Patients with loss of awareness and with red flags present should be sent to the Emergency Department.
If a patient with loss of awareness has no red flags, please try to differentiate between a seizure or dissociative seizure and syncope. All patients should have an ECG.
If you think the patient has had more than one epileptic seizure, you should offer them anti-seizure medication while they are waiting for their appointment. Please contact the neurology team via switch board for advice.
Ask the person who has had the suspected Transient Loss of Consciousness (TLoC), and any witnesses, to describe what happened before, during and after the event. Try to contact by telephone witnesses who are not present. Record details about:
- Circumstances of the event
- Person’s posture immediately before loss of consciousness
- Prodromal symptoms (such as sweating or feeling warm/hot)
- Appearance (for example, whether eyes were open or shut) and colour of the person 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 one side during the recovery period.
Tonic-clonic seizure
- Can have 'aura', not prodrome
- Can occur while the patient is lying down, may arise from sleep
- At the beginning of the seizure the person may cry/shout out
- The person will lose consciousness
- Body will stiffen, they will fall if standing
- Lips may turn blue, saliva may run from their mouth and they might bite their tongue
- Rhythmical jerking of the limbs, crescendo in amplitude with gradually slowing (deceleration) following which cardio-respiratory rate may slow
- Usually lasts no longer than three minutes, but is followed by a slow recovery period lasting minutes to hours
- Patient will be amnestic for event
Dissociative seizure
- Should not arise from sleep, can arise shortly after waking
- Can have bilateral clonic movements without loss of consciousness
- Injury and hypoxia-cyanosis is rarer but can occur
- Asynchronous movements, no deceleration, can 'stop and start'
- Can be prolonged (>10 minutes with spontaneous recovery)
- The patient is likely to be oriented within a few minutes
Syncope
Although syncope is rarely caused by neurological problems, in the majority of cases a cardiovascular cause should be considered or ruled out.
- Pre-syncopal prodrome:
- Feel light headed
- Tachycardic
- Hot and sweaty
- Nauseated
- Grey out of vision
- Tends to occur when standing or sitting (syncope while lying down is a major red flag)
- If they lie down the patient may not lose consciousness
- Body will go limp, they will fall if standing
- May bite tongue, may be cyanosed
- Rhythmical jerking of the limbs can occur (reflex anoxic seizure or myoclonus) usually just a few beats
- Frequently unconscious for 10 to 20 seconds
- The patient will recall the prodrome and be oriented within a few minutes
Please describe the seizures as comprehensively as possible. Details of what seizures look like can be found on the 'seizure types' page:
It is vital to provide a corroborative witness statement. Wherever possible, patients need to bring a witness to clinic or have the phone number of a witness and warn them that they will be called.
All patients should be given advice on driving:
All patients should be given the following safety advice:
- Shower rather than bath
- Avoid climbing ladders
- Alcohol should be limited
- Share a bedroom or use an auditory monitoring device
More information on monitors is available on the Epilepsy Action website.
Last reviewed: 22 September 2026