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11/13/24, 8\:10 PM Guide | Loss of consciousness history

Loss of consciousness history

Table of contents

Background

Syncope

Syncope occurs due to global cerebral hypoperfusion which can itself have a variety of underlying causes which are
discussed below.
Re
Re
Vasovagal syncope is a form of re
Emotional distress (e.g. fear, pain, instrumentation, blood phobia, enclosed space)
Orthostatic stress (e.g. prolonged standing)
Situational syncope is a form of re
and eating (post-prandial).
Carotid sinus hypersensitivity is another form of re
tight collar and shaving.
Cardiovascular syncope
Cardiovascular syncope involves sudden decreased cardiac output secondary to pathology within the cardiovascular system
such as\:
Arrhythmias
Structural cardiovascular disease (e.g. coronary artery disease, valve disease, cardiac tamponade, hypertrophic
cardiomyopathy and aortic dissection)
Structural pulmonary disease (e.g. pulmonary embolism)
Orthostatic hypotension
Orthostatic hypotension involves a sudden drop in blood pressure after standing upright.
Causes of orthostatic hypotension include\:
Hypovolaemia (e.g. haemorrhage, diarrhoea, vomiting)
Iatrogenic (e.g. beta-blockers, diuretics, alcohol, vasodilators, antidepressants, phenothiazines)
Autonomic failure (e.g. diabetic neuropathy, Parkinson's disease, spinal cord injury)

Seizure

Seizures are caused by abnormal excessive neuronal activity in the brain, leading to impairment of normal cognitive function.
Seizures that involve a complete loss of consciousness are known as generalised seizures (either convulsive or non-
convulsive).
Causes of generalised seizures include\:
Metabolic disturbances (e.g. hypoglycaemia, electrolyte abnormalities, drug or alcohol intoxication and adrenal insu
Space-occupying lesions (e.g. brain metastases, primary brain tumour, cerebral abscess)
Head trauma
Stroke
Medication\: some medications lower the seizure threshold (e.g. nefopam).
Epilepsy\: spontaneous abnormal excessive neuronal activity in the brain.
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Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you're running through a checklist in your head doesn't mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
“ W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?”
“ T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
“ O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?”
“ C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di
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History of presenting complaint

A comprehensive history is essential to e
consciousness. A collateral history from someone who witnessed the episode is often required to gain accurate details about
what happened during and immediately after the loss of consciousness.

