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Author: Kanchan Ganda, M.D.
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1. Fits and Faints

Epilepsy, vasovagal syncope - (hypoglycemic coma is discussed in endocrine section)

1.1. Epilepsy

A seizure may or may not be associated with a loss of consciousness. Grand Mal Epilepsy manifests as a generalized seizure and is associated with a transient loss of consciousness. Grand Mal Epilepsy may be associated with a prodromal phase. Petit Mal Epilepsy is a generalized seizure, but is not associated with a loss of consciousness.

1.1.1. Grand Mal Epilepsy

Clinical Note: Alcohol destroys the potency of seizure medications so seizures may be more frequent in such patients. The patient needs to be clear of alcohol 24-48 hours prior to treatment so the drug potency isn’t jeopardized. Always ask the patient how many seizures occur in a year, a week, a month? If the patient has 1 or 2 seizures a year, you can use epinephrine in the LA. If more than 2-4 attacks occur per month, epinephrine should not be used.

1.1.1.1. Prodromal Phase of Grand Mal Epilepsy

The prodromal symptoms, occur prior to the seizure. There may be abnormal sensations, feelings, movements or thoughts. Patients with a history of grand mal epilepsy may experience a prodromal phase lasting a few minutes to a few hours or sometimes days. During this phase, the patient may feel low, depressed, have “tunnel vision” and have a distinct feeling that an attack is imminent. The prodromal phase does not occur in all patients, but in those who experience it, every attack will be preceded by the same specific prodromal symptoms.

1.1.1.2. Ictal/Seizure Phase of Grand Mal Epilepsy

The actual seizure phase consists of four subphases—Aura, Tonic, Clonic and Flaccid phase. A typical seizure lasts for two minutes or less.

1.1.1.2.1. Aura

The Aura may not occur in all patients, but if it occurs in a patient (the patient will be informed subsequently about it by those seeing his/her attack), it will always be present with every attack.

During the aura phase the patient has abnormal sensations. He/she may see, hear, taste or smell something. The patient is conscious but unaware that they are experiencing these sensations. They may talk about these experiences and people in their surroundings may hear and inform them later. You should always establish if an aura exists. Aura lasts for a few seconds.

You do not have time to move the patient out of the dental chair (should this be happening in your office). Make the chair horizontal and push the tray away. You and your dental assistant stand on either side of the chair to prevent injury. The aura leads into the tonic phase.

1.1.1.2.2. Tonic

The patient gives out a loud cry, takes in a deep breath, holds his/her breath, becomes unconscious, and the entire body becomes hyperextended. This phase lasts for less than one minute. Don’t hold the patient down - you can cause fractures. The tonic phase goes into the clonic phase.

1.1.1.2.3. Clonic

The Clonic phase is characterized by the patient resuming the breathing and having jerking movements involving the entire body. This phase also lasts for less than one minute. Do not hold the patient down. The clonic phase goes into the flaccid phase.

1.1.1.2.4. Flaccid

In the Flaccid phase all of the muscles relax and the body becomes limp. There is frothing at the mouth, the tongue falls back, and there is grunting. Incontinence of the bladder and/or bowel with epileptic seizures occur in this stage. When a patient is in the flaccid stage, you must immediately hyperextend the neck to prevent the tongue from falling back and tilt the head to the side to help drainage. Use the suction, to clear the secretions.

Once the airway is clear, shake the patient to elicit a response to confirm that the patient is regaining consciousness. An unconscious patient can have recurrent seizures and this is status epilepticus. Mortality rate is 15% with status epilepticus so you must call the hospital code response team and transfer the patient to the ER after stabilization. As you wait for the code team you must maintain the ABC’s and monitor the patient. Never send a patient home alone after a seizure has ended and the patient has regained consciousness.

The patient coming out of a seizure does not recall anything. There is a tremendous amount of confusion/fogginess and depression.

1.1.2. Petit Mal Epilepsy

Occurs mostly in children with no loss of consciousness. Often times the child is sitting in front of the TV , staring blankly, momentarily or is involved in a conversation that gets partly skipped as for a few seconds the child is lost to the environment. The child has a blank face with no blinking. The patient never falls to the ground and fully recovers in a few seconds. This type of seizure may occur in adults as well, but less frequently. So there is no loss of consciousness, but rather a temporary loss of contact with reality.

1.1.3. Syncope

Syncope is a temporary but sudden loss of consciousness when blood flow to the brain is compromised. In young individuals, fear, anxiety, sight of blood, etc., can result in a temporary loss of consciousness. This is referred to as vasovagal syncope. Frequently, syncope is associated with symptoms like light headedness, muscle weakness, and dizziness before the actual fainting occurs.

1.1.3.1. Vasovagal Syncope

Vasovagal syncope occurs commonly in young patients who are apprehensive about dental visits, blood or needles. It never occurs in children and the elderly.

Hot, humid environments and upright positioning promotes these attacks.

Vasovagal syncope is associated with a distinct prodromal stage lasting for a few seconds to minutes. The patient clenches the chair, epinephrine is released endogeneously due to a fight or flight response. The blood pools in the extremities because the patient is immobilized in the chair, and so the cardiac output decreases. This causes tachycardia in the patient. The patient experiences blurring of vision, perspiration, light-headedness, blackouts, and a feeling of imminent collapse. The tachycardia is soon replaced with bradycardia, the BP drops (hypotension) and the patient becomes unconscious.

1.1.3.1.1. Bradycardia with Hypotension
  • Bradycardia with hypotension is diagnostic of vasovagal syncope.
  • Placing the patient with vasovagal syncope in a horizontal position helps the patient to come around, as the circulation to the brain and heart is increased.
  • An ammonia vaporole cartridge can be snapped and waved in front of the patients nostrils as the best form of treatment. This causes the patient to respond quickly.
  • Always use stress management with these patients for future dental visits to avoid vasovagal syncopal reactions.