4- Vertigo and Syncope Flashcards by Colleen Cahill

What is defined as a sensation of abn movement (spinning, tumbling, falling forward/ backward) when there is no motion and what is it often a/w?

Vertigo- a symptom

A/w nystagmus and postural instability

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What is defined as a sense of imbalance (losing balance w/o sensation of movement) and is characterized by imbalance and gait difficulties?

Disequilibrium

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What is defined as vague and nonspecific dizziness?

Lightheadedness

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What is defined as a feeling of impending faint or LOC and is generally a/w cardiac etiology?

Presyncope

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Peripheral vs central causes of syncope imply a lesion where?

Peripheral- vestibular lesion

Central- central lesion

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What is the suspected cause of vertigo if sudden/ acute onset, and horizontal or torsional nystagmus?

Would you expect ear sxs and/ or neuro sxs?

Peripheral

YES ear sxs, NO neuro sxs

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What is the suspected cause of vertigo if gradual/ progressive onset, associated HA or N/V and vertical, nonfatigable nystagmus?

Would you expect ear sxs and/ or neuro sxs?

Central

NO ear sxs, YES neuro sxs

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What are a few serious causes of vertigo that must be ruled out as part of a workup for a “dizzy” pt?

CV disease

Acoustic neuroma

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PE of “dizzy” pt should include what specifically?

(in additional to general PE)

Check BP for orthostasis

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How is nystagmus characterized and referred to?

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

Referred to by direction of fast component

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Horizontal nystagmus indicates what cause?

Peripheral or metabolic

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Horizontal/ torsional nystagmus indicates what cause?

Peripheral or positional

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Vertical nystagmus indicates what cause?

CNS

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What dx study is the most helpful for BPPV as it reproduces vertigo and horizontal nystagmus?

(BPPV: benign paroxysmal positional vertigo)

Dix-Hallpike maneuver

(quickly lower seated pt to supine position w/ head turned to right w/ head to 30˚ below horizontal, observe for nystagmus, repeat w/ head turned to left)

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What dx studies would you use to assess for vestibular function/ ocular motility?

ENG (electronystagmography) or VNG (videonystagmography)

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What dx study would you use to test the vestibulo-ocular reflex?

Caloric testing- CN III, VI

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What is considered a normal result for caloric testing?

Cold water: eyes deviate ipsilateral and nystagmus beats away to opposite side

Warm water: eyes deviate contralateral and nystagmus beats toward same side

COWS

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What is considered an abnormal result for caloric testing and what does it indicate?

Vestibular paresis (absent thermally induced nystagmus) → pathology in labyrinth on irrigated side

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What is the most common cause of vertigo?

BPPV

(secondary to canalithiasis)

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Pt w/ hx of prolonged bedrest following head trauma presents with transient (< 1 min) episodes of vertigo a/w changes in head position and no hearing changes. What are you concerned for?

BPPV

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What would you note with BPPV sxs with repeated Dix-Hallpike test?

Fatigue

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What is the management for BPPV?

Pt EDU/ reassurance (self-limited weeks to months)

Particle repositioning maneuvers

OT/ positional exercises

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What vestibular suppressant meds can be used in the tx of vertigo?

(not effective for BPPV)

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Anticholinergics (scopalamine)

Antihistamines (meclizine, dimenhydrinate)

What condition is often preceded by a viral infection (URI)?

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Vestibular neuritis

(vestibular neuronitis = vestibular n. only

labyrinthitis = vestibular & cochlear n.)

Pt presents with single attack of severe vertigo (sxs last days- 1 week), N/V, gait instability, and NO associated tinnitus or hearing loss. Hx of viral URI. What are you concerned for?

Vestibular neuritis (labyrinthitis if (+) hearing loss)

How is vestibular neuritis diagnosed?

**(+) head thrust test = nystagmus** **(+) caloric testing = vestibular paresis** No CNS deficits, N audiogram

What is the management for vestibular neuritis?

Symptomatic tx, self-limited

What condition is thought to be secondary to endolymphatic hydrops?

Meniere disease

Pt presents with sudden onset attacks of **episodic vertigo, tinnitus, and fluctuating hearing loss**. Associated sxs include ear fullness, N/V. Audiogram shows sensorineural hearing loss. What are you concerned for?

Meniere disease

How does hearing loss progress with Meniere disease?

