Guidelines

Transient loss of consciousness—initial assessment, diagnosis, and specialist referral: summary of NICE guidance

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c4457 (Published 2 September 2010)
Cite this as: BMJ 2010;341:c4457

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I used Automated ECG interpretation back in 1985. It was a new technology then with lots of problems. The criteria I chose was who wrote the interpretation program.At first it was Japanese machines and Japanese cardiologists. Later it was USA machines and Cardiologists. I did not trust it fully,but it did help. I was a junior surgeon manning a rural hospital. At night and when alone and when I needed to make judgment and actions, this was really helpful.It would be best having a senior cardiologist by my side always but it was not reality in many occasions. Having some views from a computer software written and endorsed by someone better than me definitely helps. I knew and did write software and helped to developed networking, and automatic interpretation and published on this aspects. Sure I knew the limitations. But I still use automatic interpretation as an adjunct.

By the way, at that time I also was the first few to use pulse oximeter after I passed endotracheal tubes in emergency resuscitations. Our anesthetist disagreed with me. But I needed support when I worked alone and at night when no one was immediately around. It is now common practice. I regarded my ECG interpretation up to my standard of training and I seldom differed much from the automated results. To be idealistic in training is good but practice in real life for sake of safety , second opinion or medical legal reasons,one has to face reality. I supported with action the guidelines. I am glad that my empirical action is shared by similar views in national guides.

ref. 1.From Buying beds to upgrading an old rural hospital. BMJ, 20/27 December 1986,293,1663-1665 2.Use of a Pulse Oximeter in the Analysis of Fall of Pulse Rate after Exercise--A Preliminary Study: Journal of Hong Kong Physiotherapy 1988 Vol. 10, p.22-26 3.Microcomputer Processing of Blood Gas Results: Abstract of Papers, Centennial Conference, Hong Kong University, Faculty of Medicine,September,1987 ,p.79 4. Telephone Transmission of Urgent Laboratory Data ------ A Pilot Study. The Hong Kong Practitioner. November 1987, vol.9(11) p.2820-2833

Competing interests: None declared

YL Yip, Hon Ass Professor

HK University, Faculty of Medicine

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The differential diagnoses in chronic instability -pre loss of consciousness due to orthostatic hypotension , characteristic of late stages of autonomic neuropathy is observed too in normal subjects.the diagnostic methods described classically - CRR tests ( variation in heart rate ( HR ) in resting respiration ,slow breathing or Valsalva maneuver.these tests were recorded in sioftware methods ( Codas ).useful study methods have been performed with current rate variation with deep breathing at 6 / minute ( delta R6) and with a valsalva maneuver ( VR ) in control subjects Ref . -Bellavere F , Ewing DJ.Autonomic control of the immediate heart rate response to lying down.Clin Sci

Competing interests: None declared

Sabino G Echebarria Mendieta, NEUROLOGIST MD.NEUROLOGY AREA.BASQUE HEALTH SERVICE-OSAKIDETZA.H. SAN ELOY ( BARAKALDO-BIZKAIA ) DIS

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It is fairly clear in the guidelines that patient should be investigated for orthostatic hypotension and for neurally mediated syncope. Please refer to the end paragraph in the section titled 'Specialist cardiovascular assessment and diagnosis'. I hope this information is helpful.

Competing interests: None declared

Farrukh Baig, Consultant Physician

Royal Shrewsbury Hospital

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Autonomic neuropathies are a collection of syndromes and diseases affecting the autonomic neurons, either parasympathetic or sympathetic, or both. Autonomic neuropathy is frequent in diabetics. The cardiovascular manifestations of autonomic neuropathy appear to be the most widely studied ones and justifiably so because they are likely to be potentially lethal. Postural giddiness and syncope are the only autonomic symptoms referable to the cardiovascular systems.

Competing interests: None declared

Rizaldy Pinzon, Neurologist

Bethesda Hospital Yogyakarta Indonesia 55224

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A very comprehensive and interesting article.

I agree with Alison. I do not think that the guidelines should encourage the use of an automated ECG interpretation device, especially as the first port of call.

An ECG should be gained and the interpretation done, in the first instance, by a healthcare professional competant in reading ECGs. This can be used in conjuncton with an automated ECG interpretation device but it is paramount that Doctor's/practioners should not let this automated diagnosis cloud their own judgement. If the doctor/practioner is unsure then advice should be gained from a colleague with further skills in this area, we should not be taking the automated machines 'word for it'.

ECG interpretation is an essential skill for any medical professional working in the emergency and acute setting and should not be replaced by a machine, which in my experience, can often mis-diagnose.

Competing interests: None declared

James Head, Student Paramedic

London

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13 September 2010

I was astonished to read in this guideline that the recommendation that automated ECG interpretation should be used - not in cases of diagnostic doubt, or as a "back up" way of checking nothing has been missed, but as the first line method for interpreting the ECG.

Is it no longer expected that medical students will learn to interpret ECGs before graduation? Surely anyone requesting an ECG should be competent to interpret it, and certainly any DOCTOR should be capable of analysing an ECG without the need for automated interpretation. It is widely known that automated interpretation leads to misinterpretation (eg diagnosing AF when there is simply a poor quality baseline, or attributing changes to ischaemia when in fact the patient has a subarachnoid haemorrhage) - I am shocked that not only is use of this technology considered acceptable, it is actually being recommended as part of a national guideline.

Is ECG interpretation no longer regarded as an essential skill for a doctor?

Competing interests: None declared

Alice L Wood, doctor

Glenfield Hospital

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