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DIZZINESS AND SYNCOPE

DIZZINESS AND SYNCOPE. « PAIN OR PLEASURE ». Jacques Bédard MD CSPQ FRCP (C). FIRST STEP IDENTIFY TYPE OF DIZZINESS. Type I: Vertigo (Vestibular - Central Nervous System). Type II: Presyncope (Cardiovascular ). Type III: Walking disequilibrium (Neuromuscular).

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DIZZINESS AND SYNCOPE

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  1. DIZZINESS AND SYNCOPE « PAIN OR PLEASURE » Jacques Bédard MD CSPQ FRCP (C)

  2. FIRST STEPIDENTIFY TYPE OF DIZZINESS TypeI: Vertigo (Vestibular - Central Nervous System) Type II: Presyncope (Cardiovascular) Type III: Walking disequilibrium (Neuromuscular) Type IV: Light headedness (Plus non specific symptoms) (Hyperventilation)

  3. SYMPTONS: Diplopia – Dysarthria Bilateral loss of vision SIGNS: Hemiparesis - hypoesthesia Ataxia Second step:Type I: Vertigo VESTIBULAR CENTRAL NERVOUS SYSTEM Nystagmus

  4. Third Step:Type I: Peripherical vestibular vertigo Other 0 0 Tinnitus Hearing ∆ Position Syndrome Labyrinthitis (Vest.N.) Recurrent neuronitis Meniere’s disease Positional vertigo Periodicity 0 + recurrent ++ recurrent +++ recurrent Duration 2 days-2 weeks 10 min - 20 hrs 10 min - 20hrs < 1 minute

  5. Dix Hallpike Positive “Objective”: Confirms the diagnosis “ Subjective”:Suggests the diagnosis Negative Does not rule out the diagnosis HISTORY is diagnostic

  6. EPLEY’s manoeuver:ex. RIGHT EAR) (Right ear: rotation from right to left- Left ear: rotation from left to right a a b a c b b a c First rotation of the HEAD of 90 degrees (B to C) and second rotation of the SHOULDERS of 90 degrees (C to D), keeping each position B - C - D during 1 1/2 minutes.

  7. POSITIONAL VERTIGO: Inform the Patient Day 1: Vertical position – sleeping, head elevated Normal activities afterward Recurrence rate: 15% (Mobile otolith) Recurrence Provoque vertigo in left -right decubitus (Identifies involved ear) Repeatposterior canal manoeuver (Patient himself) Horizontal canal?:specific manoeuver

  8. Epley’s manoeuver:FAILURE? 1)Wrong diagnosis 2)Wrong ear 3)Wrong position: cervical arthrosis - position “D” 4)Wrong “timing”:<1 1/2 min each position 5)Wrong canal: horizontal canal? (other manoeuver) “We shall never surrender!” (Churchill)

  9. Type II: Presyncope Presyncope = cardiovascular syncope Syncope Recovery • SystemSudden • Cardiovascular(90%) • Neuro(epilepsy) • Metabolic Onset Sudden Sudden Slow Slow Slow Slow

  10. FIRST STEPType II: Presyncope « MER » Mechanical: Aortic Stenosis - Left atrium Myxoma Electric: bradycardia, tachycadia (supra. orVentricular) AV block, prolonged sinus pauses... Reflex: vagal - «cardiac reflex» - micturition - etc.

  11. Second Step:Type II: Presyncope “Initial evaluation” • History(sens. 95% - spec. 45%) • Physical • ECG Specific diagnosis (75 %) Opinion Normal heart / Sick heart (REFLEX: 70%) (ELECTRIC: 70%)

  12. Past History - Medication Onset: Advanced age Position: Lying down Concomitant Symptoms: Chest pains Palpitations Past history Onset: Young age Position: Standing Activity: Micturition - cough - etc Stimulus: Pain - Discomfort Concomitant Symptoms: Nausea - Vomiting Yawning - Fatigue +++ Second Step:Type II History Sick Heart Normal Heart Reflex Cardiac

  13. Second Step:Type IIPhysical • BP Lying - Standing: orthostatic hypotention Diminution BP < 90 mmHg or change BP >20 mmHg standing position Carotid sinus massage • Aortic murmur • Heart failure signs: • Increased jugular veins - pulmonary rales • S3(+) - Legs oedema

  14. Second Step: Type IIElectrocardiogram • Sinus bradycardia (diagnostic if < 40) - sinus pause > 3 seconds • Bifascicular bundle branch block • Second degree AV block (Mobitz I) • Prolong QT (> 500 milliseconds) • WPWBrugada’s syndrome • Supraventricular or ventricular tachycardia • Myocardial infarction (old or new)

  15. Normal Heart Ambulatory Monitoring Carotid Sinus Massage Loop recorder Tilt table test Sick Heart Hospit - ambul. monitoring Echo - Treadmill Loop recorder EPS Third Step: Type II« SPECIFIC EVALUATION »

  16. Second Step: Type IV PROVOQUE PATIENT’S HYPERVENTILATION IDENTIFICATION by the patient of the cause of his symptoms “Break vicious circle” EXPLANATION of “respiratory alcalosis” RECOGNITION of controlling the symptoms by breath holding ELABORATION of strategies for stress management

  17. 1 STEP 2 STEP 3 STEP BPVDix Hallpike-Epley Meniere’s disease Labyrinthitis (vestibular neuronitis) Acoustic neurinoma Vascular - Inflammatory - Tumoral (CT - Magnetic resonnance) Vertigo (Vestibular - CNS) VESTIBULAR CNS (Focal sings - symptoms) Presyncope (Cardiovascular) INITIAL EVALUATION History - Physical - ECG DIAGNOSIS OR Normal heart - Sick heart (Réflex: 70%) (Electric: 70%) SPECIFIC EVALUATION Normal heart Sick heart Carotid sin. Massage Treadmill-Echo . Loop recorder Loop recorder Tilt table test EPS Disequilibrium (Neuromuscular) Physical Neurological - Locomotor Recognizes the cause of physical symptoms Lightheadedness ( Anxiety) HYPERVENTILATION

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