Dizziness, Vertigo, Syncope Flashcards
What are the two pathophysiologic categories of syncope?
Non Cardiac
1. Reflex syncope/neurally mediated
a. Vasovagal
b. Carotid sinus syndrome
c. Situational
- Orthostatic intolerance
a. Dehydration
b. Medication
c. Primary autonomic failure
d. Secondary autonomic failure
Cardiac
a. Arrhythmia
b. Structural
c. Cardiopulmonary
Features suggesting cardiac syncope
More likely
1. Prolonged sitting/standing
2. AF/flutter
3. SOB
4. Palpitations
5. Hx cardiac disease
6. Cyanosis during LOC
Less likely
1. Normal ECG
2. Normal labs
3. No hx heart disease
4. Feeling cold, HA, abdomen pain
What is part of the initial evaluation for someone with syncope?
- Hx and px
- 12 lead ECG
- Postural vitals
What is in the initial diagnostic work up for syncope?
- TTE (if you think ischemic, structural, valvular)
- Stress test (if before/during/after exertion)
- Brain imaging only if high suspicion of disease/trauma
- Carotid dopplers only if focal neuro finding
- Holter monitor only if likely to have sycnope within 4 weeks
- Tilt table if abnormal presentation
What type of cardiac monitor based on symptom frequency?
- Holter = daily sx
- Extended holter/external loop/patch = weekly or monthly sx
- Insertable = recurrent, infrequent
Management of vasovagal syncope
Non Pharm
- Avoid triggers/situations
- Inc salt/water
- Lie down quickly if onset
- Leg cross, limb/abdo contractions, squatting
Pharm
- Midodrine 1st, fludrocoritosne 2nd
Intervention
- Pacing (only if highly sx, recurrent, symptomatic systole >3 s or asymptomatic >6 s)
Syncope and driving guidelines
Single ep vasovagal = no restriction
Dx and tx cause (ex. pacemaker) = 1 week
Reversible (dehydration) or situational (micturition) = tx and wait 1 wk
Single unexplained or recurrent vasovagal within 12 mos = 1 week
Recurrent unexplained within 12 mos = wait 3 months
What is the definition of vertigo?
A false or distorted sense of movement
Ddx vertigo peripheral lesions
- BPPV (with head position)
- Vestibular neuritis (no HL, hr-days, continuous)
- Ménière’s disease (HL, hours)
- Labyrinthitis
Ddx vertigo central lesions
- Stroke (cerebellar, posterior circulation)
- Tumor
- MS
- Vestibular migraine
Approach to assessment of dizziness
TITRATE
Timing of symptoms
Triggers that provoke
And a Targeted Exam
4 large categories of causes of dizziness
- Vertigo
- Presyncope
- Disequilibrium
- Ill defined (psychiatric)
What are the 8 components of the dizziness simulation battery?
- Orthostatic BP
- Potentiated val salva
- Carotid sinus stimulation
- Dix Hallpike
- Barany rotation
- Walk and turn
- Seated head turn
- Hyperventilation
4 features of BPPV
- No symptoms at rest
- Symptoms occur with movement (turning head, turning over in bed)
- No hearing loss
- Nystagmus produced during Dix Hallpike
- No spontaneous or gaze evoked nystagmus
How do you perform a Dix Hallpike?
- Patient sit upright on table, examiner behind
- Turn their head 45 degrees to one side and extend
- Brisk smooth motion to move from sitting to supine with head hanging over bed at 30 degrees
- Look for nystagmus for min 30 seconds
- Repeat on other side if no nystagmus witnessed
Positive test = torsional or horizontal nystagmus, patient feels dizzy
