Excerpt

There are a number of existing guidelines, for epilepsy, falls and cardiac arrhythmias; which all relate to transient loss of consciousness (TLoC), but there is no guideline which addresses the initial assessment and management of patients who blackout. As such patients may come under the care of a range of clinicians, the lack of a clear pathway contributes to their misdiagnosis, and inappropriate treatment.

This guideline aims to define the appropriate pathways for the initial assessment of these patients, and so to derive the correct underlying diagnosis quickly, efficiently, and cost-effectively, and tailor the management plan to suit their true diagnosis.

Contents

• Key Priorities for Implementation
• Recommendations
• Care Pathways
• 1. Introduction
  • 1.1. Clinical Needs Assessment for Transient Loss of Consciousness
  • 1.2. Context Definitions and Approach of the guideline
  • 1.3. Aim of the guideline
  • 1.4. How the guideline is set out
  • 1.5. Scope
  • 1.6. Responsibility and support for guideline development
• 2. Methods
  • 2.1. Introduction
  • 2.2. Developing key clinical questions (KCQs)
  • 2.3. Literature search strategy
  • 2.4. How the evidence was reviewed and synthesized
  • 2.5. Development of Patient Information Recommendations
  • 2.6. Interpretation of the evidence and development of the recommendations
  • 2.7. Consensus methodology
  • 2.8. Choice of Key Priorities for Implementation (KPI’s)
  • 2.9. Consultation
  • 2.10. Relationships between the guideline and other national guidance
  • 2.11. Research Recommendations
  • 2.12. Acknowledgements
  • 2.13. Glossary and Abbreviations
• 3. Initial assessment and diagnosis of people who had TLoC
  • 3.1. Clinical questions
  • 3.2. Interactive diagnostic simulation
  • 3.3. Reviews of diagnostic test accuracy: initial assessment
  • 3.4. Health Economics
  • 3.5. Evidence Statements
  • 3.6. Evidence to Recommendations
  • 3.7. Recommendations
• 4. 12-lead ECG
  • 4.1. Clinical Questions
  • 4.2. Clinical evidence review: introduction to the use of the standard electrocardiogram
  • 4.3. Clinical Evidence Review: 12-lead ECG for predicting serious adverse outcomes in people who had TLoC
  • 4.4. Clinical Evidence Review: Automatic 12-lead ECG in diagnosing life threatening arrhythmias in people who may or may not have had TLoC
  • 4.5. Clinical evidence review: automatic and manual determination of heart rate, PR interval, QT and QTc intervals in a TLoC population
  • 4.6. Health Economics
  • 4.7. Evidence Statements
  • 4.8. Evidence to recommendations
  • 4.9. Recommendations
• 5. Specialist assessment and diagnosis
  • 5.1. Clinical Question
  • 5.2. Introduction
  • 5.3. Clinical Evidence Review: ambulatory ECG following initial assessment for people with (i) a suspected arrhythmic cause of syncope; (ii) with unexplained syncope and (iii) with suspected neurally mediated syncope
  • 5.4. Clinical Evidence Review: people with exercise-induced syncope - accuracy of exercise testing
  • 5.5. Clinical Evidence Review: people with suspected neurally mediated syncope after initial assessment - accuracy of tilt testing
  • 5.6. Clinical Evidence Review: people with suspected neurally mediated syncope after initial assessment - accuracy of carotid sinus massage
  • 5.7. Economic review of second stage diagnostic tests
  • 5.8. Economic evaluation of ambulatory ECG
  • 5.9. Evidence Statements
  • 5.10. Evidence to Recommendations
  • 5.11. Recommendations
• 6. Diagnostic tests to direct pacing therapy
  • 6.1. Clinical Questions
  • 6.2. Introduction
  • 6.3. Clinical Evidence Review: efficacy of pacemakers in people with suspected neurally mediated syncope with a cardioinhibitory response identified during tilt testing
  • 6.4. Clinical Evidence Review: efficacy of pacemakers in people with suspected carotid sinus syncope with a cardioinhibitory response to carotid sinus massage
  • 6.5. Clinical Evidence Review: people with suspected neurally mediated syncope after initial assessment - accuracy of tilt testing, ambulatory ECG and carotid sinus massage to direct pacing therapy
  • 6.6. Diagnostic test accuracy of tilt testing versus IER as a reference standard for the diagnosis of cardioinhibitory, neurally mediated syncope
  • 6.7. Economic evaluation of testing strategies to direct pacing therapy
  • 6.8. Evidence Statements
  • 6.9. Evidence to Recommendations
  • 6.10. Recommendations
• 7 Reference List
• Appendices
  • Appendix A. Scope
  • Appendix B. Declarations of Interest
  • Appendix C1. Clinical Questions
  • Appendix C2. Search strategies
  • Appendix D1. Included studies characteristics
  • Appendix D2. Methodological quality
  • Appendix D3. Forest plots, tables, stage one
  • Appendix D4. Forest plots, tables, stage two
  • Appendix D5. Patient profile for interactive diagnostic simulation
  • Appendix D6. Narrative Review
  • Appendix E1. Health economic extractions
  • Appendix E2. Quality and applicability of HE papers
  • Appendix F. All excluded studies
  • Appendix G. Further guidance on driving following TLoC
  • Appendix H. Quality of Life Review to inform Health Economics
  • Appendix I. PSA parameter distributions

Suggested citation:

Westby M, Davis S, Bullock I, Miller P, Cooper P, Turnbull N, Beal R, Braine M, Fear J, Goodwin M, Grünewald R, Jelen P Pawelec J, Petkar S, Pitcher D, Pottle A, Rogers G, Swann G (2010) Transient loss of consciousness (‘blackouts’) management in adults and young people. London: National Clinical Guideline Centre for Acute and Chronic Conditions, Royal College of Physicians.