Becomes irreversible → low tones lost first Attacks of vertigo stop when deafness complete

What is the tx for an acute attack of Meniere disease?

Bed rest, symptomatic care

What is used for prophylactic management of Meniere disease?

Low salt diet, diuretics Limit caffeine, nicotine, EtOH, MSG

What is the tx for refractory Meniere?

Surgery

What is defined as an abn connection between the perilymph and the middle ear?

Perilymphatic fistula

Pt presents with hearing loss and tinnitus and hx of head trauma/ barotrauma. What are you concerned for and how would you confirm your suspected dx?

Perilymphatic fistula Dx with pneumatic otoscopy

What is the management for perilymphatic fistula?

Bedrest, hydration, sx tx, surgery

What would be considered red flags in vertigo? (4)

Neuro deficit Ipsilateral hearing loss Gait abn Direction changing nystagmus

What is defined as a **sudden, transient LOC w/ spontaneous recovery**, and is a/w loss of postural tone due to diminished cerebral BF?

Syncope- a *symptom*

What syncope etiology is a/w a higher risk of death?

Cardiac

What prodromal sxs are consistent w/ **vasovagal** syncope?

**Lightheadedness** **Facial pallor** **Diaphoresis** **Nausea** (other general: uneasiness/ apprehension, visual blurring, CP/ SOB, HA/ focal neuro sxs)

What BP changes are considered (+) for othostasis?

P systole \> 20 mmHg P diastole \> 10 mmHg

What provacative test is indicated if recurrent episodes of unexplained vasovagal syncope and no hx of cardiac disease?

**Tilt table** **Abn**: exaggerated drop in BP, dizziness/lightheadedness +/- drop in HR (normal: minimal drop in BP/increase in HR)

What test is indicated for recurrent episodes of syncope with negative work-up and used if NO prior hx of carotid sinus syncope?

**Carotid sinus massage** Palpate/auscultate for carotid bruits → STOP if present → massage carotid sinus for 5-10 sec → (+) if sxs reproduced and peroid of asystole \> 3-5 sec or drop in BP \> 50 mmHg

What are contraindications for carotid sinus massage?

Hx of TIA/ stroke w/i past 3 months Carotid bruits

Pt presents with episodes of presyncope/ syncope and associated palpiations with NO prodrome. EKG shows sinus node dysfunction and AV block. What are you concerned for?

Cardiac syncope due to bradyarrhythmia

Pt presents with episodes of presyncope/ syncope and associated palpiations with NO prodrome. EKG shows SVT, Wolff Parkinson White, and VT. What are you concerned for?

Cardiac syncope due to tachyarrhythmia

What is the most common cause of obstructive cardiac syncope?

Aortic stenosis (a/w exertion) (can also be due to aortic dissection)

What type of syncope is neurally mediated, and due to loss of SNS tone or sudden ↑ in PNS tone?

Reflex syncope

What is the most well-known reflex syncope and is aka "common faint"?

Vasovagal syncope (attacks solitary, no long term rx needed)

What type of syncope is typically seen in middle aged/ eldery pts w/ athersclerotic vascular disease and is due to the carotid sinus being abnormally responsive to pressure (ex. tight shirt collor/shaving)?

Carotid sinus syncope

What is the tx for carotid sinus syncope?

Cardiac pacemaker

What is defined as a syncopal episode after emptying a distended bladder and is seen after excess fluid ingestion?

Micturition syncope

What type of syncope is seen with severe coughing leading to increased intrathoracic pressure and decreased CO and may be a/w with barrel chest/ COPD or children w/ asthma?

Tussive syncope

When is orthostatic (postural) hypotension more worrisome?

Delayed sxs (a few moments to several min after standing) (orthostatic hypotension worsened by autonomic/ peripheral neuropathies and debilitation)

What is the management of orthostatic hypotension?

Avoid volume depletion, behavior mod (slow changes in position, dorsiflexion of feet/ handgrip exercises prior to standing, Jobst stockings)

Pt presents with **vertigo, syncope**, +/- diplopia, dysarthria, and ataxia. You eval for sxs with arm exertion and look for difference in pulses in the UEs. What are you concerned for?

Subclavian steal syndrome (stenosis of subclavian artery near origin, reversal in ipsilateral vertebral artery = decreased cerebral perfusion)

What is indicated if syncope remains unexplained after workup?

Benign w/ good prognosis

4- Vertigo and Syncope Flashcards

(57 cards)