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CG109 Transient loss of consciousness: implications for ambulance services, with John Pawelec of Yorkshire Ambulance Service

John Pawelec, a paramedic clinical tutor at Yorkshire Ambulance Service discusses the implications for ambulance services of the NICE Clinical guideline CG109

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This podcast was added on 24 Aug 2010

Podcast transcript

Q1 Interviewer: Hello, thank you for choosing the NICE podcast on the clinical guideline Transient Loss of Consciousness. For short we will be calling this TLoC. In particular this podcast will focus on the impact of the recommendations in the guideline to the ambulance service.

I am Katie Worrall a nurse and the implementation lead for this guidance and with me is John Pawelec, paramedic clinical tutor from Yorkshire ambulance service and a member of the guideline development group which produced this guideline

So John, why is this guideline important to the ambulance service and the way it managed people who have had a blackout?

JP: Hi Katie, well first of all I suppose it would be good to start off with a definition. What we actually mean when we are talking about transient loss of consciousness is spontaneous loss of consciousness with complete recovery and very often people will refer to this as a blackout. In this context complete recovery would involve full recovery of consciousness without any residual neurological deficit.

An episode of TLoC is often described as a blackout or collapse but it must be borne in mind that some people collapse without transient loss of consciousness and this guideline is not intended to cover that situation. So Transient loss of consciousness is very common - it actually effects up to half of the population in the United Kingdom at some point in their lives and of course there are various causes of TLoC -  including cardiovascular disorders which are the most common;  neurological conditions such as epilepsy; and psychogenic attacks. The main focus of this is that the diagnosis of the underlying cause of TLoC is often inaccurate. So we need to be aware that just because a patient has been told they are epileptic, it doesn’t necessarily mean that they are.

The ambulance service are often present during, or just after, a person has experienced TLoC and they are responsible for ensuring the patient is directed towards the appropriate pathway, to ensure the person received the correct diagnosis quickly and efficiently, leading to a suitable management plan 02:34

Q2 Interviewer: What should ambulance staff assess first when they encounter a patient with suspected TLoC?

JP: Well first of all the ambulance staff will make an assessment for safety and look at the patients overall condition - looking for injuries and the patients vital signs  - and they will use their clinical judgement to determine appropriate management and the urgency of treatment. In the case of a person who has sustained an injury for example or in the case of a person who has not made a full recovery to consciousness 03:04

Q3 Interviewer: Thank you. John what would the ambulance staff be expected to collect about the history of the TLoC

JP: Well firstly can I say that the information gathered by the ambulance staff can have considerable impact on the diagnosis and management of the patient. So the information we need to gather is to ask the person who has had the suspected TLoC, and importantly any witnesses to describe what happened before, during and after the event.

You asked me the details that need to be recorded. Well certainly the circumstances surrounding the event  - we need to know the persons posture immediately before the loss of consciousness find out if there were any prodromal symptoms, such as sweating, feeling particularly hot;  the patients appearance. for example were their eyes open or shut;  and the colour of the patient during the event.

Going on to thinking about presence or absence of movement during the event  - for example limb jerking, and the duration of that;  was there any tongue biting; and even recording any information such as whether the side or the tip of the tongue was bitten can be relevant.

We need to think about injuries occurring during the event; we need to know the duration of the event - in other words from the onset to regaining consciousness;  we need to know about the presence or absence of confusion during the recovery period; and if there was any weakness down one side during the recovery period.

So when recording a description of the TLoC from a patient or a witness, take care to ensure that their communication and other needs are taken into account. And finally all the useful information that has been gathered from all the accounts of the suspected TLoC needs to be documented, to confirm whether or not a TLoC has occurred 05:40

Q4 Interviewer:Wonderful! So from the guideline I understand that once they have made this assessment, as to if a TLoC has occurred or not,  if it is definitely not a TLoC, then the patient will be managed appropriately. However, if it is confirmed that the patient had a TLoC, or it remains unclea,r that the patient had a TLoC, what would the ambulance staff do next?

JP: Moving on from the information already gathered from the accounts we just described of the suspected TLoC, to confirm whether or not a TLoC has occurred, its worth saying at this juncture that if it is uncertain, it should be assumed that they has a transient loss of consciousness, until proven otherwise. Moving on then from the information already gathered, the next part of the assessment moves on to detailing any previous TLoC episodes, and including the number and frequency of these; thinking about the patient’s medical history; asking about any family history of cardiac disease, for example personal history of heart disease and family history of sudden cardiac death.

Current medication may give some important clues, so the questions need to be asked about any medication the patient is currently taking  - and these may have contributed to the TLoC, for example patients taking diuretics

(It is) Certainly important to record vital signs, for example the pulse and thinking about the actually pulse rate, the rhythm of the pulse if it regular, irregular, and the strength of the pulse - is it a weak or strong pulse? The respiratory rate and the patients temperature and these all need to be repeated if clinically indicated.

