Syncope, Dizziness & Vertigo: Case Review

1. Amy Gutman MD ~ EMS Medical Director www.prehospitalmd@gmail.com / www.TEAEMS.com Syncope, Dizziness & Vertigo:Case Review

2. Objectives “The only difference between syncope & sudden death is that in one you wake up”. Engel GL. Ann Intern Med 1978 • “Weak & Dizzy” is a common complaint with both benign & lethal causes • Etiologies of dizziness & syncope • Connection of cardiovascular & neurovascular disorders • Assessment & management strategies

3. Prehospital Dizziness Protocol? • No specific “dizziness” or “syncope” protocols • Protocol(s) used depends upon cause & effect(s) of symptoms • A good history & physical exam provides diagnosis in most patients • Not the patients to test how good you are at obtaining refusals!

4. Case Presentation • 82 yo WF presents with CC of “dizziness”. States intermittent, but persistent & unpredictable moments of dizziness that “made her head spin”. During the episodes, patient would nearly pass out, c/o dizziness & lightheadedness with some “blurred” vision. No CP, SOB, palpitations, seizure, loss of consciousness. No trauma, recent illness or other complaints • Vitals & exam unremarkable by BLS crew. Patient initially did not want to be transported to the hospital but was convinced to get checked out. ALS crew called but unavailable • What is your differential diagnosis based upon this info?

5. Case Continued • History fairly unremarkable in otherwise healthy patient who recently started OTC antihistamines for sinus congestion • Vitals stable but patient had at least 3 more episodes on the way to the ED in which she would lean back in stretcher & become extremely dizzy • In ED, placed on a hallway bed. During her triage, while the RN had the patient on a monitor and was checking her pulse he noted the following:

6. Definitions • Syncope (Greek: sunkoptein / to cut short) • Sudden & self-limiting loss of consciousness with loss of postural tone & a spontaneous recovery. A symptom, not a diagnosis • Vertigo (Latin: vertere / to turn) • Sensation of dizziness or abnormal motion resulting from a disorder of the sense of balance • Dizzy • Having a whirling sensation with tendency to fall; bewildered or confused; producing giddiness

7. Challenges of Syncope & Dizziness • 50% with no specific causes • Significant cost & time to diagnose & manage • Unpredictability leads to negative impact on quality of life • Management specific to the cause / suspected cause(s); varies significantly in effectiveness

8. Dizziness & Syncope • Syncope, dizziness & vertigo are generally symptoms rather than diseases • Benign to fatal causes • Cardiac causes have highest mortality rates • >500,000 new patients annually • 70,000 have recurrent, infrequent, unexplained syncope • 3-6% ED visits annually • 2-10% hospital admissions

9. Associated Symptoms • Traumatic sequellae • Fever, signs of illness • Focal neurological symptoms • Prodromal or post-episodic • Palpitations / CP • SOB • Seizures • Nausea, Vomiting • Micturition • Loss of continence

10. Pathological Risk Factors • >2 associated with 10-20% incidence of death from neurovascular or cardiovascular causes within 1 year • CAD, CHF, arrhythmia • Chest pain • Abnormal ECG • Persistent orthostatic hypotension • Age >45yrs • Traumatic sequellae for any fall

11. Syncope Etiology

12. Syncope Etiology* Neurological Orthostatic Arrhythmia Structural Non-CV • Vasovagal • Carotid Sinus • Peripheral vestibular dysfunction • Brainstem lesion • Situational • Cough • Micturition • Meds • Autonomic Failure • Presyncope • Brady • Sick sinus • AV block • Tachy • VT • SVT • Long QT * 11% • Aortic Stenosis • HOCM • • PulmonaryHTN 14% 24% 4% 12% • Psychogenic • • Metabolic • Neurological Unknown Cause = 34% *DG Benditt, UM Cardiac Arrhythmia Center

13. Misdiagnosed or Associated with Dizziness • Migraine • Hypoxia • Hyperventilation • Somatization / Psychiatric • Intoxication • Seizures • Hypoglycemia • Sleep disorders / OSA • Subclaviansteal syndrome • Basilar artery migraine (syncope + headache) • Vertebrobasilarinsufficiency (syncope + vascular disease)

14. Syncope Diagnosis History & Physical Exam IncludingECG • ENT Evaluation • Sinus CT • Otolith evaluation • Hearing exam • Metabolic • Laboratory • Cardiovascular • Ambulatory • Tilt Table • Echocardiogram • EPS • Angiogram • Stress Testing • Neurological Testing • Head CT / MRI / MRA • Carotid Doppler • EEG Psychological Evaluation

15. SAMPLE History & OPQRST Assessment • SSX: • Associated symptoms • Sequelae • Allergies: • +/- & what is the reaction • Medications: • Include OTCs & topicals • PMH: • Cardiovascular, neurovascular diseases, migraine, prior similar episodes • Last Oral Intake: • Events • Onset & Duration • Provocation or Palliation • Position • Medications • Temperature • Quality • Region &Radiation • Severity • Loss of consciousness • Time • Time of day, duration of event History & physical exam leads to cause identification in nearly half of patients

