Reisert: Dizziness and Syncope

Question 1

Having disturbed ambulation

Associated sx:

Changes in vision

Orthostasis

….just about anything else

Answer 1

Dizziness

Question 2

Change in blood pressure and cerebral blood flow due to transient low blood pressure

Answer 2

Orthostasis

Question 3

Alteration in normal response to standing

May occur with aging due to loss of vascoconstriction (With standing, blood falls to feet adn you get dizzy or pass out)

Answer 3

Orthostasis

Question 4

Lie for 10 mins, stand for at least 2 mins though response in worst case may last 10 mins

Answer 4

Test of orthostasis

Question 5

Fall in systolic BP > ____ mmHg

Fall in diastolic BP > ____ mmHg

Increase in heart rate ______ beats per min

With orthostasis

Answer 5

20

10

10-25

Question 6

___% of people have orthostasis

Answer 6

24%

Question 7

Mineralcorticoids like fludrocortisone

Midodrine

Atomoxetine

Pyridostigime

Droxidopa: new med approved 2015

Answer 7

Tx for Orthostasis

Question 8

Loss of buffers to remain conscious

Syncope prodrome

Answer 8

Fainting

Question 9

Cardiac

Neurological

Simple (anxiety, stress)

Answer 9

Causes of syncope

Question 10

What is the most common type of syncope?

Answer 10

Simple fainting from anxiety/stress

Question 11

Arrythmia/dysrrhythmia

Heart block

Aortic stenosis (severe)

Medications (orthostasis)

MOST WORRISOME

Answer 11

Cardiac causes of syncope

Question 12

Echocardiogram

Electrophysiological study

Signal average EKG

Answer 12

Cardiac syncope workup

Question 13

Implantable cardiac defbrillator

Anti-arrhythmics less so

Answer 13

Tx of true cardiac syncope

Question 14

Impaired vestibular system

May be due to disturbance of inner ear

Altered head position in space –> aleration of CN VIII

Some say room spinning or they feel like they are spinning

Answer 14

Vertigo

Question 15

Visiual imput

Somatosensory input (skin, joints, muscles, spinal cord)

Cerebellum

Cerebrum

Answer 15

Normal balance maintenance

Question 16

What happens to people with true syncope?

Answer 16

They get injured!

Question 17

Alerations of eye movement with oscillation to lateral gaze

Answer 17

Nystagmus

Question 18

Two types of vertigo?

Answer 18

Physiologic

Pathologic

Question 19

Abnormal input to stabilize (car sickness)

Unfamiliar head position (sea sickness)

Unusual head position (painting ceiling)

Spinning

Physiologic causes of ______?

Answer 19

Vertigo

Question 20

• Disturbance of vision
• Disturbance of somatosensory system
• Disturbance of vestibular system
• CNS tries to correct
  
  • Change in frequency of normal firing (homeostasis is disrupted), unequal signal results, abnormal head sensation
• Worse with rapid head movement
• Often nausea and ataxia

Pathological causes of _____?

Answer 20

Vertigo

Question 21

MOA of Fludrocortisone?

Answer 21

Causes fluid retention

Question 22

Table that goes up in down

Indication: Patient that is having repeat syncope

To test of orthostasis

Answer 22

Tilt table test

Question 23

What should you think of when you see a young athelete pass out on the field?

Answer 23

hypertrophic cardiomyopathy

Question 24

Loss of bowel/bladder control

Bite tongue

More common in seizures or syncope?

Answer 24

SEIZURES!

Question 25

Triad of aortic stenosis

Answer 25

Syncope, chest pain, dyspnea

Question 26

Most common cause of orthostatic HTN?

Answer 26

Dehydration!

Question 27

Fast phase of nystagmus goes away from lesion (affected side) Rotation goes away from affected side Falling toward side of lesion

Answer 27

Patterns of vertigo

Question 28

2-3 beats at when look extreme left or right Is this normal or abnormal (mystagmus)?

Answer 28

Normal!

Question 29

Acute labrynthitis Vestibular neruitis Causes of _____ vertigo

Answer 29

Idiopathic

Question 30

Idiopathic Infection (HSV 1) Trauma Ischemia (nausea and vomiting) Drugs (Alcohol, Aminoglycoside antibx)

Answer 30

Causes of significant vertigo

Question 31

Cochlear disease Progressive hearing loss (low frequency) Tinnitus Dizziness

Answer 31

Meniere's disease

Question 32

Etiology unknown Possibly infection, autoimmune, inflammatory, demyelization, tumor, trauma

Answer 32

Meniere's disease

Question 33

Diuretics (Hydrochlorothiazide) Very low salt restriction, \<1g per day

Answer 33

Tx for Meniere's Disease

Question 34

Unilateral hearing loss Tinnitus Schwannoma or meningioma

Answer 34

Acoistic neuroma

Question 35

What CN does acoustic neuroma effect?

Answer 35

CN VIII

Question 36

What is the diagnostic **test of choice** for Acoustic neuroma?

Answer 36

MRI

Question 37

Due to changes in head position No clear known cause May last months

Answer 37

Benign Positional Vertigo

Question 38

What maneuver can you do to treat BPPV?

Answer 38

Epley maneuver

Question 39

H&P Orthostatic vitals Swivel chair Cardiac testing Provocative tests: head shaking, Frenzel glasse

Answer 39

Evaluation of dizzy patient

Question 40

* EKG * Rules out heart block * Echocardiogram * Rules out structural heart disease (cardiomyopathy) * Holter monitor * 24 hour hear monitor * Tape recording device * Good for symptomatic evaluation (palpitations) and tachycardia * Event monitor * Wear up to a month * Trans-telephonic transmission of data * Exercise stress testing (low yield) * Electrophysiologic study (EP study) * Looks for risk for Ventricular tachycardia * Tilt table test for orthostatic hypotension

Answer 40

Cardiac testing for syncope

Question 41

Treat cause if known Bed rest Vestibular rehabilitation (PT) Medications: Vesticular suppresants (Meclizine, Dimenhydrinate, Promethazine), Benzodiazepines (Diazepam), Steroids Epley maneuver (BPPV)

Answer 41

Treatment for dizziness

Question 42

Alteration when the vestibular sense, visual sense, and somatosensory sense are not congruent

Answer 42

Sea sickness/motion sickness

Question 43

Principle sx: nausea/vomiting Other sx: Dizziness, salvation, diaphoresis, and malaise. May look pale

Answer 43

Sea sickness/motion sickness

Question 44

Antihistamines like dimenhydrinate Anticholinergics like scopalamine both are SEDATING

Answer 44

Tx for sea sickness/motion sickness