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The Magic of Spells John E Morley St Louis University St Louis VAMC Hypoglycemia Hypoxemia Hypocalcemic tetany Alkalotic tetany Acidosis Hypercapnia Low carbon dioxide (hyperventilation) SPELLS Syncope Seizures Dizziness Psychiatric Metabolic Pulmonary embolus CVA Drop attack

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the magic of spells

The Magic of Spells

John E Morley

St Louis University

St Louis VAMC

spells

Hypoglycemia

Hypoxemia

Hypocalcemic tetany

Alkalotic tetany

Acidosis

Hypercapnia

Low carbon dioxide

(hyperventilation)

SPELLS
  • Syncope
  • Seizures
  • Dizziness
  • Psychiatric
  • Metabolic
  • Pulmonary embolus
  • CVA
  • Drop attack
  • Migraine
  • Narcolepsy
slide4

“Those who suffer from frequent and strong faints

Without any manifest cause die suddenly”

Hippocrates (460 – 375 BC)

“Ubi pulsus sit rarus semper

expectanda est syncope”

Geronimo Mercuriale

(1530 – 1606)

syncope
Vasovagal

Carotid sinus hypersensitivity

Cardiac

Dehydration

Anemia

Vasodilatation

Autonomic dysfunction

Drug induced

Syncope
mechanisms of syncope
Mechanisms of Syncope
  • Sudden failure of the heart as a pump – “cardiogenic syncope”
  • Sudden reduction of ‘venous return’ – “orthostatic syncope”
  • Sudden abnormal

distribution of cardiac

output – “inappropriate

arterial vasodilatation”

  • Chronic arterial disease – “atherosclerosis”
cardiogenic syncope
Cardiogenic Syncope
  • Tachycardia
  • Bradycardia
  • Asystole
  • Prolonged QT
  • Myxoma
  • Hypertrophic Obstructive Cardiac Myopathy
brugada syndrome brugada brugada j am coll cardiol 1992 20 1391 1396
Brugada SyndromeBrugada & Brugada J Am Coll Cardiol 1992;20:1391-1396
  • Right bundle branch block
  • ST segment elevation in V1 to V3
  • Propensity to develop

sustained ventricular

arrhythmias

work up for cardiac syncope
Work-up for Cardiac Syncope

Greatest utility in

older patient

Do not do if:

Carotid bruit

Recent MI

Recent stroke

History of ventricular

tachycardia

POSITIVE: asystole >3 secs

  • Carotid sinus massage
  • Cardiac Enzymes
  • Echocardiogram
  • Stress test
  • Long term ambulatory loop electrocardiography
  • Tilt table
treatment of orthostasis
Treatment of Orthostasis
  • Eliminate medications
  • Increase salt
  • Elevate head of bed
  • Bedside commode
  • Avoid hot showers
  • Get up slowly
  • Orthostatic training
  • Jobst stockings
  • Two cups of coffee in morning
treatment of orthostasis11
Treatment ofOrthostasis
  • Midodrine (alpha-1 adrenergic antagonist)
  • Motrin
  • Fludrocortisone
  • Erythropoetin
  • 3,4 Dl-threo-diphenoxyphenylserine

(DOPS)

orthostatic syncope
Orthostatic Syncope

Drugs

Neuropathy

Varicose veins

Jacuzzi syncope

  • Venous pooling >20% on standing
  • Excessive loss of water or blood
  • Failed venoconstriction
  • Increased pressure in

chest or abdomen

Valsalva manevure

Weight Lifting

Trumpet blowing

Tussive syncope

Micturition syncope

Deglutition syncope

valsalva manoevure
Valsalva Manoevure

R-R interval < 1.2

Diagnostic of

autonomic neuropathy

inappropriate arterial vasodilatation
Inappropriate arterial vasodilatation

EXERCISE SYNCOPE :

Expansion of arteries to muscle

Compression of veins

Diversion of blood from other organs

STRESS “fright” SYNDROME :

Muscular arterial vasodilatation

“playing dead”

postprandial hypotension big mac attack
POSTPRANDIAL HYPOTENSION(“BIG MAC ATTACK”)
  • VARIABLE
  • MORE COMMON IN AM
  • PREVALENCE 26%
  • falls

syncope

stroke

myocardial infarction

death

  • STIMULATED BY

CARBOHYDRATE

  • DUE TO CGRP RELEASE
postprandial hypotension predicts all cause mortality in nursing home residents age 65yr

1.00

0.75

0.50

0.25

0.00

0

20

40

60

Postprandial hypotension predicts all-cause mortality in nursing home residents age >65yr

 10 mmHg

 11 - 19 mmHg

≥20 mmHg

Probability of

survival

P=0.009

Months

(n=179)

(Fisher et al 2005)

effects of meal composition on postprandial blood pressure
Effects of meal composition on postprandial blood pressure

Glucose

Fat

Protein

Water

P<0.001

Mean arterial

blood pressure

(mmHg)

Time (min)

n=10 hypertensive elderly subjects

Jansen et al (1990)

effect of octreotide on the blood pressure response to oral glucose 75g
Effect of octreotide on the blood pressure response to oral glucose (75g)

P<0.05

octreotide

(50µg s.c.)

mean arterial

blood pressure

(mmHg)

placebo

Time (min)

n=10 hypertensive older subjects

Jansen et al (1989)

slide19

Anorexia

Delayed Gastric

Emptying

Inhibits hepatic

glucose production

GLUCAGON-LIKE PEPTIDE

Stimulates insulin

Decreases glucagon

GLP-1 levels are reduced in diabetes

slide20

Effect of acarbose (100mg) on GIP and GLP-1

GIP

GLP-1

control

acarbose

pmol/L

pmol/L

*

*P<0.001

*P<0.004

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

Time (min)

n=8 healthy older subjects

Gentilcore et al (2005)

slide21

Effect of acarbose on blood pressure and heart rate

Systolic BP

Heart rate

control

acarbose

mmHg

BPM

P<0.0001

P<0.05

Time (min)

n=8 healthy elderly subjects

Gentilcore et al (2005)

slide22

***

****

***

*****

EFFECT OF MIGLITOL

Lee et al Diab Ob & Metab 4:329, 2002

Glucagon-Like Peptide

Satiety

Satiety (cm)