16. Family History • Sudden death • Deafness • Arrhythmias • Congenital heart disease • Heart attack or CVA at young age • Seizures • Metabolic disorders

17. Physical Exam • Serial vitals • Focus on cardiac & neurologic exams • Stroke scale • Glucose • Monitor / ECG • If syncope + fall, presume a spinal injury present until proven otherwise

18. Stroke Scales

19. Vasovagal Episodes after pain, fear, excitation, exertion; standing w/ locked knees “i.e. “at attention” Situational Micturition, cough, swallowing Neuralgic or Migranous Facial Pain or headache Carotid Sinus Head rotation or pressure on carotid sinus TIA / CVA Focal neurological symptoms that persist (CVA) or resolve within 1-72 hours (TIA); positive stroke scale Subclavian Steal Post exercise Seizure Seizure activity, LOC >5 mins with post-ictal period Murmur Presence of heart murmur on exam or echocardiogram Arrhythmia Intermittent or persistent irregularity of rhythm or regularity Psychogenic Anxiety, hyperventilating, personal gain

20. Other Syndromes • Vertebral-Basilar Stroke • Diplopia, dysarthria, dysphagia, weakness, numbness • Meniere’s • Aural fullness, deafness, tinnitus • Brainstem evoked audiometry 95% sensitive for detecting acoustic neuromas • Multiple Sclerosis • Vertigo preceded by other neurologic dysfunction

21. Nonspecific Dizziness • Psychiatric disorders • Depression 25% • Anxiety or panic disorder 25% • Somatization • Alcohol / drug abuse • Personality disorder • Hyperventilation • Syncope & presyncope overlap • CAD, CHF, PE, dysrhythmias

22. Disequilibrium • Multisensory disorder • Peripheral neuropathy • Visual impairment • Musculoskeletal disorder interfering with gait • Vestibular disorder • Cervical spondylosis • Symptoms worsened with antidepressants & anticholinergics • May occur while sitting, driving or position change

23. Peripheral vs Central Vertigo (Vestibular Dysfunction) Peripheral vertigo causes Central vertigo causes Cerebellar infarction or hemorrhage Lateral medullary infarction (Wallenberg’s syndrome) Brainstem infarction or hemorrhage Multiple sclerosis Vertebrobasilarinsufficiency • Vestibular neuronitis • Labyrinthitis • Meniere’s syndrome • Head trauma • Drug-induced • Aminoglycosides, phenytoin, phenobarbital, carbamazepine, salicylates, quinine Central vertigo associated with poor outcomes while peripheral vertigo is often “benign”. Can have overlap in symptoms, therefore difficult to differentiate

24. Nystagmus: Characteristics Central origin Peripheral origin Horizontal, torsional Does not change direction with gaze change Diminished by fixation May fatigue (if elicited by head movement) • Vertical, horizontal or rotary • May change direction with gaze • Not diminished by fixation • Does not significantly worsen with head movement

25. Cerebellar Infarction Horner’s Syndrome: Ptosis, Miosis, Anhidrosis Cerebellar infarction Lateral Medullary Infarction: Wallenberg Syndrome Nystagmus +dizziness Nausea & vomiting Ataxia & ipsilateralasynergia No focal weakness or motor abnormality Hoarseness Horner’s syndrome Ipsilateralfacial analgesia; contralateral body analgesia • Nystagmus + dizziness • Nausea & vomiting • Ataxia & ipsilateralasynergia • No focal weakness or motor abnormality

26. Carotid or Vertebral Artery Dissection • Often spontaneous • Acute dizziness after neck trauma / manipulation • Presents with posterior circulatory infarction symptoms • MRA may reveal double-lumen, but full angiography has higher yield

27. Neurally-Mediated Reflex Syncope (NMS) • Neurally mediated reflex mechanism with cardioinhibitory (bradycardia) & vasodepressor (hypotension) components • Vasovagal syncope (VVS) • Carotid sinus syndrome (CSS) • Situational syncope • Loss of the normal balance between sympathetic & parasympathetic nervous system • Triggered by stretch & mechanoreceptors (carotid sinus, bladder, esophagus, respiratory tract) • Peripheral venous pooling causes sudden decreased venous return • Pallor, nausea, sweating, palpitations common

28. Carotid Sinus Syndrome (CSS) • Rare except in elderly • “Falls after losing balance” • Sensory nerves in carotid sinus walls respond to stimulation increasing afferent signals to brain stem • Reflexive increase in efferent vagal activity & decreased sympathetic tone results in bradycardia & vasodilation • Different syndrome than carotid sinus hypersensitivity, similar management

29. Other Forms of VVS • Drug-induced • Often from diuretics, vasodilators • Primary autonomic failure • Deconditioning, parkinsonism • Secondary autonomic failure • Diabetes +/- neuropathy, amyloidoisis • Alcohol • Orthostatic intolerance +/- neuropathy

30. Orthostatic Hypotension • Decline of >20mmHg SBP or 10mmHg DBP from supine to standing • Elderly vulnerabledue to decreased baroreceptor sensitivity, decreased cerebral blood flow, increased renal sodium wasting, decreased thirst response with aging • Peripheral sympathetic tone impairment due to diabetic neuropathy, anti-HTN medication

