Patients with loss of awareness and with red flags present should be sent to the Emergency Department.
If a patient with loss of awareness has no red flags, please try to differentiate between a seizure or dissociative seizure and syncope. All patients should have an ECG.
Tonic-clonic seizure
- Can have 'aura', not prodrome
- Can occur while the patient is lying down, may arise from sleep
- At the beginning of the seizure the person may cry/shout out
- The person will lose consciousness
- Body will stiffen, they will fall if standing
- Lips may turn blue, saliva may run from their mouth and they might bite their tongue
- Rhythmical jerking of the limbs, crescendo in amplitude with gradually slowing (deceleration) following which cardio-respiratory rate may slow
- Usually lasts no longer than three minutes, but is followed by a slow recovery period lasting minutes to hours
- Patient will be amnestic for event
Dissociative seizure
- Should not arise from sleep, can arise shortly after waking
- Can have bilateral clonic movements without loss of consciousness
- Injury and hypoxia-cyanosis is rarer but can occur
- Asynchronous movements, no deceleration, can 'stop and start'
- Can be prolonged (>10 minutes with spontaneous recovery)
- The patient is likely to be oriented within a few minutes
Syncope
Although syncope is rarely caused by neurological problems, in the majority of cases a cardiovascular cause should be considered or ruled out.
- Pre-syncopal prodrome:
- Feel light headed
- Tachycardic
- Hot and sweaty
- Nauseated
- Grey out of vision
- Tends to occur when standing or sitting (syncope while lying down is a major red flag)
- If they lie down the patient may not lose consciousness
- Body will go limp, they will fall if standing
- May bite tongue, may be cyanosed
- Rhythmical jerking of the limbs can occur (reflex anoxic seizure or myoclonus) usually just a few beats
- Frequently unconscious for 10 to 20 seconds
- The patient will recall the prodrome and be oriented within a few minutes
Please describe the seizures as comprehensively as possible. Details of what seizures look like can be found on the 'seizure types' page:
It is vital to provide a corroborative witness statement. Wherever possible, patients need to bring a witness to clinic or have the phone number of a witness and warn them that they will be called.
All patients should be given advice on driving:
All patients should be given the following safety advice:
- Shower rather than bath
- Avoid climbing ladders
- Alcohol should be limited
- Share a bedroom or use an auditory monitoring device
More information on monitors is available on the Epilepsy Action website.
Last reviewed 14 May 2024