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Amy Gutman MD ~ EMS Medical Director www.prehospitalmd@gmail.com / www.TEAEMS.com. Syncope, Dizziness & Vertigo: Case Review. Objectives. “ The only difference between syncope & sudden death is that in one you wake up ”. Engel GL. Ann Intern Med 1978.

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objectives
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
prehospital dizziness protocol
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!
case presentation
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?
case continued
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:
definitions
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
challenges of syncope dizziness
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
dizziness syncope
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
associated symptoms
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
pathological risk factors
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
syncope etiology1
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

misdiagnosed or associated with dizziness
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)
syncope diagnosis
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

sample history opqrst assessment
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

family history
Family History
  • Sudden death
  • Deafness
  • Arrhythmias
  • Congenital heart disease
  • Heart attack or CVA at young age
  • Seizures
  • Metabolic disorders
physical exam
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
slide19

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

other syndromes
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
nonspecific dizziness
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
disequilibrium
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
peripheral vs central vertigo vestibular dysfunction
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

nystagmus characteristics
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
cerebellar infarction
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
carotid or vertebral artery dissection
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
neurally mediated reflex syncope nms
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
carotid sinus syndrome css
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
other forms of vvs
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
orthostatic hypotension
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
radiologic imaging
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
electroencephalogram eeg
Electroencephalogram (EEG)
  • Not 1st line testing
  • Differentiates syncope from seizures
head tilt test
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
epley maneuver particle repositioning
Epley Maneuver Particle-Repositioning
  • Potential consequence is carotid occlusion / clot resulting in stroke
cardiovascular syncope
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
12 lead ekg monitor
12 Lead EKG & Monitor
  • Normal or abnormal?
      • Normal “now” does not equal normal “always”
  • Fast or slow?
  • Pauses?
  • Pacemaker?
ambulatory ecg
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
what s my rhythm all seen in dizziness syncope
What’s My Rhythm? All Seen in Dizziness & Syncope

From the files of DG Benditt, UM Cardiac Arrhythmia Center

bradyarrhythmic syncope
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%

weird bradyarrythmia idioventricular
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
tachyarrhythmic syncope
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
premature ventricular complex pvc
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
qt prolongation r on t phenomenon
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
vt vs vf
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
case conclusion
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
pacemakers
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!
cv related management
CV-Related Management
  • Recognize symptoms & avoid provocation
    • Avoid alcohol, lack of sleep, environmental stressors
    • Adequate hydration & food intake
    • Avoid drugs that lead to hypotension
    • Avoid activities that precipitate syncope
  • Preventing LOC or Injury
    • Supine position upon onset of prodrome
    • Avoid driving or other activities that could lead to injury
  • Cardiovascular / neurovascular interventions
    • Routine follow-up
    • Take prescribed medications as prescribed!
r eferences
References
  • Dubin’s Guide to EKGs.
  • Images: Wikipedia, Google, Bing searches.
  • www.UpToDate.com. “Dizziness”, “Syncope”, “Ventricular Tachyarrythmias”. 2013.
  • D. Okorn MD. “Approach to Dizziness”. Swedish Family Medicine. Dec 2009
  • G. Bergey MD. “Acute Dizziness & Vertigo: Diagnosis, Assessment and Management”. 2001
  • M. Lehmann MD. “Tacchyarrythmias”. 2010
  • E. Veiga, M.D, 2008
  • WN Kapoor. Syncope. NEJM 2000; 343: 1856-62
  • Freeman, R. “Neurogenic Orthostatic Hypotension” NEJM 2008; 358: 615-624
  • Soteriades, et al. Incidence and Diagnosis of Syncope. NEJM 2002; 347:878-885
  • Grubb, B. Neurocardiogenic Syncope. NEJM 2005; 1004-1010
  • DG Benditt. “Syncope - A Diagnostic & Treatment Strategy”. Royal Brompton Hospital, London, UK
  • KapoorW, Med. 1990;69:160-175
  • JJ Blanc, et al. EurHeart J, 2002; 23: 815-820
  • WN Kapoor. “Evaluation and outcome of patients with syncope”. Medicine 1990;69:160-175
summary prehospitalmd@gmail com www teaems com
Summaryprehospitalmd@gmail.com / www.TEAEMS.com
  • History & exam important in providing or eliminating a diagnosis
  • Most causes benign & self-limited but almost impossible to make a prehospital diagnosis
  • Serious causes suspected by abnormal CV or neuro exam
  • Recognize stroke syndromes that may present with dizziness as a prominent feature