Dizziness - PowerPoint PPT Presentation

1 / 72
About This Presentation
Title:

Dizziness

Description:

In Panel B, the examiner moves the patient, ... Effective Communication and Skillful Conflict Resolution Author: Dr. Walter Himmel Last modified by: halsband – PowerPoint PPT presentation

Number of Views:292
Avg rating:3.0/5.0
Slides: 73
Provided by: DrWalte1
Category:

less

Transcript and Presenter's Notes

Title: Dizziness


1
Dizziness
  • 4 is
  • Central

Walter Himmel 2008
2
Dizziness
  • 1.5 3 of ED visits ? dizziness
  • 1 patient / shift is dizzy
  • Im dizzy ? whats your approach

3
Dizziness - Syncope
  • Syncope 1-3 ED visits
  • Syncope 10 serious outcomes by 7 days
  • ½ of these patients ?sent home
  • (Quinn. Ann EM 2006)

4
Dizziness - Vertigo
  • Isolated vertigo dizziness (gt 44 yr) ?
    3.2 CVA/TIA(Kevin. Stroke 2006)
  • Isolated vertigo (50-75 yr) ? 25
    cerebellar stroke(Norrving. Acta Neurol Scand
    1995)

5
Dizziness Goals
  • Approach to dizziness
  • Approach to vertigo
  • Approach to syncope
  • Identify the life-threatening

6
Dizziness
  • David Drachman - dizziness
  • Daniel Drachman myasthenia gravis
  • Drachman DA. An approach to the dizzy patient.
    Neurology 1972.

7
Dizziness 4 Types (Drachman)
  • Vertigo
  • Syncope
  • Disequlibrium
  • Other dizziness, non-specific light-headedness
  • Patients a bit of all may be present
  • One type predominates

8
64 yr Male
  • Complaint on chart DIZZY
  • CC dizzy getting out of bed
  • Sat up, dizzy, spinning, nausea for 15 min
  • Tended to fall to right but could walk
  • 3 further episode in next hour
  • Each episode lt 1 min spinning (felt unwell
    afterwards)
  • No other symptoms
  • ?

9
64 yr Male
  • Type of dizziness?
  • Vertigo

10
Dizziness (4 types)
  • Vertigo Syncope Disequilibrium
    Nonspecific
  • Seconds
  • Minutes
  • Hours
  • Days

11
Vertigo 4 types
  • Seconds
  • Benign positional vertigo
  • Benign ? delay 3-5 seconds fatigues
  • Benign ? can walk, unidrectional nystagmus
  • Central postional vertigo
  • Central ? no delay, does not fatigue
  • Central ? gait poor ?nystagmus
    multidirectional

12
Vertigo 4 types
  • 2. Minutes
  • TIA (BPV lt 60 seconds)
  • Tumor
  • Migraine up to 20 ? vertigo

13
Vertigo 4 types
  • 3. Hours
  • Peripheral Menieres, peripheral vestibulopathy
  • Central Migraine, tumor, stroke, MS, concussion

14
Vertigo 4 types
  • 4. Days
  • Peripheral vestibular neuronits, labyrinthits
  • Central stroke, MS, tumor, concussion

15
Vertigo Central or Peripheral
  • Central
  • 4 Ds Diplopia, Dysarthria, Dysphagia, Drop
    attack
  • Crossed sensory/motor findings
  • Ataxia
  • Reduced vision
  • Headache
  • Memory Loss, Personality Change

16
Dizziness (4 )
  • Vertigo (4) Syncope
    Disequilibrium Nonspecific
  • 1. Seconds
  • 2. Minutes
  • 3. Hours
  • 4. Days

Central
Peripheral
17
Nystagmus Central or Peripheral
  • Peripheral
  • Vertigo fatigues
  • Nystagmus unidirectioal
  • Horizontal/Vertical with a rotatory element
  • Can walk usually
  • No or minimal HA
  • No paresis / sensory loss/confusion
  • Central
  • Vertigo persists
  • Nystagmus multidirectional
  • Purely vertical central
  • Ataxia
  • Headache more common
  • Focal symptoms/findings

18
64 yr Male - Examination
  • O/E
  • Alert, spoke clearly
  • No focal findings at rest or if sitting up very
    slowly
  • Vertigo if got up fast or rolled over
  • Able to walk and talk well
  • No cerebellar signs
  • Dx?