Before the loss of consciousness

Triggers
pathology\:
It is important to explore potential triggers for the loss of consciousness as they may provide insight into the likely underlying
" W a s t h e r e a n y o b v i o u s t r i g g e r t h a t p r e c e d e d y o u r l o s s o f c o n s c i o u s n e s s ?"
" W h a t w e r e y o u d o i n g j u s t b e f o r e y o u l o s t c o n s c i o u s n e s s ?"
Re
Vasovagal syncope\: triggers include emotional distress (e.g. fear, pain, instrumentation, blood phobia) and orthostatic stress
(e.g. prolonged standing).
Situational syncope\: triggers include cough, sneeze, defecation, micturition, exercise and eating (post-prandial).
Carotid sinus hypersensitivity\: triggers include shaving, tight-
Triggers in other types of loss of consciousness can include\:
Physical exertion\: associated with cardiovascular syncope (e.g. aortic stenosis, arrhythmia).
Standing from sitting\: associated with orthostatic hypotension (e.g. hypovolaemia, autonomic failure).
Working with arms elevated above head\: associated with subclavian steal syndrome.
Exposure to rapidly
Prodromal symptoms including aura
Vasovagal syncope is often preceded by prodromal symptoms such as\:
Progressive light-headedness
Visual disturbances (dimming of vision or loss of vision)
Weakness or sensory disturbances of the extremities
Sweating
Nausea
Tinnitus
The patient also typically demonstrates a slow, controlled collapse towards the ground (unlike cardiovascular syncope which
typically involves a sudden uncontrolled fall to the ground).
Cardiovascular syncope often lacks any prodromal symptoms, with the patient feeling ok and then losing consciousness
suddenly with no warning. Sometimes patients with cardiovascular syncope may experience palpitations or chest pain prior to
the loss of consciousness (secondary to an arrhythmia). You should, therefore, consider the possibility of an underlying
arrhythmia or structural heart disease if the patient reports palpitations, chest pain or a complete absence of prodromal
symptoms. Chest pain is also associated with pulmonary embolism and aortic dissection, both of which can cause syncope.
Ask the patient if they experienced any prodromal symptoms\:
" D i d y o u h a v e a n y s y m p t o m s b e f o r e y o u l o s t c o n s c i o u s n e s s ?"
" D i d y o u n o t i c e a n y v i s u a l c h a n g e s b e f o r e y o u r l o s t c o n s c i o u s n e s s ?"
" D i d y o u f e e l n a u s e a t e d o r s w e a t y b e f o r e y o u l o s t c o n s c i o u s n e s s ?"
" D i d y o u n o t i c e a n y c h a n g e s t o y o u r h e a r i n g b e f o r e y o u l o s t c o n s c i o u s n e s s ?"
" D i d y o u n o t i c e a n y w e a k n e s s o r c h a n g e s i n s e n s a t i o n b e f o r e y o u l o s t c o n s c i o u s n e s s ?"
" D i d y o u n o t i c e t h a t y o u r h e a r t b e a t b e c a m e m o r e p r o m i n e n t b e f o r e y o u l o s t c o n s c i o u s n e s s ?"
" D i d y o u e x p e r i e n c e a n y c h e s t p a i n b e f o r e y o u l o s t c o n s c i o u s n e s s ?"
Generalised seizures can begin with epileptic auras or focal motor/sensory seizures causing symptoms such as\:
Olfactory or gustatory hallucinations (e.g. a speci
Visual hallucinations (e.g.
A sense of déjà-vu
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Sensory disturbances (e.g. numbness, tingling)
Motor weakness (e.g. unilateral limb weakness, twitching)
Ask the patient if they experienced any focal motor/sensory or aura-like symptoms\:
" D i d y o u n o t i c e a n y u n u s u a l s m e l l s o r t a s t e s p r i o r t o l o s i n g c o n s c i o u s n e s s ?"
" D i d y o u e x p e r i e n c e a n y v i s u a l h a l l u c i n a t i o n s p r i o r t o l o s i n g c o n s c i o u s n e s s ?"
" D i d y o u e x p e r i e n c e a s e n s e o f d é j à-v u p r i o r t o l o s i n g c o n s c i o u s n e s s ?"
" D i d y o u e x p e r i e n c e a n y c h a n g e s t o t h e s e n s a t i o n o f y o u r b o d y p r i o r t o l o s i n g c o n s c i o u s n e s s ?"
" D i d y o u n o t i c e a n y t w i t c h i n g o r w e a k n e s s o r y o u r a r m s , l e g s o r f a c e p r i o r t o l o s i n g c o n s c i o u s n e s s ?"

During the period of unconsciousness

Motor symptoms
Ask the person providing the collateral history if the patient's muscles appeared sti
movements\:
" D i d t h e p a t i e n t' s m u s c l e s a p p e a r s t i
" D i d y o u n o t i c e a n y j e r k i n g m o v e m e n t s d u r i n g t h e e p i s o d e ?"
During a syncopal episode, most patient's muscles will become
patient has a syncopal episode which results in them remaining upright (e.g. against a wall), they may then develop sti
the muscles and jerking movements as a result of a secondary anoxic seizure due to prolonged cerebral hypoperfusion.
Initial tonic sti
clonic seizures.
Duration
Ask the person providing the collateral history how long the episode of LOC lasted\:
" H o w l o n g d i d t h e e p i s o d e l a s t i n t o t a l ?"
" W a s t h e e p i s o d e s e c o n d s o r s e v e r a l m i n u t e s l o n g ?
Episodes of syncope typically last less than 20 seconds.
Seizures typically last longer than 20 seconds, although it is possible to have seizures of a shorter duration.
Other clinical features
Ask the patient or the person providing the collateral history if they noticed any other clinical features during the episode\:
" D i d y o u n o t i c e a n y e v i d e n c e o f t o n g u e b i t i n g d u r i n g t h e e p i s o d e ?"
" W a s t h e r e l o s s o f c o n t i n e n c e d u r i n g t h e e p i s o d e ?"
" D i d t h e p a t i e n t a p p e a r b l u e i n c o l o u r d u r i n g t h e e p i s o d e ? W a s t h i s i m m e d i a t e o r d i d i t d e v e l o p a f t e r a w h i l e ?"
Tongue biting (typically the lateral aspect) is more commonly associated with generalized tonic-clonic seizures.
Urinary or faecal incontinence is more commonly associated with seizures than syncope (although it can occur in either).
Cyanosis caused by cardiorespiratory arrest is typically associated with arrhythmias, structural cardiac disease and
pulmonary embolism.
Cyanosis can also occur in the context of a prolonged seizure, however tonic-clonic movements will typically precede the
development of cyanosis.

