Transient loss of consciousness clinic (TLOC) clinic

• Based at UHCW
• Accepts referral for patients over 18 years old
• Will consider referrals for 16-18 year olds in exceptional circumstances only
• Applies to patients from the Coventry, Rugby and Warwickshire areas

Purpose

To provide guidance for clinicians referring patients to the transient loss of consciousness clinic (TLOC) clinic

It outlines strict referral criteria to guide referral decisions for patients presenting with syncope and to streamline clinic triage

Please note: Referrals will be REJECTED if there is NO HISTORY OF LOSS OF CONSCIOUSNESS

Strict diagnostic criteria:

Patient’s must meet ALL of the following criteria for review:

• Detailed history (circumstances, prodromal, recovery)
• Standing or seated loss of consciousness
• Detailed history of fluid intake
• Lying & standing blood pressure

Required Pre-Referral Investigations:

• 12 lead ECG
• Orthostatic vital signs if possible* (supine and standing HR & BP at 1,3,5 and 10 minutes ideally) *this may not be fully possible practically in a Primary Care setting – editor
• Blood tests – FBC, U&E and TSH
• Brief symptom summary including duration, frequency and functional impact
• Medication list (such as antihypertensives, diuretics, beta-blockers)

(Referrals from other tertiary hospitals please provide relevant clinic letters confirming diagnosis including tilt test reports attached to the referral)

High risk patients:  Unexplained syncope/ seated LOC/exertional syncope/ no provoking factors/abnormal ECG/ background of significant cardiac conditions/ family history of sudden cardiac death

High risk patients require ***URGENT Referral to syncope clinic***

Low risk patients:  Syncope coinciding with  vasovagal syncope/reflex mediated/orthostatic intolerance  (one single episode)  prodrome/provoking factors, normal ECG/no seated loss of consciousness or cardiac history or significant family history of sudden cardiac death

Low risk patients ***Do NOT require a referral- please follow the lifestyle modification plan advice below***

Suggested Pre-Referral Management:

• Encourage adequate hydration 2-3 L daily, front load in the beginning of the morning
• Limit consumption of caffeine/alcohol (trigger dehydration)
• Include isotonic and mineral based drinks such as milk, smoothies, pure juices, cordials
• Increase dietary salt intake (10 g daily)
• Advise avoidance of prolonged standing, dehydration and heat exposure
• Lower recumbent (seated) calf clench exercises to prevent venous pooling
• Consider compression garments waist-high or abdominal binders

Other useful resources:  STARS (Syncope Trust and Reflex anoxic Seizures) www.stars.org.uk

TLOC referral checklist:

Please ensure ALL criteria are met before referral:

• Lying and standing BP & HR (up to 5 – 10 minutes)
• Recent ECG and blood tests (FBC, U&E, TFT)
• Detailed symptom summary provided including a good fluid history