Fainting vs. Seizures

Fainting vs Seizures

Seizures of all types are caused by disorganized and sudden electrical activity in the brain. Causes of seizures can include: Abnormal levels of sodium or glucose in the blood. Brain infection, including meningitis. Feb 27, 2016

Fainting is a temporary loss of consciousness that happens when the brain does not receive enough oxygen. It comes on suddenly, only lasts for a short time and you recover fully within a short time. It is also often called a blackout. The medical term is syncope. It isn't the same thing as a seizure which usually causes jerking. It is important to seek medical attention if you experience faints. Faints may be caused by a serious problem. However, this is very unusual unless you are aged over 40 or they have happened while you were lying down or during exercise. The most common causes are mentioned below.

What are faints?
When you faint, you become unconscious for a few seconds. It is also called passing out or blacking out. The medical term for this is syncope. You may feel sick and sweaty first or pass out with no warning at all. When you pass out, you fall to the ground. It isn't the same thing as a seizure which usually makes you jerk. You come round after a few seconds and feel back to normal. Some people feel very tired after they've come round. Usually, fainting happens for a reason, like when you're in pain or have been standing for a long time in a hot place. Fainting happens because the brain needs a constant supply of oxygen. If that supply falls below a certain level, we fall to the ground, which makes it easier for the more oxygen-rich blood to reach the brain.

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How common is fainting?
Fainting is common at all ages and affects up to 4 in 10 people at least once in their lives. Most people never get medical help. Most people (95%) have their first attack of syncope before they're 40 years old. If you have it for the first time after 40, it is more likely to be due to a serious underlying problem. The most common cause is a common faint, also called neurally mediated syncope (NMS). Common faints usually happen for the first time in teenage years and affect girls more than boys. In older people, fainting is more likely to be due to an underlying heart problem, low blood pressure or as a side-effect of medication.

What problems can cause fainting?
Here are some of the more common causes of faints:

Common faint (NMS): this is also known as vasovagal syncope. It is the most common cause of fainting. NMS can occur in various situations. These include:

Fear.
Severe pain or emotional distress.
After extreme exercise.
After prolonged standing, especially in hot places (which is why soldiers on parade may faint).
When wearing tight collars that constrict the neck.
During attacks, you may look pale and feel sweaty. Your eyes will usually stay open.

Orthostatic hypotension: this is a fall in blood pressure on standing up, which can cause fainting. It can occur:

Due to medication prescribed to lower blood pressure.
During being sick (vomiting) or experiencing runny stools (diarrhoea) and other reasons for having a lack of fluid in the body (being dehydrated).
As a result of neurological diseases such as Parkinson's disease and peripheral neuropathy.
After a big meal.
Cardiac syncope: this occurs due to an underlying heart problem. There may be a family history of sudden death. The faint may be preceded by chest pain or the sensation of having a 'thumping heart' (palpitations) and may happen during exercise.

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What investigations might be advised?
The doctor will want to know more about what you were doing when you blacked out. You will be asked whether you've recently started new medication. Try to remember whether you had any warning before you blacked out. Did anyone see you fall? (If so, ask them to speak to the doctor if possible). How did you feel when you came round? These details will help the doctor to make a diagnosis. Your doctor will examine you. He or she will check your heart, including your blood pressure when sitting and standing and your pulse. You may be asked to have a heart tracing (an electrocardiogram, or ECG). You may have blood tests for anaemia and diabetes. Further tests of your heart and nervous system may be necessary.
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What else could it be?
The most common cause of blacking out is fainting. Other causes include epileptic seizures, syncope due to anxiety (psychogenic pseudosyncope) and other rare causes of faints. Other causes of blacking out may be due to low blood sugar (hypoglycaemia) and lack of oxygen (hypoxia) from a variety of causes. It may be due to over-breathing (hyperventilation) but this is rare.

You may also black out after a fall or blow to the head or due to excess alcohol or street drugs.

Strokes and mini strokes (transient ischaemic attacks) can also result in a blackout.

Prolonged blackout, confusion after the event, incomplete recovery and tongue biting all suggest that the cause is not a simple faint.

What treatments may be offered?
Treatment will depend on the likely cause of your blackout. You may be asked to keep a diary of your faints, including what you were doing when each happened. Most people will only need to see their GP but you may be referred for further investigation and treatment at a hospital.

