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X Clin Med III Final Exam > Vertigo and Syncope > Flashcards

Vertigo and Syncope Flashcards

1
Q

What is vertigo?

A

Sensation of movement when there is none or just abnormal movement, often spinning (tumbling, falling forward/back)
It is a symptom!
Associated with nystagmus and postural instability

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2
Q

What is disequilibrium?

A

Sense of imbalance (losing balance without sensation of movement)
-Imbalance and gait difficulties

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3
Q

What is presyncope?

A

Feeling of impending faint of LOC (no true syncope, generally associated with cardiac etiology)

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4
Q

Causes of vertigo

A

Peripheral (vestibular ex otologic lesion)

Central (central ex brainstem lesion)

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5
Q

Presentation of peripheral vertigo

A

Sudden, acute onset (may be severe)
Associated ear sxs (hearing loss, tinnitus)
Nystagmus can be horizontal and/or torsional (rotary)
Neuro sxs ABSENT

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6
Q

Presentation of central vertigo

A

May be gradual and progressive
Rare to have ear sxs
Nystagmus can occur in any direction, can be dissociated in 2 eyes (often vertical and nonfatigable)
Neuro sxs PRESENT (diplopia, ataxia, dysrthria)
May see HA or n/v

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7
Q

Lightheadedness

A

Vague, nonspecific “dizziness”

Can be associated with psych disorders (anxiety, depression, stress rxn) and hyperventilation

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8
Q

What to ask with the dizzy pt?

A

Duration of sxs and events
Relation to position (standing. head movement etc)
Possible triggers
Associated sxs (n/v, hearing loss, ear fullness, tinnitus, HA, vision, seizures, weakness)

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9
Q

What serious causes of vertigo MUST always be ruled out?

A

Cerebrovascular disease (vertebrobasilar insufficiency/stroke)
MS
Acoustic neuroma

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10
Q

Important parts of PE in vertigo

A

VS (orthostasis)
Ear (obstruction, fluid, perf)
Cardiac
Neuro (CNs, motor, cerebellar testing)

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11
Q

What is nystagmus?

A

Slow drift in one direction followed by fast response in the opposite direction

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12
Q

Categories of nystagmus

A

(direction of fast component)
Horizontal: peripheral or metabolic cause
Horizontal/torsional: peripheral or positional
Vertical: think CNS!!!

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13
Q

What is Dix-Hallpike maneuver most helpful for?

A

BPPV

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14
Q

What is electronystagmography or videonystagmography?

A

Assessment of vestibular function/ocular motility

-Record eye movements in response to visual, positional or rotational stimuli

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15
Q

What is caloric testing used for?

A

Vestibulo-ocular reflex

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16
Q

Normal response in caloric testing

A

COWS (Cold Opposite Warm Same)-direction of fast bearing nystagmus response
Cold water: eyes deviate ipsilateral and nystagmus beats away to opposite side
Warm water: eyes deviate contralateral and nystagmus beats to same side

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17
Q

What is vestibular paresis?

A

Seen in abnormal caloric testing

Impaired or absent thermally induced fast nystagmus (indicates pathology in labyrinth on irrigated side)

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18
Q

Most common cause of vertigo

A

Benign Paroxysmal Positional Vertigo

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19
Q

Presentation of BPPV

A

Transient (<1 min) episodes of vertigo associated with changes in head position
No hearing changes
Self limited but may last weeks or months

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20
Q

What is BPPV associated with?

A

Prolonged bed rest and head trauma

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21
Q

PE for BPPV

A

Normal
Dix-Hallpike can reproduce vertigo and horizontal nystagmus
Sxs fatigue with repetition

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22
Q

Management of BPPV

A

Reassurance that self-limited
Particle repositioning maneuvers
Vestibular rehab (OT or positional exercises)
Anti vertigo meds might help

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23
Q

First line vestibular suppressants

A

Anticholinergics (Scopolamine) or antihistamines (Meclizine or dimenhydrinate)

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24
Q

Other vestibular suppressants

A

Phenothiazines (prochlorperazine, promethazine)

