From the Guidelines
For a patient with sudden loss of consciousness and emotional distress, the next investigations should prioritize stabilizing the patient and ruling out life-threatening conditions, with a focus on comprehensive medical history, physical examination, vital signs assessment, and neurological evaluation, as well as laboratory tests including complete blood count, comprehensive metabolic panel, glucose levels, toxicology screening, and cardiac enzymes, and further tests such as ECG, EEG, CT or MRI, and specialist referrals as indicated by clinical presentation 1. The initial assessment of a patient with sudden loss of consciousness and emotional distress is crucial in determining the underlying cause and guiding further investigations.
- A comprehensive medical history, including details of the loss of consciousness, prodromal symptoms, and any previous similar episodes, is essential.
- Physical examination, vital signs assessment, and neurological evaluation can help identify potential causes such as cardiac arrhythmias, stroke, or hypoglycemia.
- Laboratory tests, including complete blood count, comprehensive metabolic panel, glucose levels, toxicology screening, and cardiac enzymes, can provide valuable information on the patient's metabolic and cardiac status.
- Electrocardiogram (ECG) should be performed to rule out cardiac causes, while electroencephalogram (EEG) can help identify seizure activity.
- Brain imaging such as CT or MRI is crucial to detect structural abnormalities, hemorrhage, or stroke.
- Additional tests may include tilt-table testing for vasovagal syncope, psychiatric evaluation for conversion disorder or panic attacks, and sleep studies if narcolepsy is suspected. These investigations are prioritized based on the clinical presentation, with immediate attention to stabilizing the patient and ruling out life-threatening conditions like cardiac arrhythmias, stroke, or hypoglycemia, as recommended by the National Institute for Health and Clinical Excellence guideline for management of transient loss of consciousness 1. The combination of these tests helps differentiate between neurological, cardiac, metabolic, psychiatric, and other potential causes of consciousness loss and emotional distress, enabling appropriate treatment planning. It is also important to consider the patient's age, medical history, and the presence of any underlying conditions that may be contributing to the loss of consciousness, as highlighted in the guideline 1. By following a systematic approach to investigation and management, healthcare professionals can provide optimal care for patients with sudden loss of consciousness and emotional distress, and improve outcomes in terms of morbidity, mortality, and quality of life.
From the FDA Drug Label
The treatment of status, however, requires far more than the administration of an anticonvulsant agent. It involves observation and management of all parameters critical to maintaining vital function and the capacity to provide support of those functions as required. Because status epilepticus may result from a correctable acute cause such as hypoglycemia, hyponatremia, or other metabolic or toxic derangement, such an abnormality must be immediately sought and corrected.
The next investigations for a patient with sudden loss of consciousness and emotional distress should include:
- Checking for correctable acute causes such as hypoglycemia or hyponatremia
- Observation and management of all parameters critical to maintaining vital function
- Immediate correction of any identified abnormalities
- Consideration of consultation with a neurologist if the patient fails to respond 2 2
From the Research
Next Investigations for Sudden Loss of Consciousness and Emotional Distress
The next investigations for a patient with sudden loss of consciousness and emotional distress may include:
- Physical examination in combination with computed tomography (CT) scan, as it was used to establish diagnoses in 23% of patients in one study 3
- Laboratory testing, which helped establish diagnoses in 25% of patients in the same study 3
- 12-lead electrocardiogram (ECG), which is recommended for the initial evaluation of patients with suspected syncope, as it may disclose an arrhythmia associated with a high likelihood of syncope 4
- Assessment of the risk of major cardiovascular events or sudden cardiac death, if the cause of syncope remains uncertain after initial evaluation 4
- Evaluation for cardiac causes of syncope, such as disorders of cardiac rhythm and mechanical obstruction to cardiac output, as these are associated with higher morbidity and mortality 5
- Investigation for psychological distress, including anger, depression, and anxiety, which may play a critical role in predicting high-risk cardiac substrate and triggering cardiac arrhythmias 6
Diagnostic Considerations
When investigating sudden loss of consciousness and emotional distress, it is essential to consider a range of potential causes, including:
- Cerebrovascular diseases, which were found to be the most common cause of unconsciousness in one study (24%) 3
- Infections, which were the second most common cause (14%) 3
- Epileptic seizures, which were found to be the cause in 12% of patients 3
- Psychiatric diseases, which were found to be the cause in 8% of patients 3
- Metabolic causes, which were found to be the cause in 7% of patients 3
- Intoxications, which were found to be the cause in 7% of patients 3
- Transient global amnesia, which was found to be the cause in 5% of patients 3
- Cardiovascular causes, which were found to be the cause in 4% of patients 3
Importance of Early Investigation
Early investigation is crucial in patients with sudden loss of consciousness and emotional distress, as it can help establish a diagnosis and guide treatment. In one study, a final diagnosis could be established in 88% of patients in the emergency department 3. Additionally, the availability of diagnostics such as cerebral imaging is indispensable and recommended as an early step in a standardized clinical approach 3.