Transcript Document 7410819

Dizziness
4 is
Central
Walter Himmel
2008
Dizziness
• 1.5 – 3% of ED visits  dizziness
• 1 patient / shift is dizzy
• “I’m dizzy … ”
 what’s your approach
Dizziness - Syncope
• Syncope: 1-3% ED visits
• Syncope: 10% serious outcomes by 7 days
• ½ of these patients sent home
(Quinn. Ann EM 2006)
Dizziness - Vertigo
• Isolated vertigo + dizziness (> 44 yr):
 3.2% CVA/TIA
(Kevin. Stroke 2006)
• Isolated vertigo (50-75 yr):
 25% cerebellar stroke
(Norrving. Acta Neurol Scand 1995)
Dizziness Goals
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Approach to dizziness
Approach to vertigo
Approach to syncope
Identify the life-threatening
Dizziness
• David Drachman - dizziness
• Daniel Drachman – myasthenia gravis
• Drachman DA. An approach to the dizzy
patient. Neurology 1972.
Dizziness: 4 Types (Drachman)
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2.
3.
4.
Vertigo
Syncope
Disequlibrium
Other dizziness, non-specific light-headedness
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Patients: a bit of all may be present
One type predominates
64 yr Male
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Complaint on chart “DIZZY”
CC : dizzy getting out of bed
Sat up, dizzy, spinning, nausea for 15 min
Tended to fall to right but could walk
3 further episode in next hour
Each episode < 1 min spinning (felt unwell afterwards)
No other symptoms
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64 yr Male
• Type of dizziness?
Vertigo
Dizziness (4 types)
Vertigo
1.
2.
3.
4.
Seconds
Minutes
Hours
Days
Syncope Disequilibrium Nonspecific
Vertigo: 4 types
Seconds:
• Benign positional vertigo
• Benign  delay 3-5 seconds + fatigues
• Benign  can walk, unidrectional nystagmus
• Central postional vertigo
• Central  no delay, does not fatigue
• Central  gait poor
nystagmus multidirectional
Vertigo: 4 types
2. Minutes:
• TIA (BPV < 60 seconds)
• Tumor
• Migraine: up to 20%  vertigo
Vertigo: 4 types
3. Hours:
• Peripheral: Meniere’s, peripheral
vestibulopathy
• Central: Migraine, tumor, stroke, MS,
concussion
Vertigo: 4 types
4. Days
• Peripheral: vestibular neuronits, labyrinthits
• Central: stroke, MS, tumor, concussion
Vertigo: Central or Peripheral
Central:
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4 D’s: Diplopia, Dysarthria, Dysphagia, Drop
attack
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Crossed sensory/motor findings
Ataxia
Reduced vision
Headache
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Memory Loss, Personality Change
Dizziness (4 )
Vertigo (4)
Syncope
1. Seconds
2. Minutes
3. Hours
4. Days
Peripheral Central
Disequilibrium Nonspecific
Nystagmus: Central or Peripheral
Peripheral
• Vertigo fatigues
• Nystagmus unidirectioal
• Horizontal/Vertical
with a rotatory element
Central
• Vertigo persists
• Nystagmus
multidirectional
• Purely vertical = central
• Can walk usually
• No or minimal HA
• No paresis / sensory
loss/confusion
• Ataxia
• Headache more common
• Focal symptoms/findings
64 yr Male - Examination
• O/E
• Alert, spoke clearly
• No focal findings at rest or if sitting up very
slowly
• Vertigo if got up fast or rolled over
• Able to walk and talk well
• No cerebellar signs
• Dx?
The 4 Important Findings
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Watch them talk
Watch them walk
Look at the eyes ( pupils, nystagmus)
Dix-Hallpike
ASC
PSC
ASC(*)
PSC(**)
Dix-Halpike
ASC
PSC
Dix-Hallpike
64 yr Male – Examination
• Dix-Hallpike to right:
- 5 second delay
- Vertigo and nystagmus – 30 sec
• Rotatory + vertical component
• Got up - massive nystagmus opposite
direction
• Retch, retch, vomit +++++
• Dix-Hallpike to left: slight dizzy
64 yr Male – Examination
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2 min later: Dix-Hallpike to right: little happened
10 min later: good findings again
Dx:
BPV
Dizziness: Syncope
Jan 13, 2002:
- sitting on a couch
- watching football
- eating a pretzel  dizzy  passed out  quick
recovery
- event syncope: ?danger ? cardiac
Syncope
• Syndrome, not disease
transient global cerebral hypoperfusion
• ? Cardiac, ?
• ?Neurological
• Life-threatening?
