Amy Gutman MD ~ EMS Medical Director @gmail.com / .

54
Syncope, Dizziness & Vertigo: Case Review Amy Gutman MD ~ EMS Medical Director [email protected] / www.TEAEMS.com

Transcript of Amy Gutman MD ~ EMS Medical Director @gmail.com / .

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Case Presentation

82 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?

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Definitions

Syncope (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

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Dizziness & Syncope

Syncope, dizziness & vertigo are generally symptoms rather than diseases

Benign to fatal causes

Cardiac causes have highest mortality rates

>500,000 new patients annually 70,000 have recurrent,

infrequent, unexplained syncope

3-6% ED visits annually 2-10% hospital admissions

0%

5%

10%

15%

20%

25%

Syn

cop

e M

ort

alit

y

Overall Due to Cardiac Causes

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Syncope Etiology*

Orthostatic Arrhythmia Structural

*

• Vasovagal

• Carotid Sinus

• Peripheral vestibular dysfunction

• Brainstem lesion

• Situational• Cough• Micturition

• Meds

• Autonomic Failure

• Presyncope

• Brady• Sick

sinus• AV

block

• Tachy• VT• SVT

• Long QT

• Aortic Stenosis

• HOCM

• Pulmonary HTN

• Psychogenic

•Metabolic

• Neurological

Non-CVNeurological

Unknown Cause = 34%

24% 11% 14% 4% 12%

*DG Benditt, UM Cardiac Arrhythmia Center

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Syncope Diagnosis

History & Physical Exam Including ECG

Neurological Testing

• Head CT / MRI / MRA

• Carotid Doppler• EEG

Cardiovascular

• Ambulatory• Tilt Table•

Echocardiogram

• EPS • Angiogram• Stress

TestingPsychological Evaluation

ENT Evaluation

• Sinus CT

• Otolith evaluation

• Hearing exam

Metabolic• Laboratory

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SAMPLE History & OPQRST Assessment

SSX: Associated symptoms Sequelae

Allergies: +/- & what is the reaction

Medications: Include OTCs & topicals

PMH: Cardiovascular, neurovascular

diseases, migraine, prior similar episodes

Last Oral Intake:

Events

Onset & Duration

Provocation or Palliation Position Medications Temperature

Quality

Region & Radiation

Severity Loss of consciousness

Time Time of day, duration of

event

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

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Vasovagal

Carotid Sinus

Neuralgic or

Migranous

Situational

TIA / CVA

Subclavian Steal

Episodes after pain, fear, excitation, exertion; standing w/ locked knees “i.e. “at attention”

Micturition, cough, swallowing

Facial Pain or headache

Head rotation or pressure on carotid sinus

Post exercise

Seizure

Murmur

Seizure activity, LOC >5 mins with post-ictal period

Presence of heart murmur on exam or echocardiogram

Arrhythmia

Psychogenic

Focal neurological symptoms that persist (CVA) or resolve within 1-72 hours (TIA); positive stroke

scale

Intermittent or persistent irregularity of rhythm or regularity

Anxiety, hyperventilating, personal gain

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Peripheral vs Central Vertigo (Vestibular

Dysfunction)PERIPHERAL VERTIGO

CAUSES Vestibular neuronitis

Labyrinthitis

Meniere’s syndrome

Head trauma

Drug-induced Aminoglycosides,

phenytoin, phenobarbital, carbamazepine, salicylates, quinine

CENTRAL VERTIGO CAUSES Cerebellar infarction or

hemorrhage

Lateral medullary infarction (Wallenberg’s syndrome)

Brainstem infarction or hemorrhage

Multiple sclerosis

Vertebrobasilar insufficiency

Central vertigo associated with poor outcomes while peripheral vertigo is often “benign”. Can have overlap in

symptoms, therefore difficult to differentiate

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Nystagmus: Characteristics

CENTRAL ORIGIN

Vertical, horizontal or rotary

May change direction with gaze

Not diminished by fixation

Does not significantly worsen with head movement

PERIPHERAL ORIGIN

Horizontal, torsional

Does not change direction with gaze change

Diminished by fixation

May fatigue (if elicited by head movement)

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Cerebellar Infarction

CEREBELLAR INFARCTION

Nystagmus + dizziness

Nausea & vomiting

Ataxia & ipsilateral asynergia

No focal weakness or motor abnormality

LATERAL MEDULLARY INFARCTION: WALLENBERG SYNDROME

Nystagmus + dizziness

Nausea & vomiting

Ataxia & ipsilateral asynergia

No focal weakness or motor abnormality

Hoarseness

Horner’s syndrome

Ipsilateral facial analgesia; contralateral body analgesia

Horner’s Syndrome:Ptosis, Miosis,

Anhidrosis

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Neurally-Mediated Reflex Syncope (NMS)

