Amy Gutman MD ~ EMS Medical Director

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Syncope & Dizziness Case Review

Syncope, Dizziness & Vertigo:Case ReviewAmy Gutman MD ~ EMS Medical /

ObjectivesWeak & Dizzy is a common complaint with both benign & lethal causes

Etiologies of dizziness & syncope

Connection of cardiovascular & neurovascular disorders

Assessment & management strategies

The only difference between syncope & sudden death is that in one you wake up. Engel GL. Ann Intern Med 1978Prehospital Dizziness Protocol?No specific dizziness or syncope protocols

Protocol(s) used depends upon cause & effect(s) of symptoms

A good history & physical exam provides diagnosis in most patients

Not the patients to test how good you are at obtaining refusals!

Case Presentation82 yo WF presents with CC of dizziness. States intermittent, but persistent & unpredictable moments of dizziness that made her head spin. During the episodes, patient would nearly pass out, c/o dizziness & lightheadedness with some blurred vision. No CP, SOB, palpitations, seizure, loss of consciousness. No trauma, recent illness or other complaints

Vitals & exam unremarkable by BLS crew. Patient initially did not want to be transported to the hospital but was convinced to get checked out. ALS crew called but unavailable

What is your differential diagnosis based upon this info?

Case ContinuedHistory fairly unremarkable in otherwise healthy patient who recently started OTC antihistamines for sinus congestion

Vitals stable but patient had at least 3 more episodes on the way to the ED in which she would lean back in stretcher & become extremely dizzy

In ED, placed on a hallway bed. During her triage, while the RN had the patient on a monitor and was checking her pulse he noted the following:

DefinitionsSyncope (Greek: sunkoptein / to cut short) Sudden & self-limiting loss of consciousness with loss of postural tone & a spontaneous recovery. A symptom, not a diagnosis

Vertigo (Latin: vertere / to turn)Sensation of dizziness or abnormal motion resulting from a disorder of the sense of balance

Dizzy Having a whirling sensation with tendency to fall; bewildered or confused; producing giddiness

6Challenges of Syncope & Dizziness50% with no specific causes

Significant cost & time to diagnose & manage

Unpredictability leads to negative impact on quality of life

Management specific to the cause / suspected cause(s); varies significantly in effectiveness

Syncope impacts patient quality of life, and health care costs in important ways.

Establishing a precise diagnosis is often challenging due to the unpredictability of events and the limited positive predictive value of most available tests. The gold standard remains the recording of the cardiac rhythm (and if possible the arterial pressure) during a spontaneous faint.Dizziness & SyncopeSyncope, dizziness & vertigo are generally symptoms rather than diseases

Benign to fatal causes

Cardiac causes have highest mortality rates

>500,000 new patients annually70,000 have recurrent, infrequent, unexplained syncope3-6% ED visits annually2-10% hospital admissions

Associated SymptomsTraumatic sequellae

Fever, signs of illness

Focal neurological symptoms Prodromal or post-episodic

Palpitations / CP



Nausea, Vomiting


Loss of continence

Pathological Risk Factors>2 associated with 10-20% incidence of death from neurovascular or cardiovascular causes within 1 yearCAD, CHF, arrhythmiaChest painAbnormal ECGPersistent orthostatic hypotensionAge >45yrsTraumatic sequellae for any fall

CausePrevalence (Mean) %Reflex-Mediated:Vasovagal18Situational5Carotid Sinus1Orthostatic hypotension8Medications3Psychiatric2Neurological10Organic Heart Disease4Cardiac Arrhythmias14Unknown34Syncope Etiology

Syncope Etiology*OrthostaticArrhythmiaStructural*


Carotid Sinus

Peripheral vestibular dysfunction

Brainstem lesion



Autonomic Failure

PresyncopeBradySick sinusAV block


Long QT

Aortic Stenosis


Pulmonary HTNPsychogenic


NeurologicalNon-CVNeurologicalUnknown Cause = 34%24%11%14%4%12%*DG Benditt, UM Cardiac Arrhythmia Center

This slide provides a simple classification of the principal causes of syncope. This scheme lists the causes of syncope from the most commonly observed (Left) to the least common (Right). This ranking may be helpful in thinking about the strategy for evaluating syncope in individual patients.Within the boxes,the most common causes of syncope are indicated for each of the major diagnostic groups. The numbers at the bottom of each column provide an approximate value for the average frequency (Kapoor 1998) with which that category appears in published reports summarizing diagnostic findings. It should be noted that orthostatic causes are not often referred to specialists and consequently tend to be under represented in the literature.