After the loss of consciousness

Time to full recovery
Ask the person providing the collateral history how long it took for the patient to regain consciousness and if they were
confused initially\:
" H o w l o n g d i d i t t a k e f o r t h e p a t i e n t t o b e b a c k t o t h e i r u s u a l s e l f ?"
" D i d t h e y s e e m c o n f u s e d a f t e r t h e l o s s o f c o n s c i o u s n e s s ?"
" D i d t h e y a p p e a r d r o w s y a f t e r t h e l o s s o f c o n s c i o u s n e s s ?"
Patients experiencing a syncopal episode will typically regain consciousness and full lucidity within 20-30 seconds.
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Patients experiencing a seizure will have a post-ictal period after the seizure in which they may be drowsy, confused and
agitated. The post-ictal period can last for several minutes to hours and is often not remembered by the patient.
Relieving factors
Ask if there was anything that seemed to quickly resolve the episode of loss of consciousness\:
" W a s t h e r e a n y t h i n g t h a t s e e m e d t o h e l p b r i n g t h e p a t i e n t a r o u n d ?"
Patients experiencing an episode of orthostatic hypotension may improve suddenly once laid
lose consciousness again if sat back up.
Patients experiencing a seizure may stop seizing upon administration of a benzodiazepine.
Further questions
Ask the patient or person providing the collateral history if they think any injuries have occurred as a result of the episode\:
" D i d y o u s e e a n y e v i d e n c e o f i n j u r i e s d u r i n g o r a f t e r t h e p e r i o d i n w h i c h t h e y l o s t c o n s c i o u s n e s s ?"
" D i d t h e y f a l l a s a r e s u l t o f t h e l o s s o f c o n s c i o u s n e s s ?"
" H a v e y o u g o t a n y p a i n a n y w h e r e a t t h e m o m e n t ?"
Ask speci
" D i d t h e p a t i e n t h i t t h e i r h e a d a t a n y p o i n t d u r i n g t h e e p i s o d e ?"
" D i d t h e p a t i e n t v o m i t w h i l s t u n c o n s c i o u s a n d w a s t h e r e e v i d e n c e o f a n y l o o s e o b j e c t s w i t h i n t h e i r m o u t h d u r i n g o r
i m m e d i a t e l y a f t e r t h e e p i s o d e ?"

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient's ideas about the current issue\:
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
"
Concerns
Explore the patient's current concerns\:
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?"
" W h a t’ s y o u r n u m b e r o n e c o n c e r n r e ga r d i n g t h i s p r o b l e m a t t h e m o m e n t ?"
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?"
" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?"
" W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?"

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient's history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.
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Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u' r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fevers (e.g. cerebral abscess, meningitis), weight change (e.g. malignancy)
Cardiovascular\: palpitations (e.g. arrhythmia), chest pain (acute coronary syndrome), shortness of breath (e.g. heart failure)
Respiratory\: dyspnoea, cough (e.g. pneumonia), pleuritic chest pain (e.g. pulmonary embolism)
Gastrointestinal\: diarrhoea, vomiting (e.g. dehydration/hypotension)
Genitourinary\: oliguria (e.g. dehydration/hypotension)
Neurological\: visual symptoms (e.g. pre-syncope), headache (e.g. brain tumour), motor or sensory disturbances (e.g. stroke)
Musculoskeletal\: trauma (e.g. secondary to syncope)
Dermatological\: rashes (e.g. meningococcal sepsis)