Benzos

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25
Etiology of vestibular neuritis
(vestibular neruonitis, labyrinthitis etc) Young to middle age Presumed viral or postviral inflammatory (affecting vestibular portion of CN VIII)
26
Presentation of vestibular neuritis
Single attack of severe vertigo (several days to a week) Associated with viral URI N/v and gait instability No tinnitus or hearing loss (if hearing loss then labyrinthitis) Fall to affected side
27
How to diagnose vestibular neuritis
Positive head thrust test No CNS deficits Audiograms normal Caloric testing shows vestibular paresis on affected side
28
Management of vestibular neuritis
``` Self-limited Symptomatic tx (bed rest, vestibular suppressants, anti-emetics PRN, prednisone taper over 10 days) ```
29
Pathogenesis of Meniere's
Secondary to endolympathic hydrops (syphilis and head trauma)-distortion of membranous endolymph containing portions of labyrinthine system
30
Rupture theory of Meniere's
Swelling then rupture of membranous labyrinth causes paralysis of vestibular nerve fibers and degeneration of cochlear hair cells
31
Presentation of Meniere's
Triad: episodic vertigo, tinnitus and fluctuating hearing loss Sudden onset of attacks (20 min-24 hrs) Fullness of ear, n/v
32
Progression of Meniere's
Hearing loss gets worse and can eventually be irreversible Audiogram will show sensorineural hearing loss Lose low tones and then high tones
33
When do attacks of vertigo stop with Meniere's?
When deafness is complete
34
Management of acute attack of Meniere's
Bed rest | Symptomatic: anti-emetics or vestibular suppressants
35
Prophylactic management of Meniere's
Low salt diets Limit caffeine, nicotine, alcohol, MSG Diuretics (HCTZ)
36
Surgical management for refractory Meniere's
``` Intratympanic corticosteroid injection Endolymphatic sac decompression Vestibular ablation (transtympanic gentamicin, vestibular nerve section, surgical labyrinthectomy) ```
37
What is a perilymphatic fistula?
Abnormal connection between perilymph and middle ear (inner ear fluid can leak into middle ear)
38
Presentation of perilymphatic fistula
Associated with sudden changes in pressure of middle ear (head trauma, weight lifting, erosion, congenital) Hearing loss, tinnitus, vertigo
39
How to confirm presence of perilymphatic fistula
Pneumatic otoscope (abnormal to see eye movements with changes in pressure but may see nystagmus)
40
Management of perilymphatic fistula
Bedrest Hydration Symptomatic Surgery
41
Red flags with vertigo
Neuro deficit Ipsilateral hearing loss Gait abnormality Direction changing nystagmus
42
Sxs leading to a diagnosis of vertigo: aural fullness
Acoustic neuroma | Menieres
43
Sxs leading to a diagnosis of vertigo: ear/mastoid pain
Acoustic neuroma | Acute middle ear disease (AOM, herpes zoster oticus)
44
Sxs leading to a diagnosis of vertigo: facial weakness
Acoustic neuroma | Herpes zoster oticus
45
Sxs leading to a diagnosis of vertigo: focal neuro findings
Cerebellar tumor CVD MS
46
Sxs leading to a diagnosis of vertigo: HA
Acoustic neuroma | Migraine
47
Sxs leading to a diagnosis of vertigo: hearing loss
``` Menieres Acoustic neuroma Otosclerosis Labyrinthitis Herpes zoster TIA Cholesteatoma Perilympathic fistula ```
48
Sxs leading to a diagnosis of vertigo: imbalance
``` Acute vestibular neuritis (moderate) Cerebellar tumor (severe) ```
49
Sxs leading to a diagnosis of vertigo: phono/photophobia
Migraine
50
Sxs leading to a diagnosis of vertigo: rash
Herpes zoster oticus
51
Sxs leading to a diagnosis of vertigo: tinnitus
Acute labyrinthitis Acoustic neuroma Menieres
52
Provoking factors leading to a diagnosis of vertigo: changes in head position
``` Acute labyrinthitis BPPV Cerebellar tumor MS Perilymphatic fistula ```
53
Provoking factors leading to a diagnosis of vertigo: spontaneous with no provoking factors
``` Vestibular neuritis TIA/CVA Menieres Migraine MS ```
54
Provoking factors leading to a diagnosis of vertigo: recent URI
Vestibular neuritis
55
Provoking factors leading to a diagnosis of vertigo: stress
Psychogenic | Migraine
56
Provoking factors leading to a diagnosis of vertigo: immunosuppresion
Herpes zoster oticus
57
Provoking factors leading to a diagnosis of vertigo: changes in ear pressure, trauma, noises
Perilymphatic fistula
58
What is syncope?
Sudden, transient loss of consciousness with spontaneous recovery (loss of postural tone, due to diminished cerebral BF)
