Fits and funny turns in adults

Abstract

Blackouts and syncope, often colloquially termed ‘fits and funny turns’, are common presentations in the adult population, with studies showing that up to 50% of the UK population may experience a blackout in their lifetime. This presentation encompasses a wide range of potential causes, which creates a diagnostic challenge for the clinician. An incorrect diagnosis can have a significant impact on the patient by delaying treatment, increasing the risk to their health and in some cases may even affect a person’s employment. As such, a deep understanding of the assessment, causes, and management is vital for any GP. This article delves into the intricacies of these episodes, shedding light on their causes, presentation, and implications for patient care.

Clinical case scenario

Mr Lee, a 70-year-old gentleman, presents to his GP with his son after fainting in the street. For the past 3 weeks he has been complaining of episodes of dizziness, however, he has not previously lost consciousness. He confirms the dizziness is a feeling of light-headedness rather than vertigo. He explains that his dizziness occurs on standing and improves once he sits down. On the occasion he lost consciousness, his son describes he was standing up, lost consciousness for a few seconds and was not particularly confused afterwards. On examination his blood pressure was 138/95 mmHg, his pulse was 85 beats per minute with a regular rhythm and normal heart sounds. It was noted that his blood pressure had dropped to 115/84 mmHg on standing. He has a history of hypertension, depression and benign prostatic hyperplasia. His current medication includes ramipril, indapamide, sertraline and tamsulosin. He has taken these medications for several years except for tamsulosin, which was started 3 weeks ago due to difficulties passing urine. What is the most likely cause of his loss of consciousness and how can this be managed?

Background

‘Fits,’ ‘funny turns’ or ‘blackouts’ are often used to describe a transient loss of consciousness (T-LOC), a temporary state of a loss of awareness and responsiveness. This state is accompanied by amnesia for the episode’s duration and either abnormal motor control or a complete loss of it. Syncope is a specific type of T-LOC caused by cerebral hypoperfusion that is characterised by its short duration and often spontaneous rapid recovery. The term ‘presyncope’ is the sensation of impending syncope without loss of consciousness, what is often described as a feeling of ‘light-headedness’ or ‘feeling faint’.

The exact prevalence of blackouts and syncope is difficult to determine, due to a variety of factors including under reporting and variations in definitions. However, a number of studies have provided some insight into their frequency and patterns. A retrospective study carried out in the UK has shown the incidence of blackouts to be 3.4 per 1000 patients per year, with up to 50% of people experiencing a blackout at some point in their life. Blackouts account for 3% of emergency department visits and 1% of admissions (Kavi, 2017). Another retrospective study of patients with confirmed vasovagal syncope found a bimodal distribution with 9% of cases affected 20–29-year-olds whereas 23% of cases affected 70–79-year-olds (Duncan et al., 2010). A systematic review and meta-analysis looking at the prevalence of orthostatic hypotension (OH) found that it affects over 20% of people over the age of 60 (Saedon et al., 2020). Lastly, from a global perspective, an international meta-analysis involving over 43,000 patients presenting to emergency departments with syncope found that around 40% resulted in admission, with a 4.4% risk of death, mainly due to cardiovascular disease. One-third of participants were discharged without a diagnosis (D’Ascenzo et al., 2013).

Blackouts and syncope carry significant implications for a person’s health and quality of life. The sudden nature of blackouts and syncope can cause physical injuries as a result of falls or accidents. In individuals exposed to high-risk environments, such as driving or working at height, these blackouts may result in far more serious outcomes. These episodes can also have psychological repercussions, including anxiety and fear. The inherent unpredictability may necessitate adjustments in lifestyle and employment, creating feelings of helplessness or a lack of control. Furthermore, employment restrictions can impose a substantial financial burden, particularly in professions requiring extended periods of absence from work. In conclusion, ‘fits and funny turns’, while often transient in nature, can have lasting effects on an individual’s health, psychological well-being, and overall quality of life.

Causes

In this section we will breakdown some of the common causes of T-LOC and discuss their typical clinical presentations, as well as their management. T-LOC has a wide range of potential causes, some of which are listed in Table 1 will offer a more comprehensive summary of these. Much of the assessment and management can be done by a GP, but some of the investigations and management options mentioned below may require referral to a specialist.

