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

Slides:



Advertisements
Similar presentations
LQTS Outline Background Identification Therapies Available
Advertisements

SYNCOPE Rasim Enar, M.D. Professor of Cardiology
بسم الله الرحمن الرحيم. PROBLEMS OF SPATIAL DISORIENTATION BY PROF. DR. MOHAMED SAAD.
Migraine and Dizziness
POTS Postural Orthostatic Tachycardia Syndrome Lorna Busmer Nurse Practitioner Rotherham.
Cardiac Stress Testing. What is a stress test? A progressive graded test that reproduces diagnostic, prognostic, and functional abnormalities in clients.
Neurologic Origins of Dizziness & Vertigo Clinical presentations of Dizziness or Vertigo that is of Neurologic Origin  Neurologically mediated dizziness.
As the World Turns: Vertigo in the Emergency Department.
W. Kissinger Tintinalli Sixth Edition Chapter 52
Referred for severe « dizzy spells » PRESENT ILLNESS: First episode March 1997 (1h) and June 1997 (2h45) Daily DIZZY SPELLS, completely incapacitating,
Benign Paroxysmal Positional Vertigo BPPV. Definition Of Vertigo Vertigo is an illusion of movement of the person itself or the environment Usually a.
Dizziness, Disequilibrium and Vertigo  There are three symptoms that are often refered to as dizziness by patients: dizziness, disequilibrium and vertigo.
Syncope AM Report 6/25/10 Nicole Wilde. Syncope  Cause Not Obvious Neurally Mediated (vasovagal) 58% Cardiac Disease (arrhythmias) 23% Neurologic or.
A practical approach to dizziness
Arrhythmia recognition and treatment
Palpitations Syncope Dysrrhythmias Hippocrates “Those who suffer from recurrent Fainting die suddenly”
Natalia Fernandez, PT, MS, MSc, CCS University of Michigan Health Care System Department of Physical Medicine and Rehabilitation.
Core Clinical Problems CHEST PAIN. Jane presents to her GP with chest pain What would you like to know?
The Heart By: Erin Sawyers. Anatomy Blood Flow Sinus Rhythm  Normal rhythm of a healthy heart  Set by Sinoatrial (SA) Node- natural pacemaker  Normal.
Your heart is a muscle that works continuously like a pump Each beat of your heart is set in motion by an electrical signal from within your heart muscle.
Chest Pain Mudher Al-khairalla.
An Approach to the Patient with Vertigo Cynthia Phelan PGY
“Doctor I feel Dizzy” AIMGP Seminar 2004 Yash Patel.
Principles of diagnsosis of ischemic heart disease Mohammad Hashemi Interventional cardiologist Department of cardiology.
Cardiology ECG Review for the ABIM. A 46-year-old woman is evaluated because of palpitations. Her 12-lead electrocardiogram, obtained while she is having.
Posterior Stroke and the H.I.N.T.S exam LMH Emergency Rounds Prepared by Shane Barclay.
Management of the Patient Presenting with Palpitation Samir Saba, MD Director, Cardiac Electrophysiology University of Pittsburgh.
Approach to dizzyness (vertigo) DR BANDAR AL-QAHTANI, MD KSMC,RIYADH.
Syncope J. Ned Pruitt II, MD Associate Professor of Neurology Medical College of Georgia.
SWOONING AND VAPORS Syncope and near syncope. Syncope accounts for 3% ER visits Syncope/pre-syncope symptoms are due to a reduction in cerebral perfusion,
Approach to Dizziness December 4, 2001 Swedish Family Medicine Dobrina Okorn, MD.
Cardiac stroke volume and sympathetic/parasympathetic measurements increase the sensitivity and specificity of HUTT in children and adolescents Mohammed.
The Dizzy Patient 4x4 Method
Syncope diagnostic algorithm and management MUDr. Jakub Honěk Kardiologická klinika, 2.LF UK a FN Motol, Praha.
SYNCOPE Prof JD Marx. DEFINITION Short transient episode of loss of consciousness.
F. Khorvash Assistant Professor Of Neurology.  Drop attacks are sudden spontaneous falls while standing or walking, followed by a very swift recovery,
晕 厥 -Syncope 浙江大学医学院附属第二医院 心内科 项美香. Definition Syncope is a T-LOC (transient loss of conscious) due to transient global cerebral hypo-perfusion characterized.
Syncope David Robertson February 9, Objectives Recognize and treat: –Severe orthostatic hypotension (AF) –Postural tachycardia syndrome (POTS) –Neurally.
Wolff-Parkinson-White Syndrome Liz Johnson, RN. Definition WPW syndrome is the presence of accessory pathways along with the normal conduction pathways.
Tachyarrhythmia, Cardioversion and Drugs. Learning outcomes At the end of this workshop you should: Be able to recognise types of tachyarrythmia, defined.
Ordering Echocardiograms for Syncope Cost Conscious Project Marvin Chang, PGY2.
ASSITANT PROFESSOR EAST MEDICAL WARD MAYO HOSPITAL,LAHORE
DOWNWARD SPIRAL Dizziness in Elders Presented by: Mary Sokolowski, BSN, RN.
Manifestations Of Cardiovasculardiseases
Electrocardiography – Abnormalities (Arrhythmias) 7
Basic Electrocardiography. Electrocardiogram ❖E❖ECG versus EKG ❖=❖= graphical recording of the electrical activity of the heart.
Dizziness Prof. H. Almuhaimed. Objective to be addressed: Difference between dizziness and vertigo. Difference between dizziness and vertigo. Treatment.
David Johnson Staff Specialist, Emergency Medicine
Vertigo Dr. Abdulrahman Alsanosi Associate professor Otolaryngology consultant Otologist, Neurotologist Head of Otology / Neurotology Unit Director of.
24hr ECG Interpretation 17 th September 2015 Trinity Park, Ipswich Andrew Chalk, Chief Cardiac Physiologist Jamie Williams, Senior Cardiac Physiologist.
DIZZNESS IN CHILDREN 林口長庚急診醫學部 : 吳孟書 醫師.
IN THE NAME OFGODIN THE NAME OFGOD SVTS.SAYAH.  All cardiac tachyarrhythmias are produced by: 1/disorders of impulse initiation :automatic 2/abnormalities.
THE HEART’S ELECTRICAL SYSTEM Marco Perez, MD Center for Inherited Cardiovascular Disease Inherited Cardiac Arrhythmia Clinic June 20, 2013.
ARRYTHMIAS IN THE YOUNG Dr Mark Earley, Consultant Cardiologist BMI The London Independent Hospital St Bartholomew’s Hospital.
Palpitations and Common Arrhythmias J. Philip Saul, M.D. West Virginia University Morgantown, WV.
Vestibulitis, Labrynthitis, Meniere’s Disease, and Tinnitis Case Study
By D. Nichelle Cashe.  A 20 yo female came into the Minute Clinic with c/o feeling poorly, ear fullness and dizziness.  Objects seem to be in motion.
Recurrent Syncope in Childhood 26/11/15. What is Syncope? Syncope is a temporary loss of consciousness resulting from a reversible disturbance of cerebral.
Emergency Medicine Junior Teaching Programme Aberdeen Royal Infirmary Adult Syncope Evaluation in the Emergency Department Jamie Cooper Teaching 4 th March.
Vertigo Dr. Thamara Gunasekera GPST3.
ECG Examples.
Assessing and treating tachyarrhythmias Workshop
SYNCOPE Prof JD Marx.
Bradycardias and Tachycardias
Vertigo Prof. Abdulrahman Alsanosi
Approach to dizzyness (vertigo)
Cardiology Consult Update
What is the most important etiology to rule out?
Syncope diagnostic algorithm and management
Evaluation of the Dizzy Patient
Presentation transcript:

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) Type IV: Light headedness (Plus non specific symptoms) (Hyperventilation)

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

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

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

a b c a b a b c a EPLEY’s manoeuver: ex. RIGHT EAR) (Right ear: rotation from right to left- Left ear: rotation from left to right 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.

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

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) Epley’s manoeuver: FAILURE?

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

FIRST STEP Type II: Presyncope « MER » M echanical: Aortic Stenosis - Left atrium Myxoma E lectric: bradycardia, tachycadia ( s upra. or Ventricular) AV block, prolonged sinus pauses... R eflex: vagal - «cardiac reflex» - micturition - etc.

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

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 Normal Heart Reflex Cardiac Sick Heart

Second Step: Type II Physical BP Lying - Standing: orthostatic hypotention Diminution BP 20 mmHg standing position Carotid sinus massage Aortic murmur Heart failure signs: – Increased jugular veins - pulmonary rales – S3(+) - Legs oedema

Second Step: Type II Electrocardiogram Sinus bradycardia (diagnostic if 3 seconds Bifascicular bundle branch block Second degree AV block (Mobitz I) Prolong QT (> 500 milliseconds) WPW Brugada’s syndrome Supraventricular or ventricular tachycardia Myocardial infarction (old or new)

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 »

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 Second Step: Type IV

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