59
Possible etiologies of syncope
Neurally mediated/neurocardiogenic-reflex syncope Cardiac (higher risk of death)- obstruction, arrhythmias Orthostatic/autonomic Psych (GAD, panic attacks, somatic sx disorder)
60
Prodrome associated with syncope
Uneasiness or apprehension Lightheaded, facial pallor, diaphoresis, nausea Visual blurring, CP, SOB, HA, neuro sxs
61
What part of the prodrome is consistent with vasovagal syncope?
Lightheaded, facial pallor, diaphoresis, nausea
62
BP positive for orthostasis
Drop in systolic >20 or diastolic >10
63
Diagnostics for syncope
``` EKC Echo (when cardiac disease, abnormal PE or ECG) Electrophysiologic testing Exercise stress testing maybe Carotid u/s Neuroimaging MRI if abnormal PE EEG r/o seizure Labs ```
64
When is tilt table indicated?
For recurrent episodes of unexplained syncope and no history of cardiac disease
65
What is the tilt table?
Provocative test for vasovagal syncope Pt is tilted upright by 60-90 degrees: Normal is minimal drop in BP and increase HR Abnormal is exaggerated drop in BP with or without drop in HR associated with dizzy or lightheaded
66
When is carotid sinus massage indicated?
Recurrent episodes of syncope with negative work up or history of carotid sinus syncope
67
What is the carotid sinus massage?
Massage it for 5-10 sec and monitor HR and BP (palpate carotids and listen for bruit first!) + is sxs reproduced and period of asystole >3-5 sec or drop in BP (>50 mmHg)
68
Contraindications for carotid sinus massage
Prior TIA or stroke within last 3 mos | Pts with carotid bruits
69
Risk factors for cardiac syncope
``` Abnormal EKG History of ventricular arrhythmias History of HF Age >45 *poor prognosis so need to ID (palpitations associated suggest hypotension and mad arrhythmia) ```
70
Bradyarrhythmia in cardiac syncope
``` Sinus node dysfunction AV block (Second degree type II or complete) ```
71
Tacharrhythmias in cardiac syncope
SVT Wolff Parkinson White Ventricular tachycardia Do ECG and Holter
72
Most common outflow obstruction leading to cardiac syncope
Aortic stenosis
73
Presentation of cardiac syncope from aortic stenosis
Exertion association and cannot compensate
74
Cardiac syncope due to aortic dissection
Acute onset of tearing pain radiating to back | Unstable pt means high mortality
75
How to distinguish HCM from cardiac syncope
See dyspnea and increased systolic heart murmur with standing or exertion
76
How to distinguish PE from cardiac syncope
Acute dyspnea, pleuritic chest pain, hemopytysis and leg swelling
77
How to distinguish cardiac tamponade from syncope
Muffled hearts sounds and increased neck veins
78
What is reflex syncope?
Loss of sympathetic tone (or sudden increase in parasympathetic) leading to vasodilation and bradycardia and then hypotension and syncope Vasovagal, carotid sinus, situational
79
Vasovagal syncope
Seen in adolescents and YAs Emotional lability and stress, usually a provoking stimulus Prodrome of diaphoresis, nausea and pallor No long term tx needed
80
Who has carotid sinus syncope?
Middle age or elderly (probs male with atherosclerotic vascular disease) Tight collars or shaving can precipitate
81
Tx for carotid sinus syncope
Cardiac pacemaker
82
What is micturition syncope?
Syncopal episode after emptying distended bladder Seen after excess fluid ingestion, maybe alcohol Secondary to vagal stimulation or orthostasis
83
What is tussive syncope?
Seen in barrel chest/COPD/ kids with asthma | Severe coughing increases intrathoracic pressure and decreases CO
84
Causes of orthostatic hypotension
Autonomic failure Vol depletion Aging Meds (anti-hypertensives, TCAs)
85
Associations of orthostatic hypotensions
Diabetic polyneuropathy, PD | Malnutrition, anemia, blood loss, adrenal insufficiency all worsen it
86
Management of orthostatic hypotension
Avoid vol depletion Med adjustment Behavior (slow movements, doriflex feet or handgrip before standing, jobst stocking)
87
What is subclavian steal syndrome?
Stenosis of subclavian artery near origin and flow reversal in ipsilateral vertebral artery causing decreased brain perfusion
88
Sxs of subclavian steal syndrome
Diplopia, vertigo, syncope, dysrthria, ataxia Look for sxs with arm exertion look for different UE pulses
89
Management of syncope
Treat underlying disorder | IF remains unexplained then probably benign with good prognosis

X Clin Med III Final Exam (6 decks)

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