Syncope, Vertigo and Altered Mental Status (AMS)

Question 1

what is the presentation of increased arousal

Answer 1

hypervigilant, agitated

Question 2

what is the presentation of decreased arounsal

Answer 2

lethargic, stuporous, comatose

Question 3

what is the presentation of decreased cognition

Answer 3

confusion, amnesia, hallucinations, detachment from reality

Question 4

define hyper alter

Answer 4

increased arousal with increased sensitivity to surroundings

Question 5

define confused

Answer 5

disoriented, bewildered, difficulty following commands

Question 6

define delirous

Answer 6

disoriented, restless, hallucinating, may be delusional

acute onset - usually reversible

Question 7

defne somnolent

Answer 7

sleepy, response to stimuli with incoherent mumbles

Question 8

define lethargic

Answer 8

reduced level of alertness, decreased interest in surroundings

Question 9

define obtunded

Answer 9

like lethargy but more so. slowed response to stimulation, sleeps more than normal, drowsy between sleep episodes

Question 10

define stuprous

Answer 10

profoundly reduced alterness, requres continued novious stimuli for arousal

Question 11

define comatose

Answer 11

state of deep, unarousable, unconsciousness

Question 12

what is the presentation of dementia

Answer 12

slow onset, progressive, degenerative

Question 13

what is the presentation of psychosis

Answer 13

sudden onset, need to rule out organic causes

Question 14

what are the initial actions for AMS

Answer 14

look for reversible causes and address ASAP
Dextrose - POC glucose
Oxygen - pulse ox
Narcan - check pupils
Thiamine - ETOH?

Question 15

what is one of the first tests that are run on patients who present with AMS

Answer 15

CT head

Question 16

what is the vestibular system

Answer 16

complex arrangement of bones and cartilage in the ear, network of semicircular canals filled with fluid. fluid position changes with movement, sensor in ears sends info to brain to contribute to balance

Question 17

what underlying conditions can cause problems with the vestibular system that lead to balance issues

Answer 17

medications
infections
inner ear problems - such as circulation
calcium debris in semicircular canals
central problems in brain, e.g. TBI

Question 18

what is the diagnostic approach to virtigo and dizziness complaints

Answer 18

TiTrATE

Timing of symptoms
Triggers that provoke symptoms
And a
Targeted
Evaluation

Question 19

what are the three main categories of vertigo

Answer 19

triggered episodic vertigo
spontaneous episodic vertigo
continuous vestibular vertigo

Question 20

what is triggered episodic vertigo

Answer 20

brief episodes lasting seconds to hours, intermittent
triggered by head or body movement or position change

Question 21

what is spontaneous episodic vertigo

Answer 21

last seconds to days - no triggers

Question 22

what is continuous vestibular vertigo

Answer 22

lasting days to week - need to ask about hearing loss

Question 23

what can trigger ‘triggered episodic vertigo’

Answer 23

BPPV (benign paroxysmal positional vertigo)
Orthostatic hypotension

Question 24

what is BPPV

Answer 24

benign paroxysmal positional vertigo - displaced canaliths in semicircular canals
most commonly occurs between 50-70 yo, no known cause in older people
can occur with head trauma in younger people
usually <1minute
often with rolling over in bed, always with change in head position

Question 25

what is orthostatic hypotension

Answer 25

change in vitals with change from supine to standing for one minute SBP down 20mmHg, DBP down 10mmHg, HR up 30 bpm

Question 26

what conditions cause spontaneous episodic vertigo

Answer 26

Meniere's disease and vestibular migraine

Question 27

what is Meniere's disease

Answer 27

with low frequency hearing loss, often unilateral associated with pain, pressure and/or fullness in affected ear hearing usually improves between attacks but can become permanent

Question 28

what is the treatment of Meniere's disease

Answer 28

diuretics, sodium restriction are initial treatments

Question 29

what is Dix Hallpike Maneuver used for

Answer 29

determining which type of triggered episodic vertigo a patient has based on the direction of their nystagmus

Question 30

what is epley maneuvers used for

Answer 30

therapeutic of for BPPV

Question 31

what is vestibular migraine

Answer 31

common, under-diagnosed, +/- headache duration of vertigo from minutes to hours (can be longer) motion sensitivity, and sensitive to visual motion (like movies) may also have photophobia, phonophobia and visual aura

Question 32

what is the treatment of vestibular migraine

Answer 32

migraine meds and anti-emetics

Question 33

what is continuous vestibular vertigo

Answer 33

not positional, continues regardless of head motion hearing is intact affect ages 30-50, possible viral trigger acute onset

Question 34

what is psychosomatic and functional dizziness

Answer 34

can be manifestation of depression, anxiety or panic disorder need to also consider that anxiety can result from vestibular disorders persistent postural-perceptual dizziness (PPPD)

Question 35

what is the treatment for psychosomatic and functional dizziness

Answer 35

SSRI, SBT, vestibular rehabilitation. avoid vestibular suppressants

Question 36

what is pre-syncopal dizziness due to

Answer 36

brain hypo-perfusion (often due to low BP)

Question 37

what is the pre-syncopal prodrome

Answer 37

poor hearing, feeling warm/cold, pallor, diaphoresis, abdominal pain, palpitations, hearing strange sounds, weakness, blurred vision, feeling "faint"

Question 38

what is syncope

Answer 38

loss of consciousness and muscle strength

Question 39

what are the most common causes of syncope

Answer 39

neurocardiogenic syncope reflex syncope vasovagal syncope

Question 40

what is cardiogenic syncope

Answer 40

life threatening most commmon cause is arrhythmia - also ichemia, valvular abnormalities often occurs without a prodrome

Question 41

what are the risk factors for cardiogenic syncope

Answer 41

FH of sudden cardiac death or MI (esp younger than 50yo) cardiac disease cardiac symptomatology

Question 42

what are differential diagnoses for syncope

Answer 42

seizure stroke trauma/head injury sleep disturbance