Table 1.

Causes of transient loss of consciousness.

Syncopal	Non-syncopal
ReflexVasovagal syncopeCarotid sinushypersensitivitySituational syncopeOrthostaticOrthostatic hypotensionPoTSDehydrationDrugs (e.g. antihypertensives)Autonomic dysfunction(e.g. from diabetes or Parkinson’s)CardiacArrhythmiasStructural heart diseaseIschemic heart diseasePulmonary embolusCerebrovascularVertebrobasilar insufficiencySubclavian stealAortic dissection	Intoxication (e.g. alcohol)SeizuresHead traumaHypoglycaemiaHyperventilationhypoxiaPsychogenic pseudosyncope and psychogenic non-epileptic seizures

Vasovagal and situational syncope

Vasovagal syncope is one of the most frequent forms of syncope. This can often be associated with certain provoking factors, such as emotional stress, pain, prolonged standing, unpleasant sight or smell, heat or dehydration. There will often be warning signs or pre-syncope prior to the episode of loss of consciousness. These can include feeling dizzy or light-headed, nausea, sweating and blurred vision. Situational syncope events are tied to specific situations where syncope can occur either during or immediately after an event. Common triggers may be micturition, swallowing, coughing and laughing.

Diagnosis can often be made with the history alone. Patients can keep a diary of events to try and identify triggers. Management involves recognising and avoiding triggers. When prodromal symptoms appear, sitting or lying down can help prevent syncope, as well as maintaining adequate fluid intake throughout the day.

Orthostatic hypotension

OH is caused by a sudden drop in blood pressure on standing. Patients may typically describe dizziness upon standing from a sitting or lying down position, which can be followed by a T-LOC. Symptoms improve or are absent on sitting or lying down. OH can be caused by volume depletion from dehydration, cardiac causes such as heart failure and autonomic failure from conditions such as diabetes and Parkinson’s disease. In the elderly population, OH is commonly caused by medication. OH is diagnosed by measuring the difference in the lying and standing blood pressures. Orthostatic intolerance can also be caused by postural orthostatic tachycardia syndrome (PoTS) where patients have an impaired vasoconstriction with a compensatory increase in heart rate on standing (Benarroch, 2012). Treatment options depend on the underlying cause and may include hydration, lifestyle changes such as rising slowly from a seated position and discontinuation of any contributing medications.

Carotid sinus syndrome

Triggered by head rotation or pressure on the carotid sinus, such as when shaving or wearing a tight collar. This occurs due to hypersensitivity of the baroreceptor where pressure causes a reflex bradycardia and hypotension. A carotid sinus massage in a controlled environment is used to confirm the diagnosis. This is usually managed by avoiding any triggers, although in some cases a pacemaker may be necessary (National Institute for Health and Care Excellence (NICE), 2014).

Cardiac syncope

Cardiac syncope can occur due to arrhythmias as well as structural heart disease (such as myocardial ischemia, valvular disease and hypertrophic cardiomyopathy). Syncope from structural heart disease can result from either direct outflow obstruction or from arrhythmias, with individuals with this condition having a higher risk of developing it. Patients may experience symptoms such as palpitations, dizziness and shortness of breath or chest pains prior to losing consciousness. However, in some cases, syncope may be the only symptom. Onset can be sudden and unlike the previous mentioned causes, it can occur while supine and may also present as syncope on exertion (Brignole et al., 2018a).

Diagnosis may be clear on a 12-lead electrocardiogram (ECG). However, in cases where arrhythmias are infrequent, longer monitoring may be required. Imaging via an echocardiogram or cardiac magnetic resonance imaging (MRI) can reveal structural heart defects. Treatment will usually be guided by a cardiologist and can range between anti-arrhythmic medication, pacemakers, and cardiac ablation. Surgical treatments may also be required for structural heart disease, for example, a myectomy or valve replacement.