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What can you do if you feel like you're going to faint?
Lie down flat with your legs up on a chair or against a wall or sit down on the ground with your head between your knees. Do not just sit on a chair.
Squatting down on your heels can be very effective and is less noticeable in public.
When feeling better, get up carefully. If symptoms return, resume the position.
If you faint again:

Discuss with your doctor stopping any medication that may be responsible.
Avoid alcohol.
Drink more fluids such as water or soft drinks.
Wear support stockings.
Do leg crossing and arm tensing exerci
---------------------------------------------------------------Driving and faints
The Driver and Vehicle Licensing Agency (DVLA) does not have to be informed of a simple faint but greater restrictions apply if the situation is more complicated or if diagnosis is less clear.

If in doubt, contact the DVLA.

What should you do next?
You should call an ambulance if you:

Have a blackout while exercising or lying down.
Have a family history of sudden and unexplained deaths
Experience chest pain or the sensation of a 'thumping heart' (palpitations).
If the attack happens again or you do not feel completely back to normal, you should also seek urgent medical attention. In all other cases, you should see your GP. If you have lots of attacks, or you hurt yourself because of the faints, your GP may want you to see a specialist. He or she may also want you to see a specialist if your faints could affect your driving.

How can I avoid faints?
You will need to find the underlying cause and try to address it if possible. Common faints are by far the most common cause. Many people who faint know when it tends to happen and how to avoid attacks.

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What is the outlook (prognosis)?
This depends on the underlying cause but is generally very good. In young people, when the blackouts are not associated with any heart or nervous system problem, there is nothing to worry about. In older people, there may be a risk to your health but this is due to the underlying condition and the risks from falling.

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Syncope is a transient loss of consciousness caused by transient global cerebral hypoperfusion characterised by rapid onset, short duration and spontaneous complete recovery.[1] The term syncope excludes seizures, coma, shock or other states of altered consciousness.

Patients presenting with a history of blackouts, faints or collapse need careful evaluation to assess the precise nature of the problem. This is essential so as to assess both the risk of a serious underlying disorder and also the risk of recurrence and subsequent injury.[1]

Aetiology[2]
Neurally mediated syncope (NMS) - also called reflex syncope:
Vasovagal syncope (common faint):
Emotional - eg, fear, severe pain, blood phobia, sudden, unexpected sight, sound or smell.
Orthostatic stress - eg, prolonged standing or when in crowded, hot places.
Situational syncope - eg, cough, sneeze, gastrointestinal stimulation (swallowing, defecation, visceral pain), micturition.
Carotid sinus hypersensitivity: occurs when rotating the head - eg, while shaving, especially if a collar is tight or in the presence of a neck tumour.
Glossopharyngeal neuralgia.
Orthostatic hypotension (postural hypotension) - syncope occurs after standing up:
Autonomic failure:
Multiple system atrophy, Parkinson's disease, diabetic neuropathy, amyloidosis.
Medications - eg, antihypertensives.
Post-exercise.
Postprandial.
Hypovolaemia:
Haemorrhage.
Vomiting, diarrhoea and other causes of dehydration.
Addison's disease.
Cardiac arrhythmias:
Sick sinus syndrome, atrioventricular (AV) conduction system disease.
Paroxysmal supraventricular tachycardia, ventricular tachycardia.
Inherited syndromes - eg, long QT syndrome, Brugada's syndrome.
Malfunction of a pacemaker or implantable cardioverter defibrillator (ICD).
Drug-induced arrhythmias.
Structural cardiac or cardiopulmonary disease:
Obstructive cardiac valvular disease.
Acute coronary syndrome.
Hypertrophic obstructive cardiomyopathy.
Atrial myxoma.
Acute aortic dissection.
Pericardial disease or tamponade.
Pulmonary embolus or pulmonary hypertension.
Cerebrovascular:
Vascular steal syndromes - eg, subclavian steal syndrome.
Substance abuse, alcohol intoxication.
Psychogenic: factitious, anxiety, panic attacks, hyperventilation.

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Investigations and assessment[1]
Investigations are guided by the history and examination. Initial tests in primary care include:[7]

Orthostatic blood pressure measurement.
ECG: there may be evidence of ischaemia or arrhythmias.
FBC if anaemia or bleeding is suspected (acute anaemia will cause syncope but patients adapt in cases of chronic anaemia).
Fasting blood glucose, if hypoglycaemia is a possibility.
In most cases, the initial assessment will lead to a definite, or at least a likely, diagnosis, which will clarify the selection of further investigations and management.[3]However, syncope is often multifactorial, especially in older individuals.

