dizziness Flashcards
which cause of vertigo would you expect to see as reoccurrent and brief (lasting seconds)
occurring with predictable head movements
BPPV
Which type of vertigo cause would you expect to see in single episodes with acute onset lasting days
vestibular neuritis
which cause of vertigo would you expect to see with reoccurring episodes lasting several minutes to hours
Meniere’s
describe central nystagmus
vertical, pendular
fast beat towards lesion
not relieved by gaze fixation
cerebellar signs
describe peripheral nystagmus
horizontal and jerking
fast beat away from lesion side
relieved by gaze fixation
no cerebellar signs
what type of nystagmus would we see with BPPV
vestibular neuritis
and menieres disease
all peripheral
which cause of vertigo would we expect to see with ear fullness or pain and hearing loss or tinnitus
Meniere’s
Unilateral sensorineural hearing loss suggests a _____
Unilateral sensorineural hearing loss suggests a peripheral lesion;
Ataxia/Fall indicate what cause of vertigo
cerebellar
with syncope and dizziness what do we think
→ could be autonomic, vascular, think more about heart stuff
head thrust test is usually abnormal with what cause of vertigo
vestibular neuritis
deficient vestibuloocular reflex (VOR) on the side of the head turn (off target), implying a peripheral vestibular lesion (inner ear or vestibular nerve) on that side
associated with endolymphatic hydrops with distortion and distention of the membranous, endolymph-containing portions of the labyrinthine system
Meniere’s
Main symptom of vestibular disease
vertigo
“room spinning” or “rocky boat”
is a common descriptor of
VERTIGO
Mainstay of treatment for BPPV i
particle repositioning maneuvers
Usually send pts home with instructions on how to do this on their own
Treatment includes pt edu, meclizine for symptom relief, return precautions
when would you worried about vertigo
Hearing loss/tinnitus, brainstem sx, lasting longer than a few weeks
Refer to Neuro if CNS s/sx develop
what referral should you make for a pt with BPPV
Refer to ENT if persistent peripheral vertigo
differential diagnosis of syncope
seizure TIA anxiety acute hemorrhage DROOGS
RF for syncope
Cardiovascular disease is the major risk factor
History of stroke or TIA
Low BMI = low BP = prone to syncopal episodes
much higher risk of vasogenic syncope
Increased EtOH intake
Diabetes or elevated blood glucose levels
most common cause of syncope
vasovagal
other than vasovagal what are some causes of syncope (5)
Orthostatic hypotension, carotid sinus hypersensitivity, situational
Cerebrovascular disease – < 1%
Cardiovascular disease – 23%
Arrhythmias, conduction abnormalities, blood flow obstruction
how frequently do you see seizures as the cause of apparent episodes
Seizure is cause in 5-15% of apparent syncopal episodes
how to differentiate seizure from syncope
postictal state, confusion, slow recovery, incontinence,
injuries especially tongue biting, tonic-clonic movements
PE for syncope
Orthostatic blood pressure isturbances in heart rhythm or breathing Cardiac auscultatory findings Physiologic maneuvers (Valsalva) Abnormal neurologic findings GI bleeding (stool guaiac) Carotid sinus massage (check for bruits first!))
diagnostic tests for syncope
EKG CHEM7: CBC sugar check cardiac enzymes Toxic screen
ECHO
what is the prodrome seen with vasovagal syncope
50%
of diaphoresis, nausea, pallor, weak/fatigue, lightheaded
Initiated by offending stimuli
triggers for vasovagal syncope
Hot environment, EtOH, fatigue, pain, hunger, prolonged standing, venipuncture, fear
pathophys with vasovagal syncope
Stimuli → increased peripheral sympathetic activity, venous pooling → cardiac/vagal reflexes inhibit sympathetic fibers, increase parasympathetic activity → vasodilation, bradycardia → hypotension, syncope
preventing vaovagal syncope
can prevent it by sitting down
and preventing triggers
permanent pacemaker is helpful in what syncope
only really in cardiogenic
why would you get a chem 7 in a pt with suspected seizures
looking at electrolytes and sugar
why would you get a cbc in a pt who you suspected had a sezirue
to check for bleeding/ hemorrhage
define orthostatic hypotension
3
Postural decrease in SBP ≥ 20mmHg
Decrease in DBP ≥ 10mmHg
Increase in HR ≥ 10 bpm
Symptoms reproduced on tilt testing
30% of elderly pts experience syncope for this reason
30% of the elderly
orthostatic hypotension
loss of vasoconstrictive reflexes in LE vessels → fall in systolic BP → syncope
major drug types that cause orthostatic hypotention
Antidepressants, antihypertensives, opiates
tx for pt with orthostatic hypotension
Tensing the legs while standing; dorsiflexion of the feet before standing
allows for equalizing
Arising slowly in stages and hold onto something
Wearing compression stockings to minimize venous pooling
especially if pts spend a lot of time sitting
Various drug therapies
when do we see carotid Sinus Hypersensitivity
men >50
pressure at the carotid leads to a pause of 3 seconds or more
pathophysiology of situational syncope
Straining-type maneuver contributes to decreased BP by decreasing venous return
Increased ICP 2˚ to increased intrathoracic pressure which decreases cerebral blood flow
Most common cardiac cause of syncope
arrhythmias
specifically
bradyarrhythmias
causes of sinus bradycardia
Intrinsic sinus node disease (sick sinus syndrome), drugs (β-blockers), or autonomic imbalance
what type of AV block would require a pacemaker
Type II second degree block is often progressive and warrants permanent pacemaker
why do we see supraventricular tachycardia causing syncope and what would be the predrome
Most commonly due to underlying structural heart disease, particularly CAD
preceded by palpitations or lightheadedness; may be abrupt onset
treatment for supraventricular tachycardia
Treatment includes antiarrhythmic drugs, ICD, radiofrequency ablation
MC blood flow obstruction that lead to syncope are:
aortic stenosis, hypertrophic cardiomyopathy
less common blood flow obstructions that lead to syncope are
Less common include pulmonic stenosis, PE, pulmonary HTN, atrial myxoma
common EKG findings with aortic stenosis
LVH, LBBB common
how would you diagnose aortic stenosis
echo
aortic stenosis
Cardiac cath may be needed for pts with severe stenosis and/or presence of CAD
High mortality if untreated
Treatment is usually surgical correction by aortic valve replacement
Up to 30% of patients who have dynamic outflow obstruction
in the familia cause of HTN
young person playing sports
poorly predicted outcomes with syncope are associated with these 5 things
Hct < 30% Abnormal EKG Systolic BP < 90 mmHg Complaint of shortness of breath These patients presenting with syncope are more likely to have a serious cardiac outcome such as acute MI