Past medical history

Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. coronary artery bypass grafts, pacemaker
insertion)\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
Examples of relevant medical conditions
Medical conditions relevant to loss of consciousness include\:
Pre-existing syncopal episodes\: clarify the type of syncope, triggers, frequency and date of the last event.
Epilepsy\: clarify the frequency of episodes, treatment and date of the last event.
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Hypertension, hypercholesterolemia, coronary artery disease, arrhythmias\: all risk factors for cardiovascular
syncope.
Parkinson’s disease\: associated with autonomic neuropathy causing secondary orthostatic hypotension.
Diabetes\: associated with autonomic neuropathy which can present with orthostatic hypotension.
Recent head trauma\: associated with an increased risk of seizures.
Pacemaker\: often used to treat cardiovascular syncope. Pacemakers can be interrogated to look for arrhythmias that
occurred at the time of the event.

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter
medications, document the medication name, dose, frequency, form and route.
Ask if the patient has recently started any medications which may have precipitated a seizure (e.g. nefopam) or caused a
syncopal episode (e.g. antihypertensive)\:
" H a v e y o u r e c e n t l y s t a r t e d a n y n e w m e d i c a t i o n s ?"
Ask the patient if they’re currently experiencing any side e
“ H a v e y o u n o t i c e d a n y s i d e e
Ask the patient if they've recently stopped any medications or had any doses changed as this may have precipitated a seizure
(e.g. gabapentin withdrawal) or resulted in hypotension (e.g. corticosteroid withdrawal causing adrenal insu
" H a v e y o u r e c e n t l y s t o p p e d a n y m e d i c a t i o n s ?"
Medication examples
Medications relevant to loss of consciousness include\:
Hypoglycaemic agents\: increased risk of hypoglycaemia and seizures.
Anticonvulsants\: if doses recently changed may precipitate a seizure.
Antihypertensives\: increased risk of hypotension and orthostatic syncope.
Tricyclic amines\: associated with orthostatic hypotension and seizures.
Short-acting benzodiazepines\: associated with seizures upon withdrawal.
Combined oral contraceptives\: increased risk of pulmonary embolism.
Corticosteroids\: cessation of corticosteroid therapy may result in adrenal insu
hypotension.

Family history

Ask the patient if there is any family history of cardiovascular disease or seizures\:
“ D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y h e a r t p r o b l e m s o r h a v e t h e y e x p e r i e n c e d s e i z u r e s i n t h e p a s t ?”
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic
factors)\:
“ A t w h a t a g e d i d y o u r f a t h e r s u
If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death\:
“ I’ m r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r d a d w a s w h e n h e d i e d ?”
“ D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h i s d e a t h ?”
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If the patient reports unexplained sudden deaths in young relatives, consider the possibility of cardiac channelopathies (e.g.
Brugada syndrome, long QT syndrome).

Social history

Explore the patient’s social history to both understand their social context and identify potential risk factors.
General social context
Explore the patient’s general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Understanding the patient's daily activities allows you to consider the risk posed by further episodes of LOC.
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years‘ the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Patients drinking signi
drinking (i.e. alcohol withdrawal seizures). Patients who binge drink are also at increased risk of seizures secondary to acute
intoxication.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Recreational drugs can cause seizures and syncope.
Fluid intake
Patients with poor
Occupation
Ask about the patient’s current occupation\:
Explore what tasks the patient performs at work to identify high-risk activities (e.g. working at heights, operating heavy
machinery).
If the patient is experiencing episodes of LOC and works with heavy machinery or at heights, it is important to advise them to
take time o
Driving
If the patient drives and has presented with LOC it is important to advise them not to drive until they have been fully
investigated and to inform the relevant driving authority (e.g. DVLA) of their current medical issues.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
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References

1. Developed in collaboration with, European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), et al. Guidelines
for the diagnosis and management of syncope (version 2009)\: The Task Force for the Diagnosis and Management of Syncope of
the European Society of Cardiology (ESC). E u r o p e a n H e a r t J o u r n a l . 2009;30(21)\:2631-2671. doi\:10.1093/eurheartj/ehp298.
2. Seizures & Syncope. In\: Amino
Accessed June 28, 2017.
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