syncope, dizziness & vertigo: case review
DESCRIPTION
Amy Gutman MD ~ EMS Medical Director [email protected] / www.TEAEMS.com. Syncope, Dizziness & Vertigo: Case Review. Objectives. “ The only difference between syncope & sudden death is that in one you wake up ”. Engel GL. Ann Intern Med 1978. - PowerPoint PPT PresentationTRANSCRIPT
Syncope, Dizziness & Vertigo:
Case Review
Amy Gutman MD ~ EMS Medical [email protected] /
www.TEAEMS.com
Objectives
“Weak & Dizzy” is a common complaint with both benign & lethal causes
Etiologies of dizziness & syncope
Connection of cardiovascular & neurovascular disorders
Assessment & management strategies
“The only difference between syncope & sudden death is that in one you wake up”. Engel GL. Ann Intern Med
1978
Prehospital Dizziness Protocol?
No specific “dizziness” or “syncope” protocols
Protocol(s) used depends upon cause & effect(s) of symptoms
A good history & physical exam provides diagnosis in most patients
Not the patients to test how good you are at obtaining refusals!
Case Presentation 82 yo WF presents with CC of “dizziness”. States
intermittent, but persistent & unpredictable moments of dizziness that “made her head spin”. During the episodes, patient would nearly pass out, c/o dizziness & lightheadedness with some “blurred” vision. No CP, SOB, palpitations, seizure, loss of consciousness. No trauma, recent illness or other complaints
Vitals & exam unremarkable by BLS crew. Patient initially did not want to be transported to the hospital but was convinced to get checked out. ALS crew called but unavailable
What is your differential diagnosis based upon this info?
Case Continued History fairly unremarkable in otherwise
healthy patient who recently started OTC antihistamines for sinus congestion
Vitals stable but patient had at least 3 more episodes on the way to the ED in which she would lean back in stretcher & become extremely dizzy
In ED, placed on a hallway bed. During her triage, while the RN had the patient on a monitor and was checking her pulse he noted the following:
Definitions Syncope (Greek: sunkoptein / to cut short)
Sudden & self-limiting loss of consciousness with loss of postural tone & a spontaneous recovery. A symptom, not a diagnosis
Vertigo (Latin: vertere / to turn) Sensation of dizziness or abnormal motion resulting
from a disorder of the sense of balance
Dizzy Having a whirling sensation with tendency to fall;
bewildered or confused; producing giddiness
Challenges of Syncope & Dizziness
50% with no specific causes
Significant cost & time to diagnose & manage
Unpredictability leads to negative impact on quality of life
Management specific to the cause / suspected cause(s); varies significantly in effectiveness
Dizziness & Syncope
Syncope, dizziness & vertigo are generally symptoms rather than diseases
Benign to fatal causes Cardiac causes have highest
mortality rates >500,000 new patients
annually 70,000 have recurrent,
infrequent, unexplained syncope 3-6% ED visits annually 2-10% hospital admissions
0%
5%
10%
15%
20%
25%
Sync
ope
Mor
talit
y
Overall Due to Cardiac Causes
Associated Symptoms
Traumatic sequellae Fever, signs of illness Focal neurological
symptoms Prodromal or post-episodic
Palpitations / CP SOB Seizures Nausea, Vomiting Micturition Loss of continence
Pathological Risk Factors
>2 associated with 10-20% incidence of death from neurovascular or cardiovascular causes within 1 year CAD, CHF, arrhythmia Chest pain Abnormal ECG Persistent orthostatic
hypotension Age >45yrs Traumatic sequellae for any
fall
Cause Prevalence (Mean) %Reflex-Mediated:
Vasovagal 18Situational 5
Carotid Sinus 1Orthostatic hypotension 8Medications 3Psychiatric 2Neurological 10Organic Heart Disease 4Cardiac Arrhythmias 14Unknown 34
Syncope Etiology
Syncope Etiology*
Orthostatic Arrhythmia Structural
*
• Vasovagal• Carotid Sinus
• Peripheral vestibular dysfunction
• Brainstem lesion
• Situational• Cough• Micturition
• Meds
