Blackout – was it a fit or a faint?

People generally experience a blackout (temporary loss of consciousness) from one of two common problems: (1) Insufficient blood flow to the brain (syncope)  or (2) Abnormal electrical activity within the brain (seizure).

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Syncope (or a faint) is caused by insufficient blood flow to the brain because of low blood pressure.  There may be a prodrome of dizziness loss of vision and hearing weakness, flushing, nausea (sometimes referred to pre-syncope).  Then there will be overt loss of consciousness that leads to the faint.  The affected patient will typically fall by dropping forwards from loss of muscle tone. The affected patient might look pale and clammy, and will usually come around quickly of they are allowed to lay down on floor allowing blood flow to return to the brain.  Syncope can be caused by dehydration, irregular heart beat, or emotion (vasovagal or “neurocardiogenic” syncope).

http://www.youtube.com/watch?v=rrjQW7UIvMU&start=35&rel=0

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A seizure (or a “fit”) is caused by abnormal electrical activity in the brain, usually accompanied by a clinical event that can vary from a brief loss of awareness (an absence seizure or “petit mal”) to loss of awareness with thrashing limb movements (a tonic-clonic or grand mal seizure).  A generalized tonic-clonic seizure will usually be associated with increased muscle tone, so the patient will stiffen up and fall backwards not forward and may bite their tongue.  The eyes will be open, and their may be loss of bladder and bowel control.  There may be flailing limb movements that lead to injury.  After the seizure stops, the patient will usually be confused or dazed, and not come around immediately like the syncope patient.

http://www.youtube.com/watch?v=wHTPfPcOHyo&start=285&rel=0

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Here is a table that emphasizes the differences between fits (seizures) and faints (syncope):

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If you have experienced a blackout, what should you do? A simple faint in an otherwise young healthy person may not need emergent medical care.  However, syncope in an older person with a cardiac history, or syncope associated with chest pain and breathlessness could indicate a heart problem and usually justify an emergency room visit.  Similarly a new onset seizure in somebody not previously know to have epilepsy should justify an emergency room visit.

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American Academy of Neurology Identifies 5 Questionable Practices

rising-cost-of-healthcare

It’s no secret that health care costs are escalating.

Although physicians value their independence, part of the problem here is the unregulated use of costly tests, medications and procedures, many of which are unproven and of questionable benefit.

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Evidence based medicine assess the strength of the evidence of risks and benefits of treatments (including lack of treatment) and diagnostic tests in an attempt to help clinicians predict whether a treatment will do more good than harm.

However, less than 1 in 5 medical decisions in the USA are made based on evidence-based medicine.

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neurology

The American Academy of Neurology has recently taken a step in the right direction by publishing a list of 5 costly neurology practices which continue to be widely performed despite being of little proven benefit:

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1. Don’t perform electroencephalography (EEG) for headaches.

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2. Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.

Syncope is caused by global cerebral hypoperfusion, not carotid artery disease, so even if a carotid stenosis is identified, it would be asymptomatic (see point number 5)

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3. Don’t use opioid or butalbital treatment for migraine except as a last resort.

Butalbital is effective short term treatment for migraine, but commonly leads to rebound, which ultimately exacerbates migraine.  Click here for more information about migraine.

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4. Don’t prescribe interferon-β or glatiramer acetate to patients with disability from progressive, nonrelapsing forms of MS.

Interferon-β and glatiramer acetate, are effective for  relapsing phases of MS, but do not prevent the development of permanent disability in progressive forms of multiple sclerosis.  These medications cost more than $40,000 a year, and put a financial strain on the patients and their families to make the co-pays.  In some series as many as 10%-15% MS patients have progressive forms of the disease and yet are still taking one of these medications.

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5. Don’t recommend carotid endarterectomy (CEA) for all patients with asymptomatic carotid stenosis.

Surgery is of much less benefit for asymptomatic carotid stenosis, and should be reserved for those with a perioperative complication risk of less than 3% and a life expectancy of greater than 3 to 5 years. Click here for more information about surgery for carotid artery disease.

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Click here for more details.