Syncope:
Not all vasovagal
Jan 13, 1992:
- formal dinner in Japan  passed out
- vomitted on the Prime Minister of Japan
- recent diagnosis of atrial fibrillation and hyerT4
-cardiac?
Life-threatening?
Syncope:
Not all
vasovagal
Hank
Gathers
1967-1990
• Syndrome, not disease
basketball: Loyola Marymount University
- Dec 9, 1989: collapsed (home game)  V Tach
- Beta blocker  he stopped it
 March 4, 1990  dunk shot (25-13)  VSA
- Autopsy: HOCM (1/500 – 1/1000)
(WPW 1.5/1000)
 Life-threatening?
Mechanism of Sudden Death in
Hypertrophic Cardiomyopathy
ICD
Cardiac syncope: 50% 5 year mortality
Six month mortality: > 10%
Syncope
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Loss of consciousness
Brief
Sudden
Loss of muscle tone
Rapid, spontaneous recovery
May feel weak for 1-2 hours
May have several “seizure-like jerks
Dizziness (4)
Vertigo (4)
1. Seconds
2. Minutes
3. Hours
4. Days
Syncope (4)
1. Vasovagal
2. Orthostatic
3. Heart and Brain
4. Unknown
Disequilibrium
Nonspecific
Syncope (4)
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2.
3.
4.
Neurally- mediated (vasovagal) > ¼
Orthostatic
<¼
Heart and brain
~ ¼
Unknown
~¼
Syncope
1. Neurally- mediated (vasovagal) > ¼
(i) Vasovagal
(iii) Event syncope
(iii) Carotid sinus syncope
Syncope
2. Orthostatic
<¼
(i) Volume depletion (dehydration, gi bleed)
(ii) Drug side effects
(iii) Autonomic dysfunction (DM, Parkinson's,
deconditioning in the elderly)
Syncope- Identify These
3. Heart and brain
~ ¼
2/3 arrythmia
Heart ~ 2/3
1/3 structural
Brain ~ 1/3
- about 6% of syncope
Syncope Summary
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Neurally
2. Ortostatic
3. Heart + Brain
1. VV
1. Volume
1. Ht rhythm
2. Event
2. Drugs
2. Ht structural
3. Carotid Sinus
3. Auto Dys.
3. TIA
4. Unkown
Dizzy
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June 13, 2007
14yr old
No breakfast, wrote exam
Later: standing at coke machine
Sip of pop  dizzy
Passed out 30 seconds
Well after 10 minutes
To ED (911)
Vasovagal?
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Exam normal
Important examination findings?
Murmur, rhythm
Investigations
Important investigations?
ECG?
Any other investigations?
ECG: 14 year old
PR: 102 (< 120 msec)
QRS 112 (>100)
Delta wave
ST-T wave changes
WPW
The EKG in the patient with syncope. AJEM 2007;25(6):688-701
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0.15% (1.5/1000) to 3% incidence
2.4 % of SVT in ED
Arrhythmias
90% orthodromic
PSVT: 70%
10% antidromic
A fib:
25%
A flutter: 5%
V fib:
rare
Heart and Brain Syncope Counts
Heart and brain
~ ¼ of all syncope at most
Heart ~ 2/3
Brain ~ 1/3
Why
worry?
Syncope and Death
Syncope:
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All causes syncope:
Non cardiac:
Unknown cause:
Neurologic cause:
Cardiac syncope:
Hazard Ratio for Death
HR 1.43
HR 1.17
HR 1.36
HR 1.98
HR 2.41
Elpidoforos S. NEJM 2002;347:878-885
Overall Survival of Participants with Syncope
2. Neurologic
3. Unknown
1. Cardiac
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4. Vasovagal
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Cardiac Syncope
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> 10% mortality first six months
10%-20%/yr after that
Aortic stenosis + syncope: 30-50% die/yr
Hints:
Hx (CAD, MI, CHF, family hx)
Exam: rhythm, murmur  always listen
ECG
RBB pattern V1-V3
(often incomplete)
ST elevation V1-V3
(often minimal)
Brugada
Patterns come and go
V. Tach  V Fib
RBB pattern V1-V3
(often incomplete)
ST elevation V1-V3
(often minimal)
Brugada
Coved (fin)
Mortality: ~ 10%/yr
Rx: ICD
Saddle
Long QT
HCM – Classical
T waves may be inverted V4,5,6
31 yr woman – presyncope, palpitations
(Sept 22, 2007)
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Palpitations, dizzy, presyncope
 with walking 1 min
Felt like she would pass out or die
2/6 SEM (insisted on going home)
ECG: very abnormal
Hx of abnormal 2D ECHO  stopped meds
Admit or send home?