Seizure

Seizures can be characterised by involuntary movements, which may or may not be preceded by an aura. An Isolated seizure can be caused by metabolic, toxic or infectious causes, while epilepsy is a disorder in which a person experiences recurring seizures (Krishnamurthy, 2016). Sleep deprivation, stress and alcohol are potential triggers for seizures. Tongue biting and incontinence are common during episodes and the recovery after regaining consciousness can be slow, where the patient may be in a confused post ictal state. Diagnosis includes blood tests to look for any underlying causes (such as electrolyte abnormalities) and an electroencephalogram (EEG). Treatment would normally involve anti-epileptic medication guided by a neurologist.

Assessment

Taking an accurate history is vital when assessing a patient who has had an episode of T-LOC. It has been reported by the European Society of Cardiology that taking a detailed history can help differentiate between causes of T-LOC up to 60% of the time (Brignole et al., 2018a). Wherever possible, it is important to try and take a history from any witnesses who were present. It is helpful to break down the history into the events before, during and after the episode of T-LOC.

Before

Explore any prodromal symptoms. Vasovagal syncope will usually be accompanied with dizziness or sweating, whereas epileptic seizures may have a preceding aura. An aura could be visual changes, sensory changes as well as déjà vu or jamais vu. Other symptoms to consider include breathlessness, chest pains, palpitations and headaches. A sudden loss of consciousness with no warning can be caused by arrhythmias or a pulmonary embolus.

Explore any precipitating factors and ask about the patient’s overall health and environment. This includes aspects such as dehydration, pain, stress, illnesses and hot weather. Then explore events immediately prior to the episode of syncope. Their posture could help differentiate between OH (syncope while standing) and arrhythmias (while sitting or lying down). Structural heart disease typically causes syncope on exertion while losing consciousness on head-turning occurs with carotid sinus hypersensitivity. Ask about any recent head injuries. Although this may seem obvious if the LOC occurs immediately following a head injury, patients may not associate the two together if the head injury occurred a few days ago. Symptoms from a subdural haematoma can have a delayed presentation after head trauma.

During

The witness statement is most important here as the patient will likely give very limited information. Explore any possible injuries from the episode such as falls from a height or head injuries, this is especially important for those on anticoagulants. Ask about the duration of the LOC, as consciousness is usually regained within seconds with vasovagal and arrhythmias whereas seizures can last for minutes. Tongue biting, incontinence and prolonged limb jerking suggest epilepsy, however, brief myoclonus can occur during uncomplicated vasovagal syncope (NICE, 2023).

After

Ask about the patient’s recovery after regaining consciousness. Vasovagal and arrhythmias have a rapid recovery whereas epilepsy has a slower recovery with confusion. Loss of consciousness associated with unilateral weakness during recovery, which resolves over time, could suggest a vertebrobasilar transient ischaemic attack (TIA), although it is important to note that TIAs themselves are a rare cause of T-LOC.

Past medical history

If the patient has had recurrent episodes, ask about the details of the previous episodes and their frequency. Patients who already have a diagnosis such as epilepsy will be able to tell you if the current episode resembles their usual seizures. A history of diabetes can cause hypoglycaemia, autonomic dysfunction and dehydration, whereas cardiac disease such as infarction increases the risk of arrhythmias. Patients may have underlying conditions that predispose to anaemia, such as menorrhagia or coeliac disease. Psychiatric illness can also be helpful as non-epileptic seizures are more common in this group.

Drug history

Several medications can increase the risk of T-LOC. These include insulin, oral hypoglycaemics, antihypertensives, vasodilators and antidepressants. It is not always easy to identify a single agent as the cause, especially in the elderly population where polypharmacy is common. See Table 2 for a list of drugs that can cause OH. Anticoagulants do not directly cause a loss of consciousness, but they can increase the risk of bleeding causing anaemia and can also lead to intracranial haemorrhage following head trauma.

Table 2.

Drugs that may cause orthostatic hypotension.