19
The 4 Important Findings
  • Watch them talk
  • Watch them walk
  • Look at the eyes ( pupils, nystagmus)
  • Dix-Hallpike

20
Dix-Halpike
ASC
ASC
ASC()
PSC
PSC()
PSC
21
Dix-Hallpike
22
64 yr Male Examination
  • Dix-Hallpike to right - 5 second delay
    - Vertigo and nystagmus 30 sec
  • Rotatory vertical component
  • Got up - massive nystagmus opposite direction
  • Retch, retch, vomit
  • Dix-Hallpike to left slight dizzy

23
64 yr Male Examination
  • 2 min later Dix-Hallpike to right little
    happened
  • 10 min later good findings again
  • Dx
  • BPV

24
Dizziness Syncope
  • Jan 13, 2002- sitting on a couch- watching
    football- eating a pretzel ? dizzy ? passed out
    ? quick recovery- event syncope ?danger ?
    cardiac

25
Syncope
  • Syndrome, not disease
  • transient global cerebral hypoperfusion
  • ? Cardiac, ?
  • ?Neurological
  • Life-threatening?

26
SyncopeNot all vasovagal
  • Jan 13, 1992- formal dinner in Japan ? passed
    out- vomitted on the Prime Minister of Japan-
    recent diagnosis of atrial fibrillation and
    hyerT4-cardiac?
  • Life-threatening?

27
SyncopeNot all vasovagal
Hank Gathers 1967-1990
  • Syndrome, not disease
  • basketball Loyola Marymount University- Dec 9,
    1989 collapsed (home game) ? V Tach- Beta
    blocker ? he stopped it
  • March 4, 1990 ? dunk shot (25-13) ? VSA-
    Autopsy HOCM (1/500 1/1000)
  • (WPW 1.5/1000)
  • ? Life-threatening?

28
Mechanism of Sudden Death in Hypertrophic
Cardiomyopathy
ICD
Cardiac syncope 50 5 year mortality Six month
mortality gt 10
29
Syncope
  • Loss of consciousness
  • Brief
  • Sudden
  • Loss of muscle tone
  • Rapid, spontaneous recovery
  • May feel weak for 1-2 hours
  • May have several seizure-like jerks

30
Dizziness (4)
  • Vertigo (4) Syncope (4)
    Disequilibrium Nonspecific
  • 1. Seconds 1. Vasovagal
  • 2. Minutes 2. Orthostatic
  • 3. Hours 3. Heart and Brain
  • 4. Days 4. Unknown


31
Syncope (4)
  • Neurally- mediated (vasovagal) gt ¼
  • Orthostatic lt ¼
  • Heart and brain ¼
  • Unknown ¼

32
Syncope
  • Neurally- mediated (vasovagal) gt ¼
  • (i) Vasovagal
  • (iii) Event syncope
  • (iii) Carotid sinus syncope

33
Syncope
  • Orthostatic lt ¼
  • (i) Volume depletion (dehydration, gi bleed)
  • (ii) Drug side effects
  • (iii) Autonomic dysfunction (DM, Parkinson's,
    deconditioning in the elderly)

34
Syncope- Identify These
  • 3. Heart and brain ¼
  • Heart 2/3
  • Brain 1/3 - about 6 of syncope

2/3 arrythmia
1/3 structural
35
Syncope Summary
  • 1. Neurally 2. Ortostatic
    3. Heart Brain 4. Unkown
  • 1. VV 1. Volume 1.
    Ht rhythm
  • 2. Event 2. Drugs
    2. Ht structural
  • 3. Carotid Sinus 3. Auto Dys. 3. TIA