Risk stratification
It is essential to assess the risk of major cardiovascular events or sudden cardiac death. The indications for urgent hospital assessment include:[1]

Severe structural or coronary artery disease - eg, heart failure, low left ventricular ejection fraction, previous myocardial infarction.
Clinical or ECG features suggesting arrhythmic syncope:
Syncope during exercise or whilst supine.
Palpitations at the time of syncope.
Family history of sudden cardiac death.
Non-sustained ventricular tachycardia.
Bifascicular block (right bundle branch block and either left anterior or left posterior fascicular block).
Bradycardia with pulse heart rate below 50 or sinoatrial block in the absence of negative chronotropic drugs (eg, beta-blockers) or physical training.
QRS complex longer than 120 milliseconds.
Prolonged or short QT interval.
Right bundle branch block pattern with ST elevation in leads V1-V3 (Brugada pattern).
Features suggestive of arrhythmogenic right ventricular cardiomyopathy.
Important comorbidities - eg, severe anaemia, electrolyte disturbance.
Referral is indicated if there is any suggestion of a serious underlying cause or if the episodes of syncope are frequent, have implications for driving, cause injuries or cannot be controlled by simple avoidance of precipitating factors.[7]There are several risk scores to help identify those patients with syncope who are at high risk of adverse events but none of the scores is widely accepted:[3]

Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score.[8]
San Francisco Syncope Rule (SFSR): this is the simplest, and uses an abnormal ECG, heart failure, anaemia and systolic hypotension (below 90 mm Hg) to identify patients who require urgent action.[9]
European Guidelines in Syncope Study (EGSYS) score.[10]
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Investigations in secondary care[2]
NMS:
Carotid sinus massage, tilt testing, implantable loop recorder.
Carotid sinus massage should be avoided in patients with previous transient ischaemic attack, stroke within the preceding three months, or with a carotid bruit, except if carotid Doppler studies excluded significant stenosis.[1]
Cardiac syncope:[1]
ECG ambulatory monitoring - eg, conventional ambulatory Holter monitoring, in-hospital monitoring, event recorders, external or implantable loop recorders, or remote (at home) telemetry. The gold standard for the diagnosis of cardiac syncope is when a correlation between the symptoms and a documented arrhythmia is recorded.
Adenosine triphosphate (ATP) test: rapid injection of a bolus of ATP (or adenosine) during ECG monitoring; the induction of AV block with ventricular asystole lasting over six seconds, or the induction of AV block lasting over ten seconds are considered abnormal.
Echocardiogram: to identify structural cardiac abnormalities and assess left ventricular function.
Transoesophageal echocardiography, CT and MRI may be performed in selected cases (eg, aortic dissection and haematoma, pulmonary embolism, cardiac masses, pericardial and myocardial diseases, congenital anomalies of coronary arteries).
Cardiac catheterisation and coronary angiography may be indicated for suspected cardiac ischaemia.
Exercise testing:[1, 11]
For patients who have experienced episodes of syncope during or shortly after exertion.
Careful ECG and blood pressure monitoring should be performed during both the test and the recovery phase.
Syncope occurring during exercise may be due to cardiac causes; syncope occurring after exercise is almost invariably due to a reflex mechanism.
'Tilt testing' to invoke syncope:[12]
The patient lies flat on the table and is attached to an ECG and a beat-to-beat blood pressure monitor. After 10 minutes supine the table is tilted head up to 70° and the position maintained for 35 minutes, 400 micrograms sublingual GTN may be used if no symptoms have developed after 20 minutes. 50-60% of patients with unexplained syncope develop symptoms after about 20 minutes.
Pseudosyncope attacks may be induced on a tilt table but there is no change in heart rate or blood pressure and the ECG is unchanged during the syncope.
If the cause still remains unclear then repeat evaluation, including neurological investigations, and possible admission to hospital may be required.[2]