Class	Examples
Antihypertensive	Diuretics	Bendroflumethiazide, furosemide
	Drugs acting on renin-angiotensin system	Lisinopril, losartan, ramipril
	Calcium channel blocker	Amlodipine, felodipine, verapamil, diltiazem
	Beta blockers	Atenolol, bisoprolol, propranolol
	Alpha blockers	Doxazocin, tamsulosin
Antidepressant	Tricyclic	Amitriptyline, imipramine
Antipsychotic	Clozapine, olanzapine
Anti-Parkinson’s disease	Levodopa, ropinirole
Opiates	Morphine
Vasodilators	Glyceryl trinitrate, isosorbide mononitrate, sildenafil

Social and family history

Alcohol intoxication and recreational drugs can cause a loss of consciousness. Drugs such as cocaine and amphetamines can induce tachyarrhythmia. A family history of cardiac disease, in particular sudden cardiac death or sudden unexplained death in family members under the age of 40 may suggest an inherited cardiac condition.

Examination

Review the patients pulse rate and rhythm, blood pressure, respiratory rate, oxygen saturations and temperature. In addition, a lying standing blood pressure should be done to assess for OH and PoTS by checking the blood pressure and heart rate after 5 minutes of lying down, then repeating this after standing for 3 minutes (NICE, 2023). This could either be integrated into the consultation, for example by taking part of the history while the patient is lying down, or by delegating the task to a nurse.

Examine any injuries, including head injuries and a bitten tongue. Examine the chest and assess for the presence of heart murmurs. Perform a neurological examination and include an assessment of their gait. This assessment aims to find signs of peripheral neuropathy, Parkinsonism and in the case of suspected seizures, to ensure a full neurological recovery.

Investigations

Blood tests can look for signs of hypoglycaemia or diabetes, anaemia and electrolyte abnormalities. An ECG can reveal arrhythmias such as atrial fibrillation, bradycardia, ventricular or supraventricular tachycardia. It can also reveal other abnormalities such as long or short QT intervals, Brugada syndrome, as well as features of structural heart disease such as left ventricular hypertrophy. However, the ECG is often normal. Where an arrhythmia is suspected, but the symptoms are infrequent, patients may require longer monitoring which can be done via a Holter, event monitor or a loop recorder. An echocardiogram is needed if a structural abnormality is suspected. Specialist referrals can be done for further investigations such as a cardiac MRI for suspected structural disease, or an EEG and brain MRI for suspected epilepsy.

Driver Vehicle and Licensing Agency and work assessment

Driving and work conditions need to be assessed in those presenting with an episode of T-LOC. People who work in high-risk environments may need to be referred to occupational health, especially if they have recurrent episodes. High risk could refer not only to a risk to themselves, such as working at heights as well as risk to others, such as lorry drivers or pilots.

The Driver and Vehicle Licensing Agency (DVLA) has set out guidance for how to manage episodes of T-LOC for cars and motorcycles (Group 1) and bus and lorry drivers (group 2). For a typical vasovagal syncope with an identifiable prodrome which occurs while standing, group 1 drivers can continue driving. If this occurs while sitting, they can still drive providing there is an avoidable trigger that will not occur whilst driving. Group 2, on the other hand, must not drive and must notify the DVLA in both cases. Patients with other causes of T-LOC, such as cardiac syncope, seizures or an episode of unexplained T-LOC, both groups must stop driving and inform the DVLA. The DVLA will then revoke their licence until they have been free from further episodes for a specified duration depending on the cause. As an example, for a single episode of a seizure, group 1 must stop driving and remain seizure free for 6 months whereas group 2 have to remain seizure free for 5 years followed by a neurology assessment to review their annual seizure risk (DVLA, 2024).

Case discussion

Having explored the assessment and diagnostic considerations for T-LOC, we will now revisit the case scenario mentioning at the beginning. The history of dizziness associated with standing and the short duration of LOC suggests OH. This can be confirmed by checking the patients lying and standing blood pressures. The onset of the symptoms coincides with the initiation of tamsulosin and the hypotensive effect is worsened due to being on two other antihypertensive medications at the same time. The options here could be to reduce the doses of the antihypertensive medications, using an alternative to tamsulosin (such as finasteride), or a urology referral to consider other treatments such as transurethral resection of the prostate.