36
Dizzy
  • June 13, 2007
  • 14yr old
  • No breakfast, wrote exam
  • Later standing at coke machine
  • Sip of pop ? dizzy
  • Passed out 30 seconds
  • Well after 10 minutes
  • To ED (911)

37
Vasovagal?
  • Exam normal
  • Important examination findings?
  • Murmur, rhythm
  • Investigations
  • Important investigations?
  • ECG?
  • Any other investigations?

38
ECG 14 year old
39
Delta wave
PR 102 (lt 120 msec)
QRS 112 (gt100)
ST-T wave changes
40
WPWThe EKG in the patient with syncope. AJEM
200725(6)688-701
  • 0.15 (1.5/1000) to 3 incidence
  • 2.4 of SVT in ED
  • Arrhythmias
  • PSVT 70
  • A fib 25
  • A flutter 5
  • V fib rare

90 orthodromic 10 antidromic
41
Heart and Brain Syncope Counts
  • Heart and brain ¼ of all syncope at most
  • Heart 2/3
  • Brain 1/3

Why worry?
42
Syncope and Death
  • Syncope Hazard Ratio for
    Death
  • All causes syncope HR 1.43
  • Non cardiac HR
    1.17
  • Unknown cause HR 1.36
  • Neurologic cause HR 1.98
  • Cardiac syncope HR 2.41

Elpidoforos S. NEJM 2002347878-885
43
Overall Survival of Participants with Syncope
5.
44
Cardiac Syncope
  • gt 10 mortality first six months
  • 10-20/yr after that
  • Aortic stenosis syncope 30-50 die/yr
  • Hints
  • Hx (CAD, MI, CHF, family hx)
  • Exam rhythm, murmur ? always listen
  • ECG

45
Brugada
RBB pattern V1-V3(often incomplete)
ST elevation V1-V3 (often minimal)
V. Tach ? V Fib
Patterns come and go
46
Brugada
RBB pattern V1-V3(often incomplete)
ST elevation V1-V3 (often minimal)
Coved (fin)
Saddle
Rx ICD
Mortality 10/yr
47
Long QT
48
HCM Classical
T waves may be inverted V4,5,6
49
31 yr woman presyncope, palpitations(Sept 22,
2007)
  • Palpitations, dizzy, presyncope
  • ?? with walking 1 min
  • Felt like she would pass out or die
  • 2/6 SEM (insisted on going home)
  • ECG very abnormal
  • Hx of abnormal 2D ECHO ? stopped meds
  • Admit or send home?

50
Not Typical HOCM 31 yr old
51
Not Typical Happens- my patient
52
31 yr woman presyncope, palpitations(Sept 22,
2007)
  • 2D-ECHO septum 15-18 mm
  • Normal max 11 mm
  • HCM!
  • 1/500
  • Death ? V Tach, obstruction, CHF (late)

53
76 yr Woman Profound Vertigo and Disequilibrium
  • CC Dizzy, Headache
  • PH Cholesterol, BP?, DM, Depression
  • Previous afternoon
  • 5-6 minutes of staggering gait
  • Felt the world was moving
  • Needed help to get home
  • Felt better
  • Diagnosis?

54
76 yr Woman Next Day
  • 1800 on day of admission
  • Sudden nausea and dizziness
  • Sense of intense movement
  • Unable to open her eyes
  • Unable to sit up would be thrown to the left
  • Arrived by ambulance at 2045

55
76 yr Woman Profound Vertigo and Disequilibrium
  • Mild headache at back and top
  • Vague odd feeling left arm
  • Odd sense of numbness right side face
  • No diplopia, no dysarthria, no confusion, no drop
    attack, no dysphagia, no focal weakness

56
Profound Vertigo and Disequilibrium
  • O/E
  • Alert, refused to open eyes, refused to move
  • 80 / min 170/90
  • Speech normal
  • Probable numbness right side face
  • Profound lateropulsion to right
  • No reflex changes
  • Toes ??

