Reisert: Dizziness and Syncope Flashcards
Having disturbed ambulation
Associated sx:
Changes in vision
Orthostasis
….just about anything else
Dizziness
Change in blood pressure and cerebral blood flow due to transient low blood pressure
Orthostasis
Alteration in normal response to standing
May occur with aging due to loss of vascoconstriction (With standing, blood falls to feet adn you get dizzy or pass out)
Orthostasis
Lie for 10 mins, stand for at least 2 mins though response in worst case may last 10 mins
Test of orthostasis
Fall in systolic BP > ____ mmHg
Fall in diastolic BP > ____ mmHg
Increase in heart rate ______ beats per min
With orthostasis
20
10
10-25
___% of people have orthostasis
24%
Mineralcorticoids like fludrocortisone
Midodrine
Atomoxetine
Pyridostigime
Droxidopa: new med approved 2015
Tx for Orthostasis
Loss of buffers to remain conscious
Syncope prodrome
Fainting
Cardiac
Neurological
Simple (anxiety, stress)
Causes of syncope
What is the most common type of syncope?
Simple fainting from anxiety/stress
Arrythmia/dysrrhythmia
Heart block
Aortic stenosis (severe)
Medications (orthostasis)
MOST WORRISOME
Cardiac causes of syncope
Echocardiogram
Electrophysiological study
Signal average EKG
Cardiac syncope workup
Implantable cardiac defbrillator
Anti-arrhythmics less so
Tx of true cardiac syncope
Impaired vestibular system
May be due to disturbance of inner ear
Altered head position in space –> aleration of CN VIII
Some say room spinning or they feel like they are spinning
Vertigo
Visiual imput
Somatosensory input (skin, joints, muscles, spinal cord)
Cerebellum
Cerebrum
Normal balance maintenance
What happens to people with true syncope?
They get injured!
Alerations of eye movement with oscillation to lateral gaze
Nystagmus
Two types of vertigo?
Physiologic
Pathologic
Abnormal input to stabilize (car sickness)
Unfamiliar head position (sea sickness)
Unusual head position (painting ceiling)
Spinning
Physiologic causes of ______?
Vertigo
- Disturbance of vision
- Disturbance of somatosensory system
- Disturbance of vestibular system
- CNS tries to correct
- Change in frequency of normal firing (homeostasis is disrupted), unequal signal results, abnormal head sensation
- Worse with rapid head movement
- Often nausea and ataxia
Pathological causes of _____?
Vertigo
MOA of Fludrocortisone?
Causes fluid retention
Table that goes up in down
Indication: Patient that is having repeat syncope
To test of orthostasis
Tilt table test
What should you think of when you see a young athelete pass out on the field?
hypertrophic cardiomyopathy
Loss of bowel/bladder control
Bite tongue
More common in seizures or syncope?
SEIZURES!
Triad of aortic stenosis
Syncope, chest pain, dyspnea
Most common cause of orthostatic HTN?
Dehydration!
Fast phase of nystagmus goes away from lesion (affected side)
Rotation goes away from affected side
Falling toward side of lesion
Patterns of vertigo
2-3 beats at when look extreme left or right
Is this normal or abnormal (mystagmus)?
Normal!
Acute labrynthitis
Vestibular neruitis
Causes of _____ vertigo
Idiopathic
Idiopathic
Infection (HSV 1)
Trauma
Ischemia (nausea and vomiting)
Drugs (Alcohol, Aminoglycoside antibx)
Causes of significant vertigo
Cochlear disease
Progressive hearing loss (low frequency)
Tinnitus
Dizziness
Meniere’s disease
Etiology unknown
Possibly infection, autoimmune, inflammatory, demyelization, tumor, trauma
Meniere’s disease
Diuretics (Hydrochlorothiazide)
Very low salt restriction, <1g per day
Tx for Meniere’s Disease
Unilateral hearing loss
Tinnitus
Schwannoma or meningioma
Acoistic neuroma
What CN does acoustic neuroma effect?
CN VIII
What is the diagnostic test of choice for Acoustic neuroma?
MRI
Due to changes in head position
No clear known cause
May last months
Benign Positional Vertigo
What maneuver can you do to treat BPPV?
Epley maneuver
H&P
Orthostatic vitals
Swivel chair
Cardiac testing
Provocative tests: head shaking, Frenzel glasse
Evaluation of dizzy patient
- EKG
- Rules out heart block
- Echocardiogram
- Rules out structural heart disease (cardiomyopathy)
- Holter monitor
- 24 hour hear monitor
- Tape recording device
- Good for symptomatic evaluation (palpitations) and tachycardia
- Event monitor
- Wear up to a month
- Trans-telephonic transmission of data
- Exercise stress testing (low yield)
- Electrophysiologic study (EP study)
- Looks for risk for Ventricular tachycardia
- Tilt table test for orthostatic hypotension
Cardiac testing for syncope
Treat cause if known
Bed rest
Vestibular rehabilitation (PT)
Medications: Vesticular suppresants (Meclizine, Dimenhydrinate, Promethazine), Benzodiazepines (Diazepam), Steroids
Epley maneuver (BPPV)
Treatment for dizziness
Alteration when the vestibular sense, visual sense, and somatosensory sense are not congruent
Sea sickness/motion sickness
Principle sx: nausea/vomiting
Other sx: Dizziness, salvation, diaphoresis, and malaise.
May look pale
Sea sickness/motion sickness
Antihistamines like dimenhydrinate
Anticholinergics like scopalamine
both are SEDATING
Tx for sea sickness/motion sickness