Key points

Fits, faints and funny turns have a wide range of causes creating a diagnostic challenge for the clinician

Fits and funny turns can have a significant impact on a patient’s health and quality of life and can impact them physically, psychologically and financially

There are a wide range of potential causes and being aware of their key features can assist diagnosis

Taking an accurate detailed history and a collateral history is vital in helping differentiate between causes

When prescribing medications be mindful of polypharmacy and the risk of falls

Always ask about driving and occupation and be aware of DVLA guidance

Footnotes

ORCID iD

Dr Zubair Ahmed Siddiqui

References

Benarroch

(2012) Postural tachycardia syndrome: A heterogeneous and multifactorial disorder. Mayo Clinic Proceedings 87(12): 1214–1225. DOI: 10.1016/j.mayocp.2012.08.013.

Brignole

Moya

de Lange

, et al. (2018a) ESC guidelines for the diagnosis and management of syncope. European Heart Journal 39(21): 1883–1948. DOI: 10.1093/eurheartj/ehy037.

Brignole

Moya

de Lange

, et al. (2018b) Practical instructions for the 2018 ESC guidelines for the diagnosis and management of syncope. European Heart Journal 39(21): 43–80. DOI: 10.1093/eurheartj/ehy071

D’Ascenzo

Biondi-Zoccai

Reed

, et al. (2013) Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the Emergency Department with syncope: An international meta-analysis. International Journal of Cardiology 167(1): 57–62. DOI: 10.1016/j.ijcard.2011.11.083.

Duncan

Tan

Newton

, et al. (2010) Vasovagal syncope in the older person: Differences in presentation between older and younger patients. Age and Ageing 39(4): 465–470. DOI: 10.1093/ageing/afq039.

DVLA (2024) Assessing fitness to drive: A guide for medical professionals. Available at: www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-for-medical-professionals (accessed 4 March 2024).

Farne

Norris-Cervetto

Warbrick-Smith

(2010) Oxford Cases in Medicine and Surgery. Oxford: Oxford University Press.

Kavi

(2017) Transient loss of consciousness (TLoC) in primary care: A review of patients presenting with first blackout. British Journal of Cardiology 24: 62–65. DOI: 10.5837/bjc.2017.013.

Krishnamurthy

(2016) Epilepsy. Annals of Internal Medicine 164(3): ITC17–32. DOI: 10.7326/aitc201602020.

10.

NICE (2014) Transient loss of consciousness (‘blackouts’) in over 16s. Available at: www.nice.org.uk/guidance/cg109 (accessed 4 March 2024).

11.

NICE (2020) Clinical knowledge summaries. Palpitations. Available at: https://cks.nice.org.uk/topics/palpitations (accessed 4 March 2024).

12.

NICE (2022) Epilepsies in children, young people and adults. Available at: www.nice.org.uk/guidance/ng217 (accessed 4 March 2024).

13.

NICE (2023) Clinical knowledge summaries, Blackouts and syncope. Available at: https://cks.nice.org.uk/topics/blackouts-syncope (accessed 4 March 2024).

14.

Popa-Fotea

Micheu

Bataila

, et al. (2019) Exploring the continuum of hypertrophic cardiomyopathy-from DNA to clinical expression. Medicina 55(6): 299. DOI: 10.3390/medicina55060299.

15.

RCGP. Clinical topic guide: Cardiovascular health. Available at: www.rcgp.org.uk/mrcgp-exams/gp-curriculum/clinical-topic-guides#cardiovascular (accessed 25 September 2023).

16.

RCGP. Learning hubs. Syncope toolkit. Available at: https://elearning.rcgp.org.uk/mod/book/view.php?id=12386 (accessed 4 March 2024).

17.

Saedon

Pin Tan

Frith

(2020) The prevalence of orthostatic hypotension: A systematic review and meta-analysis. Journals of Gerontology 75(1): 117–122. doi:10.1093/gerona/gly188.

18.

Van Dijk

Boer

Colman

, et al. (2008) High diagnostic yield and accuracy of history, physical examination, and ECG in patients with transient loss of consciousness in FAST: The Fainting Assessment study. Journal of Cardiovascular Electrophysiology 19: 48–55. DOI: 10.1111/j.1540-8167.2007.00984.x.