57
Profound Vertigo and Disequilibrium
  • Walking impossible
  • Sitting impossible thrown to left
  • Lids opened by physician
  • Vertigo worse
  • Profound, persisting spontaneous nystagmus

58
Profound Vertigo and Disequilibrium
  • Cerebellar testing
  • Took encouragement
  • Patient kept eyes closed
  • F ? N / H ? S / RAM slow but not bad

59
Vertigo Cant Walk Central Features
  • CT normal
  • Numbness L face, R arm
  • Latero-pulsion severe
  • Severe ataxia
  • Unable to fixate
  • Persisting nystagmus
  • Mild headache
  • Would you admit?

60
MRI
Right vertebral artery occluded
61
Syncope Man
62
Syncope Man ?Do You Have Pain?
63
Syncope Man ?Do You Have Pain?
ICH/CVA
SAH
PE
MI
Dissection
DU
Aorta
Dissection
AAA
DU
GI Bleed
Dissection
GI Bleed
64
San Francisco Syncope Rules
  • Predict serious outcomes within 1 week
  • After syncopal episode
  • Serious outcomes ?
  • Death, MI
  • Arrythmia, PE
  • CVA, SAH
  • Significant hemorrhage
  • Return to hospital for related event

65
San Francisco Syncope Rules
  • Canadians are different
  • Admission rates ?
  • USA / Italy 50-60
  • Canada / Australia 30
  • Should reduce USA admissions by 10
  • Increase Canadian admissions by 10

66
San Francisco Syncope Rules5 Risk Factors
  • Abnormal ECG
  • Not sinus
  • New changes since last ECG
  • SOB as a complaint
  • Hct lt 30
  • SBP lt 90 at triage
  • Hx CHF

67
San Francisco Syncope Rules
Any 1 high risk ? ?admit
  • Any 1 of CHESS
  • C hx of CHF
  • H hematocrit lt 30
  • E abnormal ECG
  • S SBPlt 90
  • S compliant of shortness of breath
  • Serious outcomes 12 (7 days)
  • Positive predictive value ? 15
  • Negative predictive value ? 99.7

68
San Francisco Syncope Rules
  • Study Bad Outcome Sensit Specif
  • SF1 12 96 62
  • (684 pat)
  • (7 days)
  • SF2 14 98 56
  • (791)
  • (30 days)

Any 1 high risk ? ?admit
69
San Francisco Derivation (684)Serious Outcomes
at 1 week 11.5 (79)
  • Death 0.7 of all patients
  • MI 4.9
  • Arrythmia 4.4
  • Structural Heart 0.7
  • PE 0.7
  • Sig hemorrhage 1.8
  • Ectopic 0.2
  • SAH 0.4
  • Stroke Syndrome 0.4

70
San Francisco Syncope Rules
  • Use as a risk stratification tool
  • Part of the Hx and Px
  • Should not replace common sense
  • After initial assessment ? then use SFSR
  • 4 syncope patients with no CHESS features
  • ? still at risk of bad event at 1 week

71
San Francisco Syncope Rules
  • the rule can not and should not be strictly
    applied without judgmentrather, it should be
    used as a risk stratification tool to augment
    physician judgment ..
  • It is unfortunate that the term rule tends to
    imply that it should be strictly enforced
  • James Quinn (CJEM 20079174-175)

72
Summary
  • 4 types of dizziness
  • 4 vertigos
  • 4 syncope
  • Hx, Px, ECG, Hb
  • CT ? rarely helpful
  • Syncope tools limited value
  • Clinical dominates
Write a Comment
User Comments (0)
About PowerShow.com