Neurally mediated reflex mechanism with cardioinhibitory (bradycardia) & vasodepressor (hypotension) components Vasovagal syncope (VVS) Carotid sinus syndrome (CSS) Situational syncope

Loss of the normal balance between sympathetic & parasympathetic nervous system

Triggered by stretch & mechanoreceptors (carotid sinus, bladder, esophagus, respiratory tract)

Peripheral venous pooling causes sudden decreased venous return Pallor, nausea, sweating, palpitations common

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Radiologic Imaging

Non-contrast CT helps r/o acute hemorrhage (but not 100% accurate)

MRI more sensitive than CT for hypoxic injury or cerebellar & brain-stem infarctions PET scan may improve

diagnostic accuracy CT angiography or MRA

useful within 24 hours

Carotids often included in evaluation

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Dix Hallpike Diagnosis

PERIPHERAL VERTIGO

CENTRAL VERTIGO

Time before onset of nystagmus

2-20 secs 0 secs

Duration of nystagmus

<1 min >1 min

Fatiguability Yes with repetitiion Non-fatiguiing

Direction of nystagmus

Upbeat & torsional May change direction

Intensity of vertigo severe Minimal to moderate

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Cardiovascular Syncope

LOC often w/o prodrome

Significant injury risk

Structural heart disease is most important risk factor for predicting risk of death from syncope or dizziness

Acute MI / Ischemia

Hypertrophic cardiomyopathy

Aortic dissection

Pericarditis

Pericardial tamponade

Pulmonary embolus

Pulmonary HTN

Aortic stenosis

Atrial myxoma

Bradyarrhythmias

Tachyarrhythmias

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QT Prolongation & R on T Phenomenon

QT widens to point when a PVC occurs early in the cardiac cycle falling on the apex of preceding T wave leading to VT or torsades

Antiarrhythmics Class IA & III: Quinidine, Procainamide, Sotalol, Amiodarone

Psychoactive Agents Phenothiazines, Amitriptyline, Imipramine, Ziprasidone

Antibiotics Erythromycin, Pentamidine, Fluconazole

Antihistamines Terfenadine, Astemizole

Others Cisapride, Droperidol

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VT vs VF

VENTRICULAR TACHYCARDIA

Abnormal tissues in ventricles generating rapid & irregular rhythm

>3 PVCs in a row; can be sustained or unsustained

Rhythm: Regular

Rate: 150-250bpm

QRS Duration: Prolonged >120ms

P Wave: Not seen, often dissociated

VENTRICULAR FIBRILLATION

Disorganized electrical signals cause ventricles to quiver ineffectively

Rhythm: Irregular

Rate: >250, disorganized

QRS Duration: Unrecognizable

P Wave: Not seen

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CV-Related Management

Recognize symptoms & avoid provocation Avoid alcohol, lack of sleep,

environmental stressors Adequate hydration & food intake Avoid drugs that lead to hypotension Avoid activities that precipitate syncope

Preventing LOC or Injury Supine position upon onset of prodrome Avoid driving or other activities that

could lead to injury

Cardiovascular / neurovascular interventions Routine follow-up Take prescribed medications as

prescribed!

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References

Dubin’s Guide to EKGs. Images: Wikipedia, Google, Bing searches. www.UpToDate.com. “Dizziness”, “Syncope”,

“Ventricular Tachyarrythmias”. 2013. D. Okorn MD. “Approach to Dizziness”.

Swedish Family Medicine. Dec 2009 G. Bergey MD. “Acute Dizziness & Vertigo:

Diagnosis, Assessment and Management”. 2001

M. Lehmann MD. “Tacchyarrythmias”. 2010 E. Veiga, M.D, 2008 WN Kapoor. Syncope. NEJM 2000; 343: 1856-

62 Freeman, R. “Neurogenic Orthostatic

Hypotension” NEJM 2008; 358: 615-624 Soteriades, et al. Incidence and Diagnosis of

Syncope. NEJM 2002; 347:878-885 Grubb, B. Neurocardiogenic Syncope. NEJM

2005; 1004-1010 DG Benditt. “Syncope - A Diagnostic &

Treatment Strategy”. Royal Brompton Hospital, London, UK

Kapoor W, Med. 1990;69:160-175 JJ Blanc, et al. Eur Heart J, 2002; 23: 815-820 WN Kapoor. “Evaluation and outcome of

patients with syncope”. Medicine 1990;69:160-175