Dizziness

1
Dizziness

• 4 is
• Central

Walter Himmel 2008
2
Dizziness

• 1.5 3 of ED visits ? dizziness
• 1 patient / shift is dizzy
• Im dizzy ? whats your approach

3
Dizziness - Syncope

• Syncope 1-3 ED visits
• Syncope 10 serious outcomes by 7 days
• ½ of these patients ?sent home
• (Quinn. Ann EM 2006)

4
Dizziness - Vertigo

• Isolated vertigo dizziness (gt 44 yr) ?
  3.2 CVA/TIA(Kevin. Stroke 2006)
• Isolated vertigo (50-75 yr) ? 25
  cerebellar stroke(Norrving. Acta Neurol Scand
  1995)

5
Dizziness Goals

• Approach to dizziness
• Approach to vertigo
• Approach to syncope
• Identify the life-threatening

6
Dizziness

• David Drachman - dizziness
• Daniel Drachman myasthenia gravis
• Drachman DA. An approach to the dizzy patient.
  Neurology 1972.

7
Dizziness 4 Types (Drachman)

• Vertigo
• Syncope
• Disequlibrium
• Other dizziness, non-specific light-headedness
• Patients a bit of all may be present
• One type predominates

8
64 yr Male

• 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 lt 1 min spinning (felt unwell
  afterwards)
• No other symptoms
• ?

9
64 yr Male

• Type of dizziness?
• Vertigo

10
Dizziness (4 types)

• Vertigo Syncope Disequilibrium
  Nonspecific
• Seconds
• Minutes
• Hours
• Days

11
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

12
Vertigo 4 types

• 2. Minutes
• TIA (BPV lt 60 seconds)
• Tumor
• Migraine up to 20 ? vertigo

13
Vertigo 4 types

• 3. Hours
• Peripheral Menieres, peripheral vestibulopathy
• Central Migraine, tumor, stroke, MS, concussion

14
Vertigo 4 types

• 4. Days
• Peripheral vestibular neuronits, labyrinthits
• Central stroke, MS, tumor, concussion

15
Vertigo Central or Peripheral

• Central
• 4 Ds Diplopia, Dysarthria, Dysphagia, Drop
  attack
• Crossed sensory/motor findings
• Ataxia
• Reduced vision
• Headache
• Memory Loss, Personality Change

16
Dizziness (4 )

• Vertigo (4) Syncope
  Disequilibrium Nonspecific
• 1. Seconds
• 2. Minutes
• 3. Hours
• 4. Days

Central
Peripheral
17
Nystagmus Central or Peripheral

• Peripheral
• Vertigo fatigues
• Nystagmus unidirectioal
• Horizontal/Vertical with a rotatory element
• Can walk usually
• No or minimal HA
• No paresis / sensory loss/confusion

• Central
• Vertigo persists
• Nystagmus multidirectional
• Purely vertical central
• Ataxia
• Headache more common
• Focal symptoms/findings

18
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?

19
The 4 Important Findings

• Watch them talk
• Watch them walk
• Look at the eyes ( pupils, nystagmus)
• Dix-Hallpike

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Dix-Halpike
ASC
ASC
ASC()
PSC
PSC()
PSC
21
Dix-Hallpike
22
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

23
64 yr Male Examination

• 2 min later Dix-Hallpike to right little
  happened
• 10 min later good findings again
• Dx
• BPV

24
Dizziness Syncope

• Jan 13, 2002- sitting on a couch- watching
  football- eating a pretzel ? dizzy ? passed out
  ? quick recovery- event syncope ?danger ?
  cardiac

25
Syncope

• Syndrome, not disease
• transient global cerebral hypoperfusion
• ? Cardiac, ?
• ?Neurological
• Life-threatening?

26
SyncopeNot 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?

27
SyncopeNot 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?

28
Mechanism of Sudden Death in Hypertrophic
Cardiomyopathy
ICD
Cardiac syncope 50 5 year mortality Six month
mortality gt 10
29
Syncope

• 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

30
Dizziness (4)

• Vertigo (4) Syncope (4)
  Disequilibrium Nonspecific
• 1. Seconds 1. Vasovagal
• 2. Minutes 2. Orthostatic
• 3. Hours 3. Heart and Brain
• 4. Days 4. Unknown

31
Syncope (4)

• Neurally- mediated (vasovagal) gt ¼
• Orthostatic lt ¼
• Heart and brain ¼
• Unknown ¼

32
Syncope

• Neurally- mediated (vasovagal) gt ¼
• (i) Vasovagal
• (iii) Event syncope
• (iii) Carotid sinus syncope

33
Syncope

• Orthostatic lt ¼
• (i) Volume depletion (dehydration, gi bleed)
• (ii) Drug side effects
• (iii) Autonomic dysfunction (DM, Parkinson's,
  deconditioning in the elderly)

34
Syncope- Identify These

• 3. Heart and brain ¼
• Heart 2/3
• Brain 1/3 - about 6 of syncope

2/3 arrythmia
1/3 structural
35
Syncope Summary

• 1. Neurally 2. Ortostatic
  3. Heart Brain 4. Unkown
• 1. VV 1. Volume 1.
  Ht rhythm
• 2. Event 2. Drugs
  2. Ht structural
• 3. Carotid Sinus 3. Auto Dys. 3. TIA

36
Dizzy

• 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)

37
Vasovagal?

• Exam normal
• Important examination findings?
• Murmur, rhythm
• Investigations
• Important investigations?
• ECG?
• Any other investigations?