Glucagon – Like Peptide – 1 (GLP-1)(pmol/L)

Time (minutes)

Test + Treatment

Meal

Time (hour)

post prandial hypotension treatment
Post Prandial hypotension Treatment
  • Coffee in am
  • Small meals
  • Decrease carbohydrate
  • Fiber with meal
  • Alpha-1 glucosidase inhibitors
  • Octreotide (somatostatin)
slide24

Of Black Swans

And Zebras

systemic mastocytosis
Systemic Mastocytosis
  • Increased gastric acid
  • Diarrhea
  • Dermatographia
  • Urticaria pigmentosum
  • Syncope
  • Diagnostic test : Tryptase
addison s disease
Addison’s Disease
  • Orthostasis
  • Weight loss
  • Abdominal symptoms
  • Increased K
  • Decreased Na
  • Eosinophillia
eagle syndrome elongated styloid process
Eagle Syndrome(Elongated Styloid Process)
  • I. Pharyngeal pain
  • II. Carotid artery syndrome

Carotodynia

Headaches

Tinnitus

Monocular blindness

Syncope

other zebras
Other Zebras
  • VIPoma (Verner-Morrison Syndrome)
  • Swallowing (Hiatal hernia and achlasia)
  • Vagal paraganglioma
  • Paraplegic induced cerebral syncope
  • Giant Cell Arteritis
incidence of epilepsy
Incidence of Epilepsy

1.7 years

to diagnosis

complex partial seizures
Complex Partial Seizures
  • Ecstasy
  • Anguish
  • Convulsions

Fyodor Dostoyevski

(1821 – 1881)

complex partial seizures33
Complex Partial Seizures

HALLUCINATIONSVisual

Auditory

Olfactory

TEMPORAL

Memory

Dreamy State

Affective

Déjà vu

Fear

PSYCHOMOTOR

Dysphasia

Chewing

Undoing clothes

seizures laboratory
Seizures : Laboratory
  • Prolactin increased at 20 min and decreased at 60 min; 90% in generalized motor seizures and 70 % in partial complex seizures
  • CPK (MM) elevated by 24 hours in 10% motor seizures
  • Elevated lactate in first hour
dizziness vertigo

Dizziness (vertigo)

“ the external world seems to revolve around the individual or in which the individual seems to revolve in space ”

causes of dizziness
Causes of dizziness
  • Acoustic neuroma
  • Arteriosclerosis
  • Benign Paroxysmal Positional Vertigo
  • Meniere’s Disease
  • Labyrinthitis
  • Vestibular neuronitis
  • Ototoxicity
  • Osteoarthritis
benign paroxymal positional vertigo
Benign Paroxymal Positional Vertigo
  • 20% of all cases
  • Fifth to seventh decades
  • Bilateral in 10%
  • Associated with head trauma, vestibular neuritis and Meniere’s disease
slide40
BPPV
  • 1921 Barany – positioning vertigo
  • 1952 Dix & Hallpike
  • 1969 Schuknecht

- culpolithiasis

  • 1979 Hall, Ruby

& McClure

– canalithiasis

menieres s disease a condition in which the inner ear cannot drain endolymph
Menieres’s Disease :A condition in which the inner ear cannot drain endolymph
  • Fluctuations in sensorineural hearing
  • Episodes of dizziness
  • Tinnitis
  • A feeling of pressure in the ear
meniere s disease
Meniere’s Disease
  • Hydrochlorthiazide and low salt diet
  • Vestibular suppressants
  • Surgery:

Endolymphatic Sac Surgery

Vestibular Nerve Sectioning

Labyrinthectomy

Gentamicin

Chemical Labyrinthectomy

vestibular supressants
Vestibular Supressants
  • Antihistamines – diphenhydramine
  • Piperazine derivatives – meclizine
  • Phenothiazine – promethazine
  • Anticholinergic – scopolamine
  • Butyrophenone – droperidol
  • Benzodiazepines – lorazepam
  • Robinul Fort - glycopyrolate
superior semicircular canal dehiscence
Superior Semicircular Canal Dehiscence
  • Described by Minor in 1998
  • Incidence 0.4% to 1.5%
  • Chronic Dysequilibrium, Noise evoked, Pressure evoked (nose blowing), Gaze evoked
  • Vertical and torsional nystagmus
  • CT shows superiot canal dehiscence in Poschi or stenver’s views
  • Visual evoked myogenic potential (lower threshold)
superior semicircular canal dehiscence treatment
Superior Semicircular Canal Dehiscence :TREATMENT
  • Avoid inciting stimuli
  • Pressure equalization tube
  • Surgical Repair (limited experience)
  • Counseling
exercise and dizziness
Exercise and Dizziness
  • Brandt-Daroff Habituation

Exercises

  • Semont (Liberatory)

Maneuver

  • Epley Maneuver
  • Gaze Stabilization Exercises
  • Crawthorne-Cooksey

Exercises

slide49

EXERCISES

and

DIZZINESS

slide50

Status Post Fall

is a

Delirium Equivalent

slide51

Causes of Delirium

FOLEY

Drugs

Emotional

Low O2 state

Infection

Retention (Urine or Feces)

Ictal

Underhydration, Undernutrition

Metabolic

Subdural

DELIRIUMS