Syncope, Vertigo, and Altered Mental Status

Question 1

What is delirium

Answer 1

mental state that is acute onset in nature, usually reversible (treatable)

Question 2

What is dementia

Answer 2

mental state that is slow in onset, progressive, degenerative mental status (can’t reverse)

Question 3

What is psychosis

Answer 3

mental state that is sudden in onset, need to rule out organic causes

Question 4

What are the initial actions in altered mental status

Answer 4

Look for reversible causes and address ASAP (DON’T)

Dextrose - POC glucose
Oxygen - pulse ox
Narcan - check pupils
Thiamine - ETOH

Question 5

How are you going to initially assess for AMS?

Answer 5

Good history

Question 6

What is going to be included in your PE for AMS?

Answer 6

Full exam of all systems (look for everything)

Question 7

What are you going to run for tests to rule in/out AMS?

Answer 7

Testing aimed at symptoms for example
ETOH, serum ETOH
Insulin, check POC glucose
Uremia (BMP, BUN/Cr)

Question 8

How do patients describe vertigo?

Answer 8

Dizziness, room is spinning, lightheadedness, “head feels funny”, and “faint”

Question 9

Are cardiac and neuro exams normal or abnormal with vertigo?

Answer 9

Normal

Question 10

What is the vestibular system

Answer 10

Complex arrangement of bones and cartilage in the ear, network of semicircular canals filled with fluid. Fluid position changes with movement, sensor in ear sends info to brain to contribute to balance.

Question 11

What are the problems causing balance issues associated with vestibular system imbalances

Answer 11

Meds
Infection
Inner ear problems (circulation)
Calcium debris in semicircular canals
Central problems in the brain (TBI)

Question 12

What is the diagnostic approach to vertigo and dizziness complaints

Answer 12

TiTrATE

Timing of the symptoms
Triggers that provoke the symptoms
And a
Targeted Evaluation

Question 13

What are the three main diagnosis categories of vertigo?

Answer 13

1. Triggered episodic vertigo
2. Spontaneous episodic vertigo
3. Continuous vestibular vertigo

Question 14

What is triggered episodic vertigo

Answer 14

Brief episodes lasting seconds to hours (intermittent) and triggered by movement or positional changes

Question 15

What is spontaneous episodic vertigo

Answer 15

Lasts seconds to days, it has no triggers

Question 16

What is continuous vestibular vertigo

Answer 16

Lasts days to weeks (need to ask about hearing loss)

Question 17

What is BPPV

Answer 17

Benign Paroxysmal Positional Vertigo, caused by displaced canaliths (crystals) in semicircular canals

Question 18

What is the epidemiology of BPPV

Answer 18

No known cause, most commonly occurs between 50-70 year old

Can occur with head trauma in younger adults

Question 19

When does BPPV often occur

Answer 19

When rolling over in bed, always with change in head position

Question 20

Where can BPPV occur

Answer 20

Posterior canal (MC) or horizontal canal (rarely)

Question 21

What maneuver is used to diagnose BBPV

Answer 21

Dix Hallpike Maneuver, (+) with transient upbeat-torsional nystagmis, vertigo

Question 22

What maneuver is used to treat BPPV

Answer 22

Epley Maneuver - move the rock (canaliths) around in the semicircular canals (patient can do this at home)

Question 23

What is orthostatic hypotension

Answer 23

A change in vitals with change from supine to standing for one minute

Question 24

What are the diagnostic criteria vital changes for orthostatic hypotension

Answer 24

SBP down 20mmHg
DBP down 10mmHg
HR up 30bpm

Question 25

What are some causes of spontaneous episodic vertigo

Answer 25

Meniere’s Disease
Vestibular migraine

Question 26

What two nerve bundles make up the vestibulocochlear nerve (CN 8)

Answer 26

Vestibular Nerve (balance/eye movements) and Cochlear nerve (hearing)

Question 27

What is persistent postural-perceptual dizziness (PPPD)

Answer 27

Fluctuating dizziness and disequilibrium, present at rest, and worse with standing

More intense symptoms while moving

Question 28

What is the cause of pre-syncopal dizziness

Answer 28

Brain hypoperfusion (often due to low BP)

Question 29

What co-occuring symptoms can present with pre-syncopal prodrome

Answer 29

poor hearing, feeling warm/cold, pallor, diaphoresis, abdominal pain, palpitations, hearing strange sounds

Question 30

Does syncope require resuscitation?

Answer 30

No, it spontaneously resolves

Question 31

What is the most common cause of cardiogenic syncope

Answer 31

Arrhythmia

Question 32

What are the risk factors for cardiogenic syncope

Answer 32

Family hx of sudden cardiac death or MI
Cardiac disease
Cardiac symptomatology

Question 33

What are the most common causes of general syncope

Answer 33

Neurocardiogenic (carotid sinus hypersensitivity, neck pressure)
Reflex syncope
Vasovagal syncope (activation of vagus nerve via the PNS)

Question 34

What are some common triggers for vasovagal syncope

Answer 34

Urinating, defecating, coughing, blood pooling in extremities due to prolonged standing, emotional stress

Question 35

What are some differential diagnoses for syncope

Answer 35

Seizure
Stroke
Trauma/Head Injury
Sleep Disturbance

Question 36

What is the immediate management of syncope

Answer 36

Goal is to restore perfusion to the brain - lie on ground, elevate legs or sit with head between knees