Reasoning GP · Algorithm · 1-page summary
Fits and funny turns (transient loss of consciousness)
For: adults with a first or recurrent fit, faint, blackout or funny turn, face to face or remote. Not for: children (use paediatric pathways). Known epilepsy: see the epilepsy protocol; a recovered TIA: see the stroke and TIA protocol.
Core rule: witness account (phone them; ask for video) and a 12-lead ECG in everyone. Cardiac syncope kills; no single feature or EEG diagnoses or excludes epilepsy.
0Stop — call 999 now — before any history
- Seizure lasting ≥5 minutes, or repeated seizures without recovery (status epilepticus) → 999
- Not fully recovered: persistent altered consciousness, new focal deficit, meningism or fever, severe persistent headache, injury needing treatment, significant metabolic disturbance → 999 / ED
- Any seizure in pregnancy or postpartum (presume eclampsia) → 999 + obstetric emergency team. Cardiac syncope with haemodynamic instability, chest pain still present, or exertional syncope with structural heart disease → 999
- While waiting: time it, protect the head, recovery position, do not restrain, nothing in the mouth. Buccal midazolam (or rectal diazepam) only per the individual emergency plan or local protocol and training. Check capillary glucose: unable to swallow → no oral treatment; glucagon or IV glucose if trained.
1Triage — recovery status after the event
| Situation | Action |
|---|---|
| Ongoing or not recovered | Block 0 → 999 |
| First seizure + injury or concern | Same-day ED / acute medicine |
| First seizure, recovered | Normal → ≤2 weeks specialist, not automatically by ambulance |
| Syncope, high-risk feature | Same-day cardiology / acute (block 2) |
| Typical vasovagal | Normal ECG and exam → primary care |
2Screen — one row is enough
- Cardiac syncope: exertional, supine or swimming, no prodrome, palpitations, structural heart disease, abnormal ECG, family sudden death or inherited arrhythmia, severe anaemia or bleeding, recurrent unexplained → Same-day cardiology / acute
- Older, recurrent falls + blackouts (heart block, carotid sinus) → Same-day ECG, lying/standing BP, cardiology
- New focal neurology: still present → 999 (stroke). Fully resolved → aspirin 300 mg unless contraindicated + TIA specialist ≤24 h (over 1 week ago: ≤7 days); no ABCD2 (NG128)
- Anticoagulant, significant head injury, immunosuppression, cancer, HIV → Same-day emergency imaging / assessment
- Diabetes on insulin or a sulphonylurea: treat glucose <4.0 mmol/L per local protocol; review the regimen.
3Assess — only once blocks 0–2 are answered
☐ Before, during, after: posture, prodrome, trigger, recovery; drugs ☐ Lying BP (after 5 min supine) and standing, with symptoms ☐ Pulse, temperature, murmur ☐ Neurology, pupils, fundi, tongue ☐ ECG: abnormal or suspicious → specialist interpretation ☐ Bloods by context: U&E, calcium, magnesium, FBC; pregnancy test
Not in primary care: carotid sinus massage, prolactin, EEG to exclude epilepsy, starting antiseizure medicines.
4Classify — only if the screen is negative
- Epileptic seizure — lateral tongue bite, confusion >5 min, aura, automatisms, Todd's paresis; supportive, none diagnostic alone → ≤2 weeks specialist.
- Vasovagal — upright, hot or emotional trigger, sweaty, greying, pale, recovery <1 min; brief jerks can occur.
- Orthostatic — fall ≥20 systolic or ≥10 diastolic within 3 min of standing; medicines, dehydration, autonomic failure.
- Functional / dissociative seizures — specialist diagnosis (often video-EEG); keep epilepsy, syncope and cardiac causes open → neurology.
- Uncertain — say so. Do not label epilepsy or "just a faint" on one feature; refer to the first-seizure clinic or cardiology.
5Treat today — only these
- Vasovagal: counterpressure (leg crossing, gripping, squatting), avoid triggers, fluids; salt only after BP, renal and cardiac check.
- Orthostatic: review antihypertensives, diuretics, alpha-blockers first; fludrocortisone is specialist-led.
- Antiseizure medicines: never started in primary care; valproate under 55 is started only after two specialists agree (MHRA).
- Driving: first suspected seizure → stop driving; the patient tells DVLA. Syncope → document the DVLA category. Written first-aid and safety advice (shower, never swim alone, no heights).
6Refer routinely
- Recurrent unexplained syncope → cardiology (ambulatory ECG or loop recorder).
- Refractory vasovagal → consider tilt-table. Persistent orthostatic symptoms → specialist.
- Epilepsy confirmed → epilepsy specialist nurse; pre-conception folic acid 5 mg daily; enzyme-inducing medicines → injection, LNG-IUS or copper IUD.
7Never reassure by
- A normal EEG or CT — neither excludes epilepsy.
- Jerking, incontinence or a tip-of-tongue bite — these occur in syncope.
- Fast recovery when the onset was exertional, supine or without warning.
- A young, fit patient — long QT, HOCM and Brugada kill the young.
- A psychiatric history or dramatic movements.
- A "faint" with no ECG and no lying/standing BP.
8Safety-net — say it, then document it
999 “Call 999 if a fit lasts over 5 minutes or fits keep coming, if they don't wake up fully, have trouble breathing or are badly hurt, for new weakness, speech or vision loss, a blackout with chest pain or palpitations, or any fit in pregnancy or after a recent birth.” Same day: “A further fit if you have epilepsy, a blackout on exercise, or new nerve symptoms that have gone — contact us today.”
Until seen: no driving; shower, don't bathe or swim alone. Review soon after the event to confirm the specialist appointment is within 2 weeks.
✓Safe to leave primary care only if — all five, documented
Fully recovered; no block 0–2 row applies
Witness account taken; ECG done and normal or sent for interpretation
Glucose and lying/standing BP recorded
Referral route and review date set
Driving advice, safety-net and written first aid given
Summary of the full Reasoning GP fits and funny turns algorithm, which holds the history, examination, investigations, DVLA detail and epilepsy follow-up. Sources: NICE NG217, CG109, NG128; SIGN 143; DVLA Assessing fitness to drive; MHRA valproate safety material; CoSRH. Clinical reference — follow local emergency and first-seizure pathways and check doses: NICE/SPC, BNF, local formulary.