the international faculty of specialty "Medicine" is made in accordance with the program of the discipline "General Practice - Family Medicine". The aim of the publication is to promote a better understanding of theoretical knowledge and practical skills in the relevant topic. The study guide is also intended for interns, family doctors, physicians and other specialties who wish to supplement their knowledge of this section of medicine. UDC 616.8-009.832-08(072) ©Mykhailovska N. S., Grytsay A. V., Kachan I.S., 2020 ©Zaporizhzhia State Medical University, 2020 3 CONTENT Preface …………………………………………………………………………. 5 List of abbreviations…………………………………………………………….. 6 Theme actuality. Study purposes. Concrete purposes of the module………….. 8 Tasks for initial independent training…………………………………………… 9 Syncope. ………………………………………………………………………… 12 Syncope Clinical Presentation………………………………………………. 16 Syncope Differential Diagnoses……………………………………………. 24 Syncope Workup……………………………………………………………. 26 Syncope Treatment & Management………………………………………… 30 Ddizziness and vertigo …………………………………………………………. 35 Treatment...................................................................................................... 43 Miscellaneous Head Sensations....................................................................... 43 Approach to the Patient................................................................................... 44 Acute confusional states and coma……………………………………………. 46 Coma-like syndromes and related states………………………………….. 48 Anatomic correlates of consciousness……………………………………. 50 Pathophysiology of coma and confusion…………………………………. 52 Approach to the Patient……………………………………………………. 54 Laboratory examination for acute confusion and coma…………………. 63 Differential diagnosis of confusion and coma……………………………. 65 Treatment…………………………………………………………………… 71 Prognosis of coma and the vegetative state……………………………….. 72 Cardiovascular collapse, cardiac arrest, and sudden cardiac death.…………… 74 Etiology, initiating events, and clinical epidemiology……………………… 75 Clinical definition of forms of cardiovascular collapse…………………… 79 Clinical characteristics of cardiac arrest…………………………………… 80 Treatment…………………………………………………………………… 84 Initial Response and Basic Life Support………………………………… 85 Long-term management after survival of out-of-hospital cardiac arrest……………………………………………………………………...... 88 Seizures and epilepsy ………………………………………………………….. 91 Overview…………………………………………………………………. 91 4 Epilepsy syndromes……………………………………………………… 99 The causes of seizures and epilepsy……………………………………… 107 Clinical Presentation……………………………………………………… 114 Laboratory Studies……………………………………………………….. 122 Medications……………………………………………………………….. 130 Management of patients with active seizure…………………………….. 133 Beyond seizures: other management issues. Interictal Behavior………. 147 Special issues related to women and epilepsy………………………….. 148 Tasks for final control…………………………………………………………… 151 Basic questions after a theme………………………………………………….. 159 Recommended literature………………………………………………………… 160 References ……………………………………………………………………… 163 5 PREFACE In the doctor`s practice, coma presents one of the greatest difficulties for the diagnosis and choice of therapy. The prognosis and fate of the patient in a coma state largely depends on the organization of care at the prehospital and hospital stage. It is important for the doctor to determine the cause of the coma. But before identifying the etiology of a coma, it is necessary to ensure effective maintenance of the vital functions of the patient - respiration and blood circulation, otherwise their serious violations may occur, while the coma itself may be reversible.This textbook includes the educational material for practical classes and individual work of students (Content module 5 «The organization of the emergency on the pre-admission stage in the practice of family doctor»), the tests for initial and final control for academic discipline «General practice – family medicine», recommended literature. The purpose of this textbook is acquiring of knowledge and practical skills of 6th-years students during preparation for classes and final module control. The necessity of this textbook is conditioned by absence of such workbooks, which satisfy requirements of basic parts of academic subject «General practice – family medicine». This textbook can be recommended for students of institutes of higher education (IV accreditation level) in the study of appropriate topic, intern, general practitioner – family doctor, other specialists. 6 LIST OF ABBREVIATIONS ABG arterial blood gas ACEP American College of Emergency Physician AV Atrioventricular BNP B-type natriuretic peptide BP blood pressure BPPV Benign paroxysmal positional (or positioning) vertigo CBF cerebral blood flow CHF congestive heart failure CK creatine kinase CNS central nervous system CO Cardiac output COPD chronic obstructive pulmonary disease CPR cardiopulmonary resuscitation CSF cerebrospinal fluid CT computed tomogaphy DIC disseminated intravascular coagulation DVT deep venous thrombosis ED emergency department EEG Electroencephalography EF ejection fraction EPS electrophysiologic studies GABA gamma-aminobutyric acid GCSE generalized convulsive SE GTCS generalized tonic-clonic seizure ICD implantable cardioverter/defibrillator ICH Intracranial hemorrhage ICP intracranial pressure 7 IM intramuscular IV Intravenous MAP Mean arterial pressure MERRF Myoclonic epilepsy with ragged red fibers MI myocardial infarction MLF medial longitudinal fasciculus MRA magnetic resonance arteriography MRI magnetic resonance image MTLE Mesial Temporal Lobe Epilepsy Syndrome NMDA N-methyl-D-aspartate NMS neurally-mediated syncope NYHA New York Heart Association PET positron emission tomography PVCs premature ventricular contractions RAS reticular activating system SCD sudden cardiac deaths SE status epilepticus SFSR San Francisco Syncope Rule SPECT single photon emission computed tomography SVR Systemic vascular resistance TCA Tricyclic antidepressant TED thromboembolic disease TIAs Transient Ischemic Attacks UTI urinary tract infection VF ventricular fibrillation VOR vestibuloocular reflex VT ventricular tachycardia 8 SYNCOPE. DIZZINESS AND VERTIGO. CARDIOVASCULAR COLLAPSE, CARDIAC ARREST, AND SUDDEN CARDIAC DEATH. SEIZURE I. Theme actuality. First aid for children and adults has great importance for their further treatment and recovering diagnosis at pre-admission stage. And at the same time family doctor always faces a problem: what is better – either to give maximum necessary scope of emergency on the site of the incident or to take the patient to the nearest hospital as soon as possible. According to expert data there is only one decision of this problem. This means give maximum necessary scope of emergency in a short- run and then to admit to specialized hospital. Stabilization of patient’s vital functions is the criteria of emergency scope in the place of the incident. Fundamental factors in this process are timeliness of emergency on the site of the incident, vocational training of a specialist and sufficient medical provision. In this textbook syncope, dizziness and vertigo, cardiovascular collapse, cardiac arrest, and sudden cardiac death and seizure are considered with particular reference to clinical manifestations, differential diagnosis, and treatment [2]. II. Study purposes: to be able to detect the signs of syncope, dizziness and vertigo, cardiovascular collapse, cardiac arrest, and sudden cardiac death, and seizure, to propose a plan of examination and treatment of patients