• Autonomic Failure
• Presyncope
• Brady• Sick
sinus• AV
block
• Tachy• VT• SVT
• Long QT
• Aortic Stenosis
• HOCM
• Pulmonary HTN
• Psychogenic
•Metabolic
• Neurological
Non-CVNeurological
Unknown Cause = 34%
24% 11% 14% 4% 12%
*DG Benditt, UM Cardiac Arrhythmia Center
Misdiagnosed or Associated with Dizziness
Migraine Hypoxia Hyperventilation Somatization / Psychiatric Intoxication Seizures Hypoglycemia
Sleep disorders / OSA
Subclavian steal syndrome
Basilar artery migraine (syncope + headache)
Vertebrobasilar insufficiency (syncope + vascular disease)
Syncope DiagnosisHistory & Physical Exam
Including ECG
Neurological Testing
• Head CT / MRI / MRA
• Carotid Doppler• EEG
Cardiovascular
• Ambulatory• Tilt Table•
Echocardiogram
• EPS • Angiogram• Stress
TestingPsychological Evaluation
ENT Evaluation• Sinus CT• Otolith
evaluation• Hearing exam
Metabolic• Laboratory
SAMPLE History & OPQRST Assessment
SSX: Associated symptoms Sequelae
Allergies: +/- & what is the reaction
Medications: Include OTCs & topicals
PMH: Cardiovascular, neurovascular
diseases, migraine, prior similar episodes
Last Oral Intake:
Events
Onset & Duration
Provocation or Palliation Position Medications Temperature
Quality
Region & Radiation
Severity Loss of consciousness
Time Time of day, duration of event
History & physical exam leads to cause identification in nearly half of patients
Family History Sudden death
Deafness
Arrhythmias
Congenital heart disease
Heart attack or CVA at young age
Seizures
Metabolic disorders
Physical Exam Serial vitals
Focus on cardiac & neurologic exams Stroke scale Glucose Monitor / ECG
If syncope + fall, presume a spinal injury present until proven otherwise
Stroke Scales
Vasovagal
Carotid Sinus
Neuralgic or
Migranous
Situational
TIA / CVA
Subclavian Steal
Episodes after pain, fear, excitation, exertion; standing w/ locked knees “i.e. “at attention”
Micturition, cough, swallowing
Facial Pain or headache
Head rotation or pressure on carotid sinus
Post exercise
Seizure
Murmur
Seizure activity, LOC >5 mins with post-ictal period
Presence of heart murmur on exam or echocardiogram
Arrhythmia
Psychogenic
Focal neurological symptoms that persist (CVA) or resolve within 1-72 hours (TIA); positive stroke
scale
Intermittent or persistent irregularity of rhythm or regularity
Anxiety, hyperventilating, personal gain
Other Syndromes Vertebral-Basilar Stroke
Diplopia, dysarthria, dysphagia, weakness, numbness
Meniere’s Aural fullness, deafness,
tinnitus Brainstem evoked audiometry
95% sensitive for detecting acoustic neuromas
Multiple Sclerosis Vertigo preceded by other
neurologic dysfunction
Nonspecific Dizziness
Psychiatric disorders Depression 25% Anxiety or panic disorder
25% Somatization Alcohol / drug abuse Personality disorder Hyperventilation
Syncope & presyncope overlap CAD, CHF, PE,
dysrhythmias
Disequilibrium Multisensory disorder
Peripheral neuropathy Visual impairment Musculoskeletal disorder interfering
with gait Vestibular disorder Cervical spondylosis
Symptoms worsened with antidepressants & anticholinergics
May occur while sitting, driving or position change
Peripheral vs Central Vertigo (Vestibular
Dysfunction)PERIPHERAL VERTIGO
CAUSES Vestibular neuronitis Labyrinthitis Meniere’s syndrome Head trauma Drug-induced
Aminoglycosides, phenytoin, phenobarbital, carbamazepine, salicylates, quinine
CENTRAL VERTIGO CAUSES Cerebellar infarction or
hemorrhage Lateral medullary infarction
(Wallenberg’s syndrome) Brainstem infarction or
hemorrhage Multiple sclerosis Vertebrobasilar
insufficiency
Central vertigo associated with poor outcomes while peripheral vertigo is often “benign”. Can have overlap in
symptoms, therefore difficult to differentiate
Nystagmus: Characteristics
CENTRAL ORIGIN Vertical, horizontal or
rotary
May change direction with gaze
Not diminished by fixation
Does not significantly worsen with head movement
PERIPHERAL ORIGIN Horizontal, torsional Does not change
direction with gaze change
