Workers who are at risk of passing out suddenly or who suffer from frequent fitting can be a danger to themselves and others. Occupational health teams can help manage these afflictions in order to minimise the associated risks. Colin Payton reports.

Occupational health practitioners are regularly asked to see workers who have suffered from what they describe as fits, faints, blackouts or turns of some other sort. It is vital to establish the true clinical nature of such episodes, whether or not they have involved a transient loss of consciousness (TLOC), and to determine the cause in order to advise employers on the afflicted member of staff's fitness for work.

It is also important to understand how underlying conditions are investigated, how they can be treated and how effective treatment can help workers to remain at, or return to, work. The most common causes of TLOC are seizures (provoked and unprovoked) and syncope (cardiac and non-cardiac); it is important to distinguish between these because seizures, generally speaking, have far greater implications on fitness for work. Other causes of TLOC include concussion following a head injury and intoxication, but these are less relevant to occupational health.

Seizures

Epileptiform seizures, also referred to as fits or convulsions, are the result of a spontaneous abnormal electrical discharge in the brain. Around 10% of people experience a seizure at some time in their life (Berg et al, 1991).

They can be provoked or unprovoked. Provoked seizures are caused by brain injury or illness, or by metabolic problems. The most common causes are cerebrovascular disease, withdrawal from alcohol and drugs, trauma and tumours. There are many different types, not all of which cause loss of consciousness. A generalised tonic-clonic seizure, or grand mal seizure, is the most common, the most debilitating and the most likely to affect fitness for work. Epilepsy is a disorder where there is a tendency for recurrent unprovoked seizures, and is diagnosed after a patient suffers two or more.

A prodromal phase is uncommon but can be the first indication of an impending seizure. The patient experiences symptoms that are ill-defined, but also has a distinct feeling that a seizure is about to happen. This phase can last just a few moments or much longer, sometimes days. An aura is more common, and very brief, and includes physical symptoms such as butterflies in the stomach, paraesthesiae (pins and needles), a feeling that they can smell something familiar, difficulties with speech and a sensation of dj vu. Consciousness is sometimes altered during the aura and the patient may be unresponsive to others' conversation. The patient then loses consciousness and falls abruptly, with an appreciable risk of injury.

It is important to understand how underlying conditions are investigated, how they can be treated and how effective treatment can help workers to remain at, or return to, work."

Their muscles go into spasm, in what is described as the tonic phase of the fit, and they sometimes cry out due to spasm of the respiratory muscles forcing air out of their lungs. This is followed by the clonic phase, which includes rhythmic jerking movements of the arms, leg and face. They sometimes bite their tongue and can lose control of their bladder and, occasionally, their bowels. When they wake up, they are confused and may then fall into a postictal sleep. Over the next 24 hours they may experience soreness and stiffness of their muscles due to the powerful repetitive jerking movements during the clonic phase. Patients may not have any recall and an eye-witness account, or even a video of an attack, can help to establish the clinical diagnosis.

Investigating seizures

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Fits, faints and blackouts: the role of occupational health