Blood pressure is obviously very important and if possible, this should be recorded with the patient lying and also with the patients standing, if this is clinically appropriate;  looking for any other cardiovascular or neurological signs; and finally, but by no means least, record a 12 lead ECG. Of course, if at any time there is suspicion of any underlying problems causing the transient loss of consciousness, carry out any relevant examinations and investigations - for example, checking blood glucose levels if you suspect diabetic hypoglycaemia; and if the TLoC is secondary to a condition that requires immediate action, use clinical judgement to determine appropriate management and urgency of treatment.  08:58

Q5 Interviewer: Thank you. What ECG abnormalities should the ambulance staff be looking out for and if they see any of these what should they do?

JP: Well first of all, ideally using an automated interpretation ECG recording, the NICE guideline talks about red flags. So just to be clear, these are any of the following abnormalities, that might be evidence on the ECG print out of conduction abnormality -  for example, complete right or left bundle branch block, or indeed any degree of heart block. Evidence of long or short QT intervals and any ST segment or T wave abnormalities - so just to be clear they are the red flags.

If ambulance staff are using a non-automated interpretation type ECG, any ventricular arrhythmia (that is including ventricular ectopic beats); long QT (so a corrected QT greater than 450 milliseconds); or a short QT (of, for instance, less than 350 milliseconds); brugada syndrome;  any ventricular pre-excitation (for instance part of the “Wolf-Parkinson-White” syndrome); any left or right ventricular hypertrophy;, abnormal T wave inversion; pathological Q waves; any sustained atrial arrhythmias;any paced rhythms -  if the ambulance practitioner is in any doubt about any of these criteria, then expert advice should be sought. 11:06

Q6 Interviewer : Thank you. And if any of those red flags were identified what should the ambulance staff do?

JP: The patient should then be transported to hospital

Q7 Interviewer: Thank you John. We have discussed the red flags which occur on ECG abnormalities. Are there any other red flag indicators, which suggests the patients needs to go to the emergency department?

JP: Yes there are Katie - and here we are thinking about heart failure with the history of physical signs, any TLoC that has occurred during exertion, as a result of exertion, family history of sudden cardiac death in people aged younger than 40 years, an inherited cardiac condition,and any new or unexplained breathlessness :and finally any heart mummers that might be heard. 12:07

Q8 Interviewer: What should the ambulance staff do, to ensure an effective transfer of care to the emergency department?

JP: The ambulance crew will transport the patient to the emergency department - unless there is a clear diagnosis of uncomplicated faint and situational syncope; and there is nothing in the initial assessment to raise clinical or social concern.

Now the handover at the emergency department is very important . Having ascertained and documented all the information that we said earlier formed the initial assessment and diagnosis , that needs to be very clearly documented. (and) A good handover needs to be made to the person taking over the patients care in the emergency department to ensure that nothing is missed; (and) nothing is overlooked: and all the vital information that has been gathered is communicated to the person taking care of the patient. Not forgetting, ofcourse, the importance of handing over the ECG’s that have been recorded prior to the patient arriving at hospital. 13:26

Q9 Interviewer: If the ambulance staff are able to clearly diagnose uncomplicated faint or a situation syncope (and they therefore do not intend to transport the patient to hospital immediately) what should they do to ensure the patient is followed up in primary care?

JP: Well Katie, as you have said, if the diagnosis is of uncomplicated faint or situational syncope; and the patient has definitely not displayed any of the red flags which we spoke about earlier; and there is nothing in the initial assessment to raise clinical or social concern - then no further immediate management is required.

The ambulance staff should advise the patient to take a copy of the patient report form and the ECG record, to their GP. They would also inform the GP about the diagnosis directly, if possible. (and) In the unusual circumstances of where the ECG has not been recorded, the GP should arrange an ECG within 3 days. The people with the uncomplicated faints, for instance uncomplicated vaso-vagal syncope, or situational syncope, - explain the mechanisms causing their syncope; (and) advise the patient on possible trigger events and strategies for avoiding them. Reassurance is important. (and) This can be that the prognosis is good; and advise them to consult their GP if they experience further TLoC -  particularly if this differs from their recent episode 15:29

Interviewer: Thank you very much John.

We both hope that you have found this podcast informative the NICE guidance is available from our website at www.nice.org.uk/guidance/CG109. In addition to the guidance, there is a set of PowerPoint slides which summarise the key learning points from this podcast. This is also alongside a quick reference guide to the whole pathway and a patient version of the guideline 15:51

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This resource should be used alongside the published guidance. The information does not supersede or replace the guidance itself.

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.