38
ECG 14 year old
39
Delta wave
PR 102 (lt 120 msec)
QRS 112 (gt100)
ST-T wave changes
40
WPWThe EKG in the patient with syncope. AJEM
200725(6)688-701

• 0.15 (1.5/1000) to 3 incidence
• 2.4 of SVT in ED
• Arrhythmias
• PSVT 70
• A fib 25
• A flutter 5
• V fib rare

90 orthodromic 10 antidromic
41
Heart and Brain Syncope Counts

• Heart and brain ¼ of all syncope at most
• Heart 2/3
• Brain 1/3

Why worry?
42
Syncope and Death

• Syncope Hazard Ratio for
  Death
• All causes syncope HR 1.43
• Non cardiac HR
  1.17
• Unknown cause HR 1.36
• Neurologic cause HR 1.98
• Cardiac syncope HR 2.41

Elpidoforos S. NEJM 2002347878-885
43
Overall Survival of Participants with Syncope
5.
44
Cardiac Syncope

• gt 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

45
Brugada
RBB pattern V1-V3(often incomplete)
ST elevation V1-V3 (often minimal)
V. Tach ? V Fib
Patterns come and go
46
Brugada
RBB pattern V1-V3(often incomplete)
ST elevation V1-V3 (often minimal)
Coved (fin)
Saddle
Rx ICD
Mortality 10/yr
47
Long QT
48
HCM Classical
T waves may be inverted V4,5,6
49
31 yr woman presyncope, palpitations(Sept 22,
2007)

• 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?

50
Not Typical HOCM 31 yr old
51
Not Typical Happens- my patient
52
31 yr woman presyncope, palpitations(Sept 22,
2007)

• 2D-ECHO septum 15-18 mm
• Normal max 11 mm
• HCM!
• 1/500
• Death ? V Tach, obstruction, CHF (late)

53
76 yr Woman Profound Vertigo and Disequilibrium

• 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?

54
76 yr Woman Next Day

• 1800 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 2045

55
76 yr Woman Profound Vertigo and Disequilibrium

• 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

56
Profound Vertigo and Disequilibrium

• 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 ??

57
Profound Vertigo and Disequilibrium

• Walking impossible
• Sitting impossible thrown to left
• Lids opened by physician
• Vertigo worse
• Profound, persisting spontaneous nystagmus

58
Profound Vertigo and Disequilibrium

• Cerebellar testing
• Took encouragement
• Patient kept eyes closed
• F ? N / H ? S / RAM slow but not bad

59
Vertigo Cant Walk Central Features

• CT normal
• Numbness L face, R arm
• Latero-pulsion severe
• Severe ataxia
• Unable to fixate
• Persisting nystagmus
• Mild headache
• Would you admit?

60
MRI
Right vertebral artery occluded
61
Syncope Man
62
Syncope Man ?Do You Have Pain?
63
Syncope Man ?Do You Have Pain?
ICH/CVA
SAH
PE
MI
Dissection
DU
Aorta
Dissection
AAA
DU
GI Bleed
Dissection
GI Bleed
64
San Francisco Syncope Rules

• 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

65
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

66
San Francisco Syncope Rules5 Risk Factors

• Abnormal ECG
• Not sinus
• New changes since last ECG
• SOB as a complaint
• Hct lt 30
• SBP lt 90 at triage
• Hx CHF

67
San Francisco Syncope Rules
Any 1 high risk ? ?admit

• Any 1 of CHESS
• C hx of CHF
• H hematocrit lt 30
• E abnormal ECG
• S SBPlt 90
• S compliant of shortness of breath
• Serious outcomes 12 (7 days)
• Positive predictive value ? 15
• Negative predictive value ? 99.7

68
San Francisco Syncope Rules

• Study Bad Outcome Sensit Specif
• SF1 12 96 62
• (684 pat)
• (7 days)
• SF2 14 98 56
• (791)
• (30 days)

Any 1 high risk ? ?admit
69
San Francisco Derivation (684)Serious Outcomes
at 1 week 11.5 (79)

• Death 0.7 of all patients
• MI 4.9
• Arrythmia 4.4
• Structural Heart 0.7
• PE 0.7
• Sig hemorrhage 1.8
• Ectopic 0.2
• SAH 0.4
• Stroke