GPAtlas🧭 When to suspect
Transient loss of consciousness (TLoC) is spontaneous loss of consciousness with complete recovery – rapid onset, short duration, and no residual neurological deficit afterwards.
• TLoC is extremely common, affecting up to half the UK population at some point in life.
• It presents as a ‘blackout’, ‘collapse’ or ‘funny turn’.
The whole task in primary care is to do three things well:
• confirm it really was TLoC (rather than a mechanical fall, vertigo or hypoglycaemia)
• separate benign reflex faints from dangerous cardiac causes
• never miss a red flag.
Every patient needs a detailed eyewitness history (before, during and after) and a 12-lead ECG.
A sobering point underpins all of this: a substantial proportion of people labelled and treated for epilepsy in fact have a cardiovascular cause for their blackouts.
| Category | Typical pointers | Examples |
|---|---|---|
| Reflex (neurally mediated) | • The 3 P’s – Posture (prolonged standing), Provocation (pain, emotion, a procedure), Prodrome (warm, sweaty, nauseated, greying vision) • Rapid full recovery |
• Vasovagal (simple) faint • Situational (cough, micturition, swallow) • Carotid sinus syncope |
| Orthostatic (postural) | • On standing or after meals • Older patients, autonomic disease • Very commonly drug-induced |
• Antihypertensives/diuretics • Hypovolaemia • Autonomic failure (e.g. Parkinson’s, diabetes) |
| Cardiac (do not miss) | • Exertional or supine syncope • No or very short prodrome • Palpitations beforehand • Family history of sudden death < 40 • Abnormal ECG |
• Arrhythmia (brady/tachy, heart block) • Structural (aortic stenosis, hypertrophic cardiomyopathy [HCM]) • Inherited (long QT, Brugada, WPW) |
| Neurological (mimic) | Lateral tongue-biting, head-turning to one side, prolonged limb-jerking, post-ictal confusion, prodromal déjà vu. | • Epileptic seizure • Dissociative (non-epileptic) seizures • Psychogenic pseudosyncope |
Source: NICE CG109 · NICE QS71
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