31. Radiologic Imaging • Non-contrast CT helps r/o acute hemorrhage (but not 100% accurate) • MRI more sensitive than CT for hypoxic injury or cerebellar & brain-stem infarctions • PET scan may improve diagnostic accuracy • CT angiography or MRA useful within 24 hours • Carotids often included in evaluation

32. Electroencephalogram (EEG) • Not 1st line testing • Differentiates syncope from seizures

33. Head - Tilt Test • Evaluates NMS predisposition • Specificity of negative test 90% • Nystagmus & vertigo with peripheral lesions whendiseased side turned downward • Peripheral nystagmus may fatigue with repeated maneuvers • Central lesions not significantly changed with position change • Symptoms of peripheral nystagmus dramatically worsened with head movement & tends to fatigue with repeated maneuvers

34. Dix Hallpike Diagnosis

35. Epley Maneuver Particle-Repositioning • Potential consequence is carotid occlusion / clot resulting in stroke

36. Cardiovascular Syncope • LOC often w/o prodrome • Significant injury risk • Structural heart disease is most important risk factor for predicting risk of death from syncope or dizziness • Acute MI / Ischemia • Hypertrophic cardiomyopathy • Aortic dissection • Pericarditis • Pericardial tamponade • Pulmonary embolus • Pulmonary HTN • Aortic stenosis • Atrial myxoma • Bradyarrhythmias • Tachyarrhythmias

37. 12 Lead EKG & Monitor • Normal or abnormal? • Normal “now” does not equal normal “always” • Fast or slow? • Pauses? • Pacemaker?

38. Ambulatory ECG • Holter • 24-48 hours • symptoms w/ arrhythmia (5%) v. symptoms without arrhythmia (17%) • External Loop Event Recorder • Weeks to months • Limited value in sudden LOC • Loop Recorder • Months • Implantable type more convenient • Provided diagnosis in 55% of pts with unexplained syncope compared to conventional methods

39. What’s My Rhythm? All Seen in Dizziness & Syncope From the files of DG Benditt, UM Cardiac Arrhythmia Center

40. So…Back to Our Patient

41. Bradyarrhythmic Syncope • Wide, weird & slow • Sinus brady • Symptomatic 1st degree HB • 3rd degree HB • Cause often correctible with medication adjustment • Indication for atrial pacemaker implantation • Ventricular pacing indicated in atrial fibrillation with slow ventricular response Bradycardia36% NSR58% Tachycardia 6%

42. Weird Bradyarrythmia:Idioventricular • Ventricles depolarizing on their own because of no atrial conduction • Rate between 20-40 • Rate of 60-120 (all PVCs) often called “Slow VT” • Diagnostic clue: no p waves or flipped p waves in all leads

43. Tachyarrhythmic Syncope • Wide, weird & fast or narrow & regular • Regular or irregular, intermittent or persistent • Cause often structural, ischemic & pathologic – not easily corrected with a simple medication change • Surgery (if related to stenosis or CAD) +/- ventricular pacing often indicated • Risk of sudden cardiac death

44. Atrial Fibrillation with Accessory Pathway Conduction Degenerating to VF

45. Premature Ventricular Complex (PVC) • AKA: • Ventricular extrasystole, premature beat, ectopic beat, premature depolarization • Occasional monomorphic PVCs common in normal hearts but also seen in the setting of heart disease • Polymorphic VT never normal • Ischemia, metabolic or structural disorders

46. QT Prolongation & R on T Phenomenon • QT widens to point when a PVC occurs early in the cardiac cycle falling on the apex of preceding T waveleading to VT or torsades • Antiarrhythmics • Class IA & III: Quinidine, Procainamide, Sotalol, Amiodarone • Psychoactive Agents • Phenothiazines, Amitriptyline, Imipramine, Ziprasidone • Antibiotics • Erythromycin, Pentamidine, Fluconazole • Antihistamines • Terfenadine, Astemizole • Others • Cisapride, Droperidol

47. VT vs VF Ventricular tachycardia Ventricular fibrillation Disorganized electrical signals cause ventricles to quiver ineffectively Rhythm: Irregular Rate: >250, disorganized QRS Duration: Unrecognizable P Wave: Not seen • Abnormal tissues in ventricles generating rapid &irregular rhythm • >3 PVCs in a row; can be sustained or unsustained • Rhythm: Regular • Rate: 150-250bpm • QRS Duration: Prolonged >120ms • P Wave: Not seen, often dissociated

48. VT Degenerating to VF

49. Case Conclusion • Patient emergently trans-thoracially paced in ED while receiving fluid boluses & amiodarone • Went to OR for permanent dual-chamber (atrial & ventricular) pacemaker • Patient’s antihistamines discontinued (unclear if contributed to symptoms) • Discharged home a few days later with no permanent sequellae

50. Pacemakers • Ventricular > atrial > dual chamber • Most pacemakers are “demand” type • EKG shows a “spike” when pacer fires • Beware the patient with a pacemaker, syncope / dizziness with no pacer spikes on EKG!