Diminished by fixation May fatigue (if elicited
by head movement)
Cerebellar Infarction
CEREBELLAR INFARCTION
Nystagmus + dizziness
Nausea & vomiting
Ataxia & ipsilateral asynergia
No focal weakness or motor abnormality
LATERAL MEDULLARY INFARCTION: WALLENBERG SYNDROME
Nystagmus + dizziness Nausea & vomiting Ataxia & ipsilateral
asynergia No focal weakness or motor
abnormality Hoarseness Horner’s syndrome Ipsilateral facial analgesia;
contralateral body analgesia
Horner’s Syndrome:Ptosis, Miosis,
Anhidrosis
Carotid or Vertebral Artery Dissection
Often spontaneous Acute dizziness after neck
trauma / manipulation Presents with posterior
circulatory infarction symptoms
MRA may reveal double-lumen, but full angiography has higher yield
Neurally-Mediated Reflex Syncope (NMS)
Neurally mediated reflex mechanism with cardioinhibitory (bradycardia) & vasodepressor (hypotension) components Vasovagal syncope (VVS) Carotid sinus syndrome (CSS) Situational syncope
Loss of the normal balance between sympathetic & parasympathetic nervous system
Triggered by stretch & mechanoreceptors (carotid sinus, bladder, esophagus, respiratory tract)
Peripheral venous pooling causes sudden decreased venous return Pallor, nausea, sweating, palpitations common
Carotid Sinus Syndrome (CSS)
Rare except in elderly “Falls after losing balance”
Sensory nerves in carotid sinus walls respond to stimulation increasing afferent signals to brain stem
Reflexive increase in efferent vagal activity & decreased sympathetic tone results in bradycardia & vasodilation
Different syndrome than carotid sinus hypersensitivity, similar management
Other Forms of VVS Drug-induced
Often from diuretics, vasodilators
Primary autonomic failure Deconditioning, parkinsonism
Secondary autonomic failure Diabetes +/- neuropathy,
amyloidoisis
Alcohol Orthostatic intolerance +/-
neuropathy
Orthostatic Hypotension
Decline of >20mmHg SBP or 10mmHg DBP from supine to standing
Elderly vulnerable due to decreased baroreceptor sensitivity, decreased cerebral blood flow, increased renal sodium wasting, decreased thirst response with aging
Peripheral sympathetic tone impairment due to diabetic neuropathy, anti-HTN medication
Radiologic Imaging Non-contrast CT helps r/o
acute hemorrhage (but not 100% accurate)
MRI more sensitive than CT for hypoxic injury or cerebellar & brain-stem infarctions PET scan may improve
diagnostic accuracy CT angiography or MRA
useful within 24 hours
Carotids often included in evaluation
Electroencephalogram (EEG)
Not 1st line testing Differentiates syncope from seizures
Head - Tilt Test
Evaluates NMS predisposition Specificity of negative test 90%
Nystagmus & vertigo with peripheral lesions when diseased side turned downward Peripheral nystagmus may fatigue with
repeated maneuvers
Central lesions not significantly changed with position change
Symptoms of peripheral nystagmus dramatically worsened with head movement & tends to fatigue with repeated maneuvers
Dix Hallpike Diagnosis
PERIPHERAL VERTIGO
CENTRAL VERTIGO
Time before onset of nystagmus
2-20 secs 0 secs
Duration of nystagmus
<1 min >1 min
Fatiguability Yes with repetitiion Non-fatiguiing
Direction of nystagmus
Upbeat & torsional May change direction
Intensity of vertigo severe Minimal to moderate
Epley Maneuver Particle-Repositioning
• Potential consequence is carotid occlusion / clot resulting in stroke
Cardiovascular Syncope LOC often w/o prodrome
Significant injury risk
Structural heart disease is most important risk factor for predicting risk of death from syncope or dizziness
Acute MI / Ischemia Hypertrophic cardiomyopathy Aortic dissection Pericarditis Pericardial tamponade Pulmonary embolus Pulmonary HTN Aortic stenosis Atrial myxoma Bradyarrhythmias Tachyarrhythmias
12 Lead EKG & Monitor
Normal or abnormal? Normal “now” does not
equal normal “always”
Fast or slow?
Pauses?
Pacemaker?
Ambulatory ECG Holter
24-48 hours symptoms w/ arrhythmia (5%) v.