Misdiagnosed or Associated with DizzinessMigraine



Somatization / Psychiatric




Sleep disorders / OSA

Subclavian steal syndrome

Basilar artery migraine (syncope + headache)

Vertebrobasilar insufficiency (syncope + vascular disease)

Syncope DiagnosisHistory & Physical Exam Including ECGNeurological Testing Head CT / MRI / MRACarotid DopplerEEGCardiovascularAmbulatoryTilt Table Echocardiogram EPS AngiogramStress TestingPsychological Evaluation ENT EvaluationSinus CTOtolith evaluationHearing exam MetabolicLaboratory

Searching for a Diagnosis:Patients can enter the diagnostic process at various points based on their presenting symptoms and/or syncope-related injuries. Also, the process of deriving a diagnosis for syncope can vary from institution to institution. As noted earlier, the diagnosis of syncope begins with a patient history and physical, and a surface electrocardiogram recording.If this initial evaluation suggests a cardiovascular cause such as myocardial infarction or structural heart disease, an echocardiogram and EP study may be performed. If no diagnosis is reached with these tests, the physician may move to any of the following tests, in any order: tilt table testing, Holter monitor, external loop recorder (ELR), or Reveal Plus Insertable Loop Recorder(IRL). If none of those tests yield a diagnosis, some tests may be performed repeatedly and/or other specialists might be consulted for further testing including: endocrinology, neurology, psychiatry, ENT, etc.If no structural cardiovascular problems are suspected, the physician may choose diagnostic testing based on suspected vasovagal etiology and frequency and severity of symptoms.New diagnostic tools, such as ILRs, will cause significant discussions about when to use them, given their high diagnostic yields and high patient compliance.NOTES:ECG: ElectrocardiogramEEG: ElectroencephalogramMRI: Magnetic Resonance ImagingEcho: EchocardiogramEP Study: Electrophysiology StudyMI: Myocardial InfarctionSHD: Structural Heart DiseaseENT: ears-nose-throat

SAMPLE History & OPQRST AssessmentSSX:Associated symptomsSequelae

Allergies: +/- & what is the reaction

Medications: Include OTCs & topicals

PMH: Cardiovascular, neurovascular diseases, migraine, prior similar episodes

Last Oral Intake:


Onset & Duration

Provocation or PalliationPositionMedicationsTemperature


Region & Radiation

Severity Loss of consciousness

TimeTime of day, duration of event

History & physical exam leads to cause identification in nearly half of patients

Family HistorySudden death



Congenital heart disease

Heart attack or CVA at young age


Metabolic disorders

Physical ExamSerial vitals

Focus on cardiac & neurologic examsStroke scaleGlucoseMonitor / ECG

If syncope + fall, presume a spinal injury present until proven otherwise

Stroke Scales

VasovagalCarotid SinusNeuralgic or MigranousSituationalTIA / CVA Subclavian StealEpisodes after pain, fear, excitation, exertion; standing w/ locked knees i.e. at attentionMicturition, cough, swallowingFacial Pain or headacheHead rotation or pressure on carotid sinusPost exerciseSeizureMurmur Seizure activity, LOC >5 mins with post-ictal periodPresence of heart murmur on exam or echocardiogramArrhythmiaPsychogenicFocal neurological symptoms that persist (CVA) or resolve within 1-72 hours (TIA); positive stroke scaleIntermittent or persistent irregularity of rhythm or regularity Anxiety, hyperventilating, personal gain

Other SyndromesVertebral-Basilar StrokeDiplopia, dysarthria, dysphagia, weakness, numbness

MenieresAural fullness, deafness, tinnitusBrainstem evoked audiometry 95% sensitive for detecting acoustic neuromas

Multiple SclerosisVertigo preceded by other neurologic dysfunction

20Nonspecific DizzinessPsychiatric disordersDepression 25%Anxiety or panic disorder 25%Somatization Alcohol / drug abusePersonality disorderHyperventilation

Syncope & presyncope overlapCAD, CHF, PE, dysrhythmias

21No diagnostic physical signs

purposeful hyperventilation is one means to confirm the diagnosis (examiner must look for nystagmus as some pathologic vestibular les