Management
NMS
Most patients with NMS require only an explanation, reassurance and education regarding the nature of the problem and avoidance of triggering events - eg, avoiding prolonged standing in a hot environment or having a hot bath.
They should be advised to take action at the first warning sign of collapse:
Lie down flat with the legs up on a chair or against a wall or sit down, ideally on the ground, with the head between the knees.
Squat down on the heels; this can be very effective and is less noticeable in public.
These techniques help move venous blood that has pooled in the limbs, aiding circulation to the brain.
When feeling better, advise them to get up carefully. If symptoms return, resume the position.
Treatment may be desired if syncope is very frequent, unpredictable or could occur during high-risk activities such as driving. However, treatment options are limited:
Tilt training: prolonged periods of upright posture; requires good compliance, as several sessions are needed and deconditioning occurs quickly on stopping.[2]
Isometric counterpressure manoeuvres - eg, leg crossing or arm tensing, which can increase blood pressure enough to prevent syncope.
Medications: various medications have been used; however, a Cochrane review concluded that there was insufficient evidence to support their use.[13]
Cardiac pacing: the same Cochrane review concluded that there was also insufficent evidence to support the use of pacemakers in NMS.
Orthostatic hypotension[14]
Stop any offending drugs.
Avoid alcohol.
Encourage a plentiful oral fluid intake: two large glasses of cold water prior to periods of increased orthostatic stress can be very effective.
Raise the head of the bed.
Wear support stockings to reduce pooling of vascular volume. An abdominal binder may also be used.
Leg crossing and arm tensing.
In some patients medication may be desired, although all may cause supine hypertension:
Low dose of fludrocortisone. May also cause hypokalaemia.
Midodrine, an alpha-1 adrenergic agonist which increases total peripheral resistance, is occasionally tried but there is insufficient high-quality evidence to support its use.[15]
Cardiac cause of syncope
Treatment is aimed at the underlying cause - eg, anti-arrhythmic drugs, pacing, implantable cardiac defibrillators, correction or amelioration of structural disorders.
Electrophysiological studies and ablation may also be required for arrhythmias.
Driving and syncope[16]
In the UK, following a single vasovagal syncope, driving is not restricted and the Driver and Vehicle Licensing Agency (DVLA) does not need to be informed. If recurrent, on each occasion it must be due to strong Provocation, associated with Prodromal symptoms and Posture, ie it is unlikely to occur while sitting or lying - the '3 Ps'.
Greater restrictions apply if the situation is more complicated, such as cough syncope, or if diagnosis is less clear.
If in doubt, contact the DVLA.
Complications[1]
Recurrent syncope has serious effects on quality of life. The impairment due to syncope is comparable with chronic illnesses such as chronic arthritis, recurrent moderate depressive disorders and end-stage kidney disease.
Morbidity is particularly high in the elderly and includes loss of confidence, reduced mobility, depressive illness, fear of falling, fractures and subsequent institutionalisation.
Female gender, a high level of comorbidity, the number of episodes of syncope and the presence of presyncope seem to be associated with poorer quality of life.
Physical injury: soft tissue and bone injuries may occur. Syncope was found to be the cause of 21% of road accidents involving loss of consciousness at the wheel, second only to epilepsy[11].
Prognosis
Prognosis varies according to the underlying cause. The all-cause mortality in subjects with reflex syncope is not higher than in the general population.[4]
Approximately 35% of patients have recurrences of syncope at three years of follow-up.[11]
In young patients, syncope is a benign event.
Isolated syncope (transient loss of consciousness in the absence of prior or concurrent neurological, coronary, or other cardiovascular disease) is not associated with any increased risk of transient ischaemic attack, stroke or myocardial infarction and is not associated with any excess of all-cause or cardiovascular mortality (including sudden death).
Poor outcomes, including deaths, are largely related to the severity of the underlying disease rather than to syncope:
Structural heart disease and primary cardiac electrical disease are major risk factors for sudden cardiac death and overall mortality in patients with syncope.
Orthostatic hypotension is associated with a two-fold higher risk of death, owing to the severity of comorbidities compared with the general population.[1]
For non-cardiac causes of syncope, excluding children and adolescents, the presence of the following risk factors is associated with increased mortality at one year (presence of two or more factors is associated with over 16% mortality):[17]
Abnormal ECG (not sinus bradycardia or sinus tachycardia, or nonspecific ST/T-wave changes).
Age older than 45 years.
History of ventricular arrhythmias or congestive cardiac failure.
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Further reading & references
Transient loss of consciousness; NICE Quality Standard, October 2014
Guidelines on Diagnosis and Management of Syncope; European Society of Cardiology (2009)
Brignole M; Diagnosis and treatment of syncope. Heart. 2007 Jan 93(1):130-6.
Parry SW, Tan MP; An approach to the evaluation and management of syncope in adults. BMJ. 2010 Feb 19 340:c880. doi: 10.1136/bmj.c880.
da Silva RM; Syncope: epidemiology, etiology, and prognosis. Front Physiol. 2014 Dec 8 5:471. doi: 10.3389/fphys.2014.00471. eCollection 2014.