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. What do you mean by Dizzy?I feel off balance Everything is spinning I'm lightheaded
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1. Heartsink Patients Tilting towards a diagnosis
3. What do you mean by Dizzy?
I feel off balance
Everything is spinning
I’m lightheaded – I might faint
I’m just dizzy, Doc!
5. Dizziness Vertigo
Dysequilibrium
Lightheadedness - presyncope
Other
6. I feel off balance Sensiosomatic
Peripheral neuropathy
Proprioception
Visual
Multiple sensory deficits of Drachman & Hart
Drugs
Psychological
Anxiety / depression
Hyperventilation
7. Everything is spinning
8. Everything is spinning Peripheral vestibular problems
Benign paroxysmal positional vertigo BPPV
Meniere’s Disease
Central vestibular and CNS problems
Brainstem lesion
Stroke
MS
Acoustic neuroma
Cerebellar
Epileptic aura
9. Benign paroxysmal positional vertigo Symptoms
Episodic – especially marked early in the day
Vertigo on looking up, looking round, lying down & rolling over
Diagnostic test –
Dix-Hallpike test
Vertigo after brief latent period
Rotational nystagmus
Symptoms resolve in 20 – 30s
Less severe on repeat manoeuvre
10. Benign paroxysmal positional vertigo
Traditional therapy:
Brandt-Daroff exercises
Cawthorne-Cooksey exercises
Exciting therapy!
Epley maneouvre
21. Epley Manoeuvre
Movie
22. Benign paroxysmal positional vertigo Traditional therapy:
Brandt-Daroff exercises
Cawthorne-Cooksey exercises
25. I feel lightheaded - I might faint Cardiovascular
Arrhythmia – tachy/brady syndrome
Ischaemia
Aortic stenosis
HOCM
Postural hypotension
29. Postural hypotension Definition
Systolic BP drop of 20 mmHg
Diastolic BP drop of 10 mmHg
with symptoms
Prevalance
10% of elderly in the community
20 – 30% of elderly in institutions
Diagnosis
At least 5 minutes supine – establish basal reading
Standing BP + HR at T = 0, 30s & 60 s
30. Postural hypotension Hypovolaemia
Dehydration
Blood loss
Hyponatraemia
Drugs
Illness
Vomiting / diarrhoea
Addison’s Disease
31. Postural hypotension Drugs
Anti-hypertensives
Anti- PD
Anti- depressants
Anti-failure
Autonomic neuropathy
Diabetes
Alcohol
Neoplasm
Amyloid
Multiple system atrophy
32. Postural hypotension Investigations
FBC + U&E
Blood glucose
Plasma viscosity
PSA LFTs
Synacthen test
Autonomic nervous system function tests
35. Postural hypotension Exclude treatable causes – then:
Education
Raise bed head
Compression stockings
Increase salt intake
Fludrocortisone – 50 mcg nocte initially
Flurbiprofen
Desmopressin
Midodrine – oral alpha agonist
37. Presyncope/ syncope Vasovagal
Simple faint
Cough / micturation syncope
Neurocardiogenic syncope
Carotid sinus syndrome
Hypoglycaemia
Hyperventilation
38. Benign Vasovagal Syncope Commonest cause of syncope
Most frequently in 30 - 50 age group
Typical triggers - pain, fear, blood etc
Prodromal symptoms
Higher centres , including limbic system, involved
39. Neurocardiogenic Syncope Any age.
Slightly more common in males
No triggers
Onset may be abrupt
Often prodromal pallor, sweating or nausea
Injury may occur
Co-existing CVS disease rare
Syncope reproduced on a Tilt Table
41. Tilt Table Test Head-up tilt - 70 degrees
Two protocols:
Westminster protocol – 40 minutes unprovoked
Italian protocol – first 20 minutes unprovoked
then 400 mcg GTN administered
42. Tilt Table Test Typical cardiovascular response:
Increased vagal tone with heart rate slowing & hypotension
Vagal tone may be intense leading to cardiac standstill
Reproduction of patient’s syncopal symptoms
Symptoms rapidly relieved by removing the tilt
48. Presyncopal bradycardia
56. Aldini (1762 - 1834) described the alleviation of cardiac syncope through "galvanic energy" utilising animal and cadaver studies.
57. Neurocardiogenic Syncope Management:
Explanation
Salt replacement
Counter manoeuvres
62. Neurocardiogenic Syncope Management continued:
Drugs:
Beta blocker
Fludrocortisone
Midodrine
SSRI
Disopyramide
63. Carotid Sinus Syndrome Syncope precipitated by
Turning round 52%
Looking up 48%
Presentation
Prodromal symptoms - LOC 30%
LOC with no prodromal symptoms 30%
Drop Attacks - LOC but retrograde amnesia 20%
64. Carotid Sinus Syndrome Diagnosis
Carotid Sinus Massage - 5 seconds to right carotid, then left.
> 3 seconds asytole - cardio-inhibitory component
or systolic BP drop > 50 mmHg - vasodepressor component
Carotid Sinus Hypersensitivity
65. Carotid Sinus Syndrome Carotid Sinus Syndrome
Carotid Sinus Hypersensitivity + symptoms
68. Carotid Sinus Syndrome Carotid sinus sensitivity is enhanced by:
Digoxin
Beta blockers
Diltiazem
Alpha Methydopa
69. Carotid Sinus Syndrome Management
Stop drugs known to enhance carotid sinus sensitivity
Dual-chamber pacing abolishes cardio-inhibitory component
No effective treatment for vasodepressor component, but worth trying Fludrocortisone
71. Treatable causes for heartsink patients Benign paroxysmal positional vertigo
Hyperventilation syndrome
Neurocardiogenic syncope
Carotid sinus syndrome
72. Syncope Clinic Unexplained falls
Unexplained syncope
Intermittent dizziness
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