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Transient loss of consciousness

About

What is covered

This interactive flowchart covers the assessment, diagnosis and specialist referral of people aged 16 and over who have experienced a blackout (the medical term for this is 'transient loss of consciousness' or TLoC for short).
TLoC is very common: it affects up to half the population in the UK at some point in their lives. TLoC may be defined as spontaneous loss of consciousness with complete recovery. 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 a 'collapse', but some people collapse without TLoC and this guideline does not cover that situation. There are various causes of TLoC, including cardiovascular disorders (which are the most common), neurological conditions such as epilepsy, and psychogenic attacks.
The diagnosis of the underlying cause of TLoC is often inaccurate, inefficient and delayed. There is huge variation in the management of TLoC. A substantial proportion of people initially diagnosed with, and treated for, epilepsy have a cardiovascular cause for their TLoC. Some people have expensive and inappropriate tests or inappropriate specialist referral; others with potentially dangerous conditions may not receive appropriate assessment, diagnosis and treatment.
People experiencing TLoC may come under the care of a range of clinicians, and the lack of a clear care pathway may contribute to misdiagnosis and inappropriate treatment.
This interactive flowchart aims to define the appropriate channels for the initial assessment, diagnosis and specialist referral of people who have had TLoC, so that they receive the correct diagnosis quickly, efficiently and cost effectively, leading to a suitable management plan.

Updates

Updates to this interactive flowchart

1 October 2014 Transient loss of consciousness ('blackouts') in over 16s (NICE quality standard 71) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on assessing, diagnosing and referring adults and young people who have experienced a blackout in an interactive flowchart

What is covered

This interactive flowchart covers the assessment, diagnosis and specialist referral of people aged 16 and over who have experienced a blackout (the medical term for this is 'transient loss of consciousness' or TLoC for short).
TLoC is very common: it affects up to half the population in the UK at some point in their lives. TLoC may be defined as spontaneous loss of consciousness with complete recovery. 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 a 'collapse', but some people collapse without TLoC and this guideline does not cover that situation. There are various causes of TLoC, including cardiovascular disorders (which are the most common), neurological conditions such as epilepsy, and psychogenic attacks.
The diagnosis of the underlying cause of TLoC is often inaccurate, inefficient and delayed. There is huge variation in the management of TLoC. A substantial proportion of people initially diagnosed with, and treated for, epilepsy have a cardiovascular cause for their TLoC. Some people have expensive and inappropriate tests or inappropriate specialist referral; others with potentially dangerous conditions may not receive appropriate assessment, diagnosis and treatment.
People experiencing TLoC may come under the care of a range of clinicians, and the lack of a clear care pathway may contribute to misdiagnosis and inappropriate treatment.
This interactive flowchart aims to define the appropriate channels for the initial assessment, diagnosis and specialist referral of people who have had TLoC, so that they receive the correct diagnosis quickly, efficiently and cost effectively, leading to a suitable management plan.

Updates

Updates to this interactive flowchart

1 October 2014 Transient loss of consciousness ('blackouts') in over 16s (NICE quality standard 71) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Transient loss of consciousness ('blackouts') in over 16s (2010 updated 2014) NICE guideline CG109
Zio Service for detecting cardiac arrhythmias (2017) NICE medtech innovation briefing 101

Quality standards

Quality statements

Initial assessment – recording the event, clinical history and physical examination

This quality statement is taken from the transient loss of consciousness quality standard. The quality standard defines clinical best practice in transient loss of consciousness care and should be read in full.

Quality statement

People who have had a suspected transient loss of consciousness have an initial assessment to record details of the event, clinical history and physical examination.

Rationale

If a suspected transient loss of consciousness has occurred, it is important to collect information as soon as possible from the person and especially from any witnesses. This is critical in confirming whether or not a transient loss of consciousness has occurred, and in establishing relevant features of the event, so that patients can be directed along the correct care pathway.
Inadequate assessment may result in inappropriate care that may be costly, ineffective and possibly harmful. It is also important to record current medications, to identify any medication that may have caused or contributed to transient loss of consciousness, and identify any ‘red flag’ signs or symptoms (see quality statement 3).