symptoms without arrhythmia (17%)
External Loop Event Recorder Weeks to months Limited value in sudden LOC
Loop Recorder Months Implantable type more convenient Provided diagnosis in 55% of pts
with unexplained syncope compared to conventional methods
What’s My Rhythm? All Seen in Dizziness & Syncope
From the files of DG Benditt, UM Cardiac Arrhythmia Center
So…Back to Our Patient
Bradyarrhythmic Syncope
Wide, weird & slow Sinus brady Symptomatic 1st degree HB 3rd degree HB
Cause often correctible with medication adjustment
Indication for atrial pacemaker implantation
Ventricular pacing indicated in atrial fibrillation with slow ventricular response
Bradycardia 36%
Tachycardia 6%NSR 58%
Weird Bradyarrythmia:Idioventricular
Ventricles depolarizing on their own because of no atrial conduction
Rate between 20-40 Rate of 60-120 (all PVCs)
often called “Slow VT” Diagnostic clue: no p
waves or flipped p waves in all leads
Tachyarrhythmic Syncope
Wide, weird & fast or narrow & regular
Regular or irregular, intermittent or persistent
Cause often structural, ischemic & pathologic – not easily corrected with a simple medication change
Surgery (if related to stenosis or CAD) +/- ventricular pacing often indicated
Risk of sudden cardiac death
Atrial Fibrillation with Accessory Pathway Conduction Degenerating to
VF
Premature Ventricular Complex (PVC)
AKA: Ventricular extrasystole,
premature beat, ectopic beat, premature depolarization
Occasional monomorphic PVCs common in normal hearts but also seen in the setting of heart disease
Polymorphic VT never normal Ischemia, metabolic or
structural disorders
QT Prolongation & R on T Phenomenon
QT widens to point when a PVC occurs early in the cardiac cycle falling on the apex of preceding T wave leading to VT or torsades
Antiarrhythmics Class IA & III: Quinidine, Procainamide, Sotalol, Amiodarone
Psychoactive Agents Phenothiazines, Amitriptyline, Imipramine, Ziprasidone
Antibiotics Erythromycin, Pentamidine, Fluconazole
Antihistamines Terfenadine, Astemizole
Others Cisapride, Droperidol
VT vs VFVENTRICULAR TACHYCARDIA
Abnormal tissues in ventricles generating rapid & irregular rhythm
>3 PVCs in a row; can be sustained or unsustained
Rhythm: Regular Rate: 150-250bpm QRS Duration: Prolonged >120ms P Wave: Not seen, often dissociated
VENTRICULAR FIBRILLATION
Disorganized electrical signals cause ventricles to quiver ineffectively
Rhythm: Irregular
Rate: >250, disorganized
QRS Duration: Unrecognizable
P Wave: Not seen
Case Conclusion Patient emergently trans-thoracially
paced in ED while receiving fluid boluses & amiodarone
Went to OR for permanent dual-chamber (atrial & ventricular) pacemaker
Patient’s antihistamines discontinued (unclear if contributed to symptoms)
Discharged home a few days later with no permanent sequellae
Pacemakers Ventricular > atrial >
dual chamber
Most pacemakers are “demand” type
EKG shows a “spike” when pacer fires
Beware the patient with a pacemaker, syncope / dizziness with no pacer spikes on EKG!
CV-Related Management
Recognize symptoms & avoid provocation Avoid alcohol, lack of sleep,
environmental stressors Adequate hydration & food intake Avoid drugs that lead to hypotension Avoid activities that precipitate syncope
Preventing LOC or Injury Supine position upon onset of prodrome Avoid driving or other activities that
could lead to injury
Cardiovascular / neurovascular interventions Routine follow-up Take prescribed medications as
prescribed!
References Dubin’s Guide to EKGs. Images: Wikipedia, Google, Bing searches. www.UpToDate.com. “Dizziness”, “Syncope”,
“Ventricular Tachyarrythmias”. 2013. D. Okorn MD. “Approach to Dizziness”. Swedish
Family Medicine. Dec 2009 G. Bergey MD. “Acute Dizziness & Vertigo:
Diagnosis, Assessment and Management”. 2001 M. Lehmann MD. “Tacchyarrythmias”. 2010 E. Veiga, M.D, 2008 WN Kapoor. Syncope. NEJM 2000; 343: 1856-62 Freeman, R. “Neurogenic Orthostatic
Hypotension” NEJM 2008; 358: 615-624 Soteriades, et al. Incidence and Diagnosis of
Syncope. NEJM 2002; 347:878-885 Grubb, B. Neurocardiogenic Syncope. NEJM
2005; 1004-1010 DG Benditt. “Syncope - A Diagnostic & Treatment
Strategy”. Royal Brompton Hospital, London, UK Kapoor W, Med. 1990;69:160-175 JJ Blanc, et al. Eur Heart J, 2002; 23: 815-820 WN Kapoor. “Evaluation and outcome of patients
with syncope”. Medicine 1990;69:160-175
[email protected] / www.TEAEMS.com
History & exam important in providing or eliminating a diagnosis
Most causes benign & self-limited but almost impossible to make a prehospital diagnosis
Serious causes suspected by abnormal CV or neuro exam
Recognize stroke syndromes that may present with dizziness as a prominent feature