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

VESTIBULAR CENTRAL NERVOUS SYSTEM

Nystagmus

Third Step:Type I: Peripherical vestibular vertigoPeripherical vestibular vertigo

Syndrome

Labyrinthitis (Vest.N.)

Recurrent neuronitis

Meniere’s disease

Positional vertigo

Periodicity

0

+ recurrent

++ recurrent

+++ recurrent

Other

0

0

Tinnitus

Hearing

∆ Position< 1 minute

10 min - 20hrs

10 min - 20 hrs

2 days-2 weeks

Duration

“Objective”: Confirms the diagnosis

“ Subjective”: Suggests the diagnosis

Does not not rule out the diagnosis

Dix Hallpike

Positive

Negative

HISTORY is diagnostic

a

b

c

a

b

a

bc

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 elevatedNormal 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

Slow

Recovery

Sudden

Slow

Slow

FIRST STEPType II: Presyncope

« MER »

Mechanical: Aortic Stenosis - Left atrium Myxoma

Electric: bradycardia, tachycadia (supra. or Ventricular)

AV block, prolonged sinus pauses...

Reflex: 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

HistoryNormal Heart

Reflex Cardiac

Sick Heart

Second Step: Type II

Physical

• BP Lying - Standing: orthostatic hypotention

Diminution BP < 90 mmHg or change 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 < 40) - sinus pause > 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 EVALUATIONHistory - Physical - ECG

DIAGNOSISOR

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 recorderTilt 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