Not Typical HOCM – 31 yr old
Not Typical Happens- my patient
31 yr woman – presyncope, palpitations
(Sept 22, 2007)
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2D-ECHO: septum 15-18 mm
Normal max = 11 mm
HCM!
1/500
Death  V Tach, obstruction, CHF (late)
76 yr Woman – Profound Vertigo
and Disequilibrium
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CC: Dizzy, Headache
PH: Cholesterol, BP, DM, Depression
Previous afternoon
5-6 minutes of staggering gait
Felt the world was moving
Needed help to get home
Felt better
Diagnosis?
76 yr Woman – Next Day
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18:00 on day of admission:
Sudden nausea and dizziness
Sense of intense movement
Unable to open her eyes
Unable to sit up: would be thrown to the left
Arrived by ambulance at 20:45
76 yr Woman – Profound Vertigo
and Disequilibrium
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Mild headache at back and top
Vague odd feeling left arm
Odd sense of numbness right side face
No diplopia, no dysarthria, no confusion, no drop
attack, no dysphagia, no focal weakness
Profound Vertigo and Disequilibrium
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O/E
Alert, refused to open eyes, refused to move
80 / min; 170/90
Speech normal
Probable numbness right side face
Profound lateropulsion to right
No reflex changes
Toes 
Profound Vertigo and Disequilibrium
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Walking impossible
Sitting impossible – thrown to left
Lids opened by physician
Vertigo worse
Profound, persisting spontaneous nystagmus
Profound Vertigo and Disequilibrium
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Cerebellar testing
Took encouragement
Patient kept eyes closed
F  N / H  S / RAM : slow but not bad
Vertigo + Can’t Walk + Central
Features
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CT normal
Numbness L face, R arm
Latero-pulsion severe
Severe ataxia
Unable to fixate
Persisting nystagmus
Mild headache
Would you admit?
MRI
Right vertebral artery occluded
Syncope Man
Syncope Man Do You Have Pain?
Head
Neck
Chest
Head
Chest
Abdomen
Melena
BP
Back
Syncope Man Do You Have Pain?
ICH/CVA
PE
Dissection MI
DU
Aorta
AAA
DU
Dissection
SAH
GI Bleed
Dissection
GI Bleed
San Francisco Syncope Rules
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Predict serious outcomes within 1 week
After syncopal episode
Serious outcomes 
Death, MI
Arrythmia, PE
CVA, SAH
Significant hemorrhage
Return to hospital for related event
San Francisco Syncope Rules
• Canadians are different
• Admission rates 
– USA / Italy: 50%-60%
– Canada / Australia: 30%
• Should reduce USA admissions by 10%
• Increase Canadian admissions by 10%
San Francisco Syncope Rules:
5 Risk Factors
• Abnormal ECG
– Not sinus
– New changes since last ECG
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SOB as a complaint
Hct < 30%
SBP < 90 at triage
Hx: CHF
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San Francisco Syncope Rules
Any 1 of “CHESS”
Any 1:
C: hx of CHF
high risk
H: hematocrit < 30%
E: abnormal ECG
 ?admit
S: SBP< 90
S: compliant of shortness of breath
Serious outcomes: 12% (7 days)
Positive predictive value  15%
Negative predictive value  99.7%
San Francisco Syncope Rules
Study
Bad Outcome
Sensit
Specif
SF#1
(684 pat)
(7 days)
12%
96%
62%
SF#2
(791)
(30 days)
14%
98%
56%
Any 1:
high risk
 ?admit
San Francisco Derivation (684)
Serious Outcomes at 1 week: 11.5% (79)
Death
MI
Arrythmia
Structural Heart
PE
Sig hemorrhage
Ectopic
SAH
Stroke Syndrome
0.7% of all patients
4.9%
4.4%
0.7%
0.7%
1.8%
0.2%
0.4%
0.4%
San Francisco Syncope Rules
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Use as a risk stratification tool
Part of the Hx and Px
Should not replace common sense
After initial assessment  then use SFSR
4% syncope patients with no CHESS
features
 still at risk of bad event at 1 week
San Francisco Syncope Rules
“… the rule can not and should not be ‘strictly’
applied without judgment;
rather, it should be used as a risk stratification tool
to augment physician judgment …..
It is unfortunate that the term ‘rule’ tends to imply
that it should be strictly enforced”
James Quinn (CJEM 2007;9:174-175)
Summary
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4 types of dizziness
4 vertigo’s
4 syncope
Hx, Px, ECG, Hb
CT  rarely helpful
Syncope tools limited value
Clinical dominates