Quality measures

Structure
Evidence of local arrangements to ensure that people who have had a suspected transient loss of consciousness have an initial assessment to record details of the event, clinical history and physical examination.
Data source: Local data collection.
Process
(a) Proportion of people with a suspected transient loss of consciousness who have the details of the event recorded.
Numerator – the number in the denominator who have the details of the event recorded.
Denominator – the number of people with a suspected transient loss of consciousness.
Data source: Local data collection.
(b) Proportion of people with a suspected transient loss of consciousness who have the details of the clinical history and physical examination assessment recorded.
Numerator – the number in the denominator who have the details of the clinical history and physical examination assessment recorded.
Denominator – the number of people with a suspected transient loss of consciousness.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (first-line staff such as paramedic and emergency service staff, GPs, and out-of-hours staff) ensure that people who have had a suspected transient loss of consciousness have an initial assessment, in which the details of the event are recorded, a clinical history is taken and a physical examination is carried out.
Healthcare professionals ensure that people who have had a suspected transient loss of consciousness have an initial assessment, in which the details of the event are recorded, a clinical history is taken and a physical examination is carried out.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that they specify in contracts with ambulance and emergency services that people who have had a suspected transient loss of consciousness have an initial assessment, in which the details of the event are recorded, a clinical history is taken and a physical examination is carried out.

What the quality statement means for patients, service users and carers

People who have had a blackout have an assessment to find out more about the blackout and why it happened. This will involve recording details of the blackout (by witnesses) and any previous blackouts, medical history, family history of heart disease, and any medicines being taken, checking vital signs such as pulse rate, blood pressure, breathing rate and temperature, and also listening to the chest.

Source guidance

Definitions of terms used in this quality statement

Detailed account of the event
An account of the event should be taken from the person and any witnesses who are present at the initial consultation at the point of contact. Attempts should be made to contact any further witnesses (for example, by telephone).
The following details should be recorded:
  • circumstances of the event
  • person's posture immediately before loss of consciousness
  • prodromal symptoms (such as sweating or feeling warm or hot)
  • physical appearance (for example, whether eyes were open or shut, and the colour of the person’s complexion during the event)
  • presence or absence of movement during the event (for example, limb-jerking and its duration)
  • any tongue-biting (record whether the side or the tip of the tongue was bitten)
  • injury occurring during the event (record site and severity)
  • duration of the event (onset to regaining consciousness)
  • presence or absence of confusion during the recovery period
  • weakness down 1 side during the recovery period.
[Adapted from NICE clinical guideline 109, recommendation 1.1.1.2]
Detailed clinical history and physical examination
Detailed clinical history and physical examination should involve recording the following:
  • details of any previous transient loss of consciousness events, including number and frequency
  • the person's medical history and any family history of cardiac disease (for example, personal history of heart disease and family history of sudden cardiac death)
  • current medication that may have contributed to transient loss of consciousness (for example, diuretics)
  • vital signs (for example, pulse rate, respiratory rate and temperature) – repeat if clinically indicated
  • lying and standing blood pressure if clinically appropriate
  • other cardiovascular and neurological signs.
[Adapted from NICE clinical guideline 109, recommendation 1.1.2.1]

Initial assessment – 12-lead electrocardiogram (ECG)

This quality statement is taken from the transient loss of consciousness quality standard. The quality standard defines clinical best practice in transient loss of consciousness care and should be read in full.

Quality statement

People who have had a transient loss of consciousness have a 12-lead electrocardiogram (ECG) during the initial assessment.

Rationale

A 12-lead ECG is an important initial diagnostic test for identifying the likely cause of the transient loss of consciousness in some people, and especially in predicting adverse events (for example, ECG abnormalities that are ‘red flag’ signs or symptoms may suggest structural heart disease or potential for arrhythmic syncope). A 12-lead ECG should be used by appropriately trained healthcare professionals (such as paramedics and GPs) to identify people who may be at high risk of a serious event, and who should therefore be referred for urgent specialist cardiovascular assessment.

Quality measures

Structure
Evidence of local arrangements to ensure that people who have had a transient loss of consciousness have a 12-lead ECG during initial assessment.
Data source: Local data collection.
Process
Proportion of people who have had a transient loss of consciousness who have a 12-lead ECG during initial assessment.
Numerator – the number in the denominator who have a 12-lead ECG during initial assessment.
Denominator – the number of people who have had a transient loss of consciousness.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (first-line staff such as paramedic and emergency service staff, GPs, and out-of-hours staff) ensure that people who have had a suspected transient loss of consciousness have a 12-lead ECG recorded during the initial assessment. Service providers ensure that systems are in place to offer training to healthcare professionals according to local need in relation to competent interpretation of 12-lead ECG recordings.
Healthcare professionals (such as paramedics and GPs) ensure that people who have had a suspected transient loss of consciousness have a 12-lead ECG recorded during the initial assessment and that the results are interpreted competently.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that all service providers have appropriate capacity in place to provide access to 12-lead ECGs.

What the quality statement means for patients, service users and carers

People who have had a blackout have an ECG (short for electrocardiogram) test during their initial assessment. This records electrical signals from the heart and may help to identify problems that can cause blackouts.

Source guidance

Definitions of terms used in this quality statement

12-lead ECG
A test that records the heart’s electrical signals, obtained by attaching electrodes in 10 standard positions on the limbs and the surface of the chest. The 12-lead ECG recording should be reported automatically, or if automated analysis is not available, by a healthcare professional competent in ECG interpretation and trained to identify specific potentially life-threatening abnormalities. This must be interpreted in the full context of the detailed history and clinical signs.
When care is transferred, copies of the ECG recording and the patient report form should be given to the receiving clinician and to the person who has had the transient loss of consciousness.
[Adapted from NICE full clinical guideline 109 and expert opinion]

Urgent specialist cardiovascular assessment within 24 hours of the initial assessment

This quality statement is taken from the transient loss of consciousness quality standard. The quality standard defines clinical best practice in transient loss of consciousness care and should be read in full.

Quality statement

People who have had a transient loss of consciousness and 1 or more ‘red flag’ signs or symptoms identified have an urgent specialist cardiovascular assessment within 24 hours of the initial assessment.

Rationale

If people have had a transient loss of consciousness and 1 or more ‘red flag’ signs or symptoms have been identified, an urgent specialist cardiovascular assessment is needed within 24 hours of the initial assessment so that they can be assessed promptly for further investigation and treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that people who have had a transient loss of consciousness and 1 or more ‘red flag’ signs or symptoms identified have an urgent specialist cardiovascular assessment within 24 hours of the initial assessment.
Data source: Local data collection.
Process
Proportion of people who have had transient loss of consciousness and 1 or more ‘red flag’ signs or symptoms identified who have an urgent specialist cardiovascular assessment within 24 hours of the initial assessment.
Numerator – the number in the denominator who have an urgent specialist cardiovascular assessment within 24 hours.
Denominator – the number of people who have had transient loss of consciousness and 1 or more ‘red flag’ signs or symptoms identified at initial assessment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (first-line staff such as paramedic and emergency service staff, GPs, and out-of-hours staff) ensure that people who have had a transient loss of consciousness and 1 or more ‘red flag’ signs or symptoms identified have an urgent specialist cardiovascular assessment within 24 hours of the initial assessment.
Healthcare professionals ensure that people who have had a transient loss of consciousness and 1 or more ‘red flag’ signs or symptoms identified have an urgent specialist cardiovascular assessment within 24 hours of the initial assessment.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that all service providers have appropriate capacity in place for people who have had a transient loss of consciousness and 1 or more ‘red flag’ signs or symptoms identified to have an urgent specialist cardiovascular assessment within 24 hours of the initial assessment.

What the quality statement means for patients, service users and carers

People who have had a blackout and have 1 or more ‘red flag’ signs or symptoms have an urgent specialist assessment within 24 hours of the initial assessment. ‘Red flag’ signs or symptoms indicate a high risk of a serious event such as having another blackout or a heart problem.

Source guidance

Definitions of terms used in this quality statement

‘Red flag’ signs or symptoms
'Red flag’ signs or symptoms indicate that the person may be at high risk of a serious adverse event and should have an urgent specialist assessment within 24 hours. The signs or symptoms include:
  • an electrocardiogram (ECG) abnormality
  • heart failure (history or physical signs)
  • transient loss of consciousness during exertion
  • family history of sudden cardiac death in people aged younger than 40 years and/or an inherited cardiac condition
  • new or unexplained breathlessness
  • a heart murmur.
[Adapted from NICE clinical guideline 109, recommendation 1.1.4.2, and expert opinion]
Urgent specialist cardiovascular assessment
People at high risk of a serious cardiovascular or cerebrovascular adverse event need urgent investigation within 24 hours of the initial assessment.
Cardiovascular assessment is carried out by a specialist team that includes healthcare professionals who are experts in cardiovascular diseases and disorders. In some hospitals, this may be carried out in a clinic specialising in assessing people with a transient loss of consciousness.
[Based on NICE full clinical guideline 109 and expert opinion]

Initial assessment – unnecessary use of electroencephalogram (EEG)

This quality statement is taken from the transient loss of consciousness quality standard. The quality standard defines clinical best practice in transient loss of consciousness care and should be read in full.

Quality statement

People who have had a transient loss of consciousness are not routinely offered an electroencephalogram (EEG) to investigate the event.

Rationale

EEGs are usually carried out as part of initial investigations for epilepsy and are not routinely offered to investigate transient losses of consciousness. Great caution is needed in performing and interpreting an EEG if the clinical history offers limited or no support for a diagnosis of epilepsy. This is because a ‘false positive’ result may lead to misdiagnosis and inappropriate treatment. It is important that EEGs are not routinely requested inappropriately in the generalist setting as a diagnostic test to investigate unexplained transient loss of consciousness.

Quality measures

Structure
Evidence of local arrangements to ensure that people who have had a transient loss of consciousness are not routinely offered an EEG to investigate the event.
Data source: Local data collection.
Process
Proportion of people who have had a transient loss of consciousness who have an EEG recorded to investigate the event.
Numerator – the number in the denominator who have an EEG recorded to investigate the event.
Denominator – the number of people who have had a transient loss of consciousness.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (acute, primary and secondary care) ensure that people who have had a transient loss of consciousness are not routinely offered an EEG to investigate the event.
Healthcare professionals ensure that they do not routinely offer an EEG to people who have had a transient loss of consciousness to investigate the event.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that they monitor and audit any routine EEG referrals to investigate a transient loss of consciousness event. They should also work with healthcare professionals to ensure that provider training and education is delivered to ensure that EEGs are not offered routinely to people who have had a transient loss of consciousness to investigate the event.

What the quality statement means for patients, service users and carers

People who have had a blackout should not normally be offered an EEG (short for electroencephalogram) to investigate the cause of their blackout. This is a test that records the brain’s electrical activity and is usually offered when epilepsy is suspected.

Source guidance

Driving advice

This quality statement is taken from the transient loss of consciousness quality standard. The quality standard defines clinical best practice in transient loss of consciousness care and should be read in full.

Quality statement

People who have had a transient loss of consciousness are advised not to drive while they are awaiting specialist assessment.

Rationale

People who have experienced a transient loss of consciousness may be at risk of injuring themselves or others if they lose consciousness again. While they are awaiting specialist assessment, the risk of recurrence is uncertain and so driving should be avoided (see Driver and Vehicle Licensing Agency’s [DVLA] At a glance).

Quality measures

Structure
Evidence of local arrangements to ensure that people who have had a transient loss of consciousness are advised not to drive while they are awaiting specialist assessment.
Data source: Local data collection.
Process
Proportion of people who have had transient loss of consciousness who are advised not to drive whilst awaiting specialist assessment.
Numerator – the number in the denominator who are advised not to drive.
Denominator – the number of people who have had transient loss of consciousness and are awaiting specialist assessment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (acute, primary and secondary care) ensure that advice is provided to people who have had a transient loss of consciousness to not to drive while they are awaiting specialist assessment.
Healthcare professionals advise people who have had a transient loss of consciousness to not to drive while they are awaiting specialist assessment.
Commissioners (NHS England area teams and clinical commissioning groups) work with healthcare professionals to ensure that education (including continuous training programmes) is delivered to advise people who have had a transient loss of consciousness are advised to not to drive while they are awaiting specialist assessment.

What the quality statement means for patients, service users and carers

People who have had a blackout and are waiting to have a specialist assessment are advised not to drive in case they have a blackout while driving.

Source guidance

Specialist cardiovascular investigation – ambulatory electrocardiogram (ECG)

This quality statement is taken from the transient loss of consciousness quality standard. The quality standard defines clinical best practice in transient loss of consciousness care and should be read in full.

Quality statement

People with a suspected cardiac arrhythmic cause of syncope are offered an ambulatory electrocardiogram (ECG) as a first-line specialist cardiovascular investigation.

Rationale

In some people, transient loss of consciousness is caused by a transient episode of abnormal heart rhythm (cardiac arrhythmia) that has resolved before recovery or initial assessment. Ambulatory ECGs allow prolonged monitoring to try to detect intermittent episodes of cardiac arrhythmia (and also of abnormal heart rate behaviour). The monitoring takes place over at least 24 hours, and often much longer.
Recording heart rate and rhythm behaviour at the time of an episode of transient loss of consciousness allows confident diagnosis. Competent expert interpretation is also needed to assess the relevance of abnormal heart rate and rhythm behaviour recorded at a time when the person has no symptoms.

Quality measures

Structure
Evidence of local arrangements to ensure that people with a suspected cardiac arrhythmic cause of syncope are offered an ambulatory ECG as a first-line specialist investigation, with the type of ambulatory ECG chosen according to the person’s history and frequency of transient loss of consciousness.
Data source: Local data collection.
Process
Proportion of people with a suspected cardiac arrhythmic cause of syncope who are offered an ambulatory ECG as a first-line specialist investigation.
Numerator – the number in the denominator who receive an ambulatory ECG as a first-line specialist investigation, with the type of ambulatory ECG chosen according to the person’s history and frequency of transient loss of consciousness.
Denominator – the number of people with a suspected cardiac arrhythmic cause of syncope.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (acute, primary and secondary care) ensure that systems are in place to offer ambulatory ECGs as a first-line specialist cardiovascular investigation for people with a suspected cardiac arrhythmic cause of syncope.
Healthcare professionals ensure that they offer an ambulatory ECG as a first-line specialist cardiovascular investigation for people with a suspected cardiac arrhythmic cause of syncope.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that they enhance training and education on offering an ambulatory ECG as a first-line specialist cardiovascular investigation for people with a suspected cardiac arrhythmic cause of syncope. They should also request evidence of practice from providers that ambulatory ECGs are being offered as a first-line specialist cardiovascular investigation.

What the quality statement means for patients, service users and carers

People whose blackout is suspected to be caused by a sudden change in heart rate or rhythm are offered an ambulatory ECG. This is a test that uses a small portable device to monitor and record the heart’s activity over a period of time (usually more than 24 hours).

Source guidance

Definitions of terms used in this quality statement

Ambulatory ECG
A test that monitors and/or records the electrical activity of the heart over a prolonged period of at least 24 hours, while the person is walking about (ambulatory) and doing other normal activities, including resting or sleeping.
Ambulatory ECG monitors and/or recorders
Holter monitor/recorder
A small, portable recorder that can take continuous ECG readings from electrodes on the skin, usually over a 24- to 72-hour period.
[Based on NICE clinical guideline 109 and expert opinion]
External event recorder
A small, portable recorder that can take ECG readings from electrodes on the skin; usually worn for 1–4 weeks. It will usually be programmed to detect and store episodes of extreme heart rate behaviour and can be triggered remotely (by the person or someone close to them) to store the current or immediately recent ECG at the time of an event, such as a further episode of transient loss of consciousness.
[Based on NICE clinical guideline 109 and expert opinion]
Implantable event recorder (also known as an implantable or insertable loop recorder, or implantable cardiac monitor)
A small, implantable device that can monitor and store ECG recordings of the heart's rhythm. It can be programmed to detect and store episodes of extreme heart rate behaviour and can be triggered remotely (by the person or someone close to them) to store the current or immediately recent ECG at the time of an event such as a further episode of transient loss of consciousness.
[Based on NICE clinical guideline 109 and expert opinion]
Cardiac arrhythmia
An abnormality of the heart's rhythm.
[Based on expert opinion]
Syncope
Transient loss of consciousness caused by transient reduction in blood flow to the brain. May be caused by many different factors, including vagal stimulation, vascular pooling in the legs, sudden change in environmental temperature or body position drug therapy, structural heart disease, cardiac arrhythmia, vertebro-basilar atheroma and emotional stress.
[NICE clinical guideline 137 and expert opinion]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Advice for people waiting for a specialist assessment

Driving: advise all people who have experienced TLoC that they must not drive while waiting for specialist assessment.
After specialist assessment, the healthcare professional should advise the person of their obligations regarding reporting the TLoC to the DVLA.
Advise people waiting for a specialist cardiovascular assessment:
  • what they should do if they have another event
  • if appropriate, how they should modify their activity (for example, by avoiding physical exertion) and not to drive (please refer to the DVLA for more information) .
Offer advice to people waiting for a specialist neurological assessment as recommended in the NICE guideline on epilepsy.
NICE has written information for the public explaining the guidance on transient loss of consciousness.

Criteria to determine type of ambulatory ECG

For people who have:
  • TLoC at least several times a week, offer Holter monitoring (up to 48 hours if necessary). If no further TLoC occurs during the monitoring period, offer an external event recorder that provides continuous recording with the facility for the patient to indicate when a symptomatic event has occurred.
  • TLoC every 1–2 weeks, offer an external event recorder. If the person experiences further TLoC outside the period of external event recording, offer an implantable event recorderWhen offering a person an implantable event recorder, provide one that has both patient-activated and automatic detection modes. Instruct the person and their family and/or carer how to operate the device. Advise the person that they should have prompt follow-up (data interrogation of the device) after they have any further TLoC. The timing of the follow-up is dependent on the storage of the device and the condition of the person..
  • TLoC infrequently (less than once every 2 weeks), offer an implantable event recorder. A Holter monitor should not usually be offered unless there is evidence of a conduction abnormality on the 12-lead ECG.
Orthostatic hypotension is a condition in which a marked fall in blood pressure is provoked by a change in posture from lying to sitting, or from lying or sitting to standing. This may cause light-headedness (dizziness), a fall, or TLoC.

Glossary

Recording of the heart's electrical signals obtained by attaching electrodes in ten standard positions on the limbs and the surface of the chest. This provides a display of the electrical activity of the heart viewed from 12 different directions.
an abnormal heart rhythm
sustained absence of the heart's electrical activity
slow heart rate (irrespective of rhythm), conventionally defined as less than 60 beats per minute
An inherited ion channel disorder characterised by abnormal ST segment elevation in leads V1 to V3 on ECG. This predisposes to ventricular arrhythmia and sudden cardiac death, and may present with syncope.
a procedure in which the carotid sinus is stimulated (by firm massage with a thumb during continuous ECG and blood pressure monitoring in both supine and upright positions) to investigate suspected or possible carotid sinus syncope
a form of neurally mediated syncope in which pressure on one or other carotid artery causes syncope
An intense sensation that what is happening for the first time has already occurred previously. This is common particularly in adolescence, but may be a manifestation of a partial seizure (rather than occurring immediately before an epileptic seizure).
electrocardiogram
electroencephalograph
A small portable recorder that is capable of monitoring and storing ECG recordings from electrodes on the skin. The device records the heart's rhythm during symptoms (including syncope) that occur intermittently. Excludes event recorders that do not perform continuous ECG monitoring (and therefore are not capable of documenting cardiac rhythm at the moment of TLoC).
Episode of TLoC due to vasovagal syncope. Fainting is a temporary loss of consciousness due to a drop in blood flow to the brain. The episode is brief and is followed by rapid and complete recovery.
a Holter monitor or recorder is a small portable recorder that is capable of continuous ECG recording from electrodes on the skin, usually used over a 24- to 72-hour period
disturbance of normal heart rhythm occurring during a seizure
small implantable device capable of monitoring and storing ECG recordings of the heart's rhythm. It is also known as an implantable/insertable loop recorder
a feeling of lack of familiarity, that what should be familiar is happening for the first time; it is usually abnormal, it doesn't commonly occur in healthy people
a form of neurally mediated syncope provoked by straining while passing urine while standing
Sometimes called 'reflex syncope'. Transient loss of consciousness due to a reflex hypotensive response and/or reflex bradycardic response to a number of causes; this category includes vasovagal syncope, carotid sinus syncope, and situational syncope.
a psychogenic non-epileptic attack characterised by loss of muscle tone and having the appearance of a faint
episodes of altered movement, sensation or experience, similar to epilepsy but caused by a psychological process and not associated with abnormal electrical discharges in the brain
A specific portion of the ECG. If this portion is prolonged or abnormally short it can indicate certain inherited conditions known as 'long QT syndrome' and 'short QT syndrome'. Both syndromes predispose to ventricular arrhythmia and sudden cardiac death, and may present with syncope.
for this guideline, the term 'red flag' indicates that the person is considered to be at high risk of a serious adverse event and should be referred for urgent specialist assessment
a form of neurally mediated syncope occurring in certain specific situations (for example, cough syncope, micturition syncope, or swallowing syncope)
a healthcare professional who has expert knowledge of, and skills in, a particular clinical area, especially one who is certified by a higher medical educational organisation
Any disease of the heart in which the structural components of the heart are abnormal. This encompasses heart muscle disease, valve disease and congenital heart disease.
test in which a patient is exposed to passive head-up tilt, during which they have beat-to-beat measurement of heart rate and blood pressure, to try to demonstrate whether or not they have a provocable tendency to vasovagal syncope
transient loss of consciousness
A form of neurally mediated syncope. This is often, but not always, triggered by circumstances such as pain, prolonged standing (especially in a warm environment), or emotional stress. This commonly presents as an identifiable uncomplicated faint but can present as sudden unprovoked syncope.

Paths in this pathway

Pathway created: December 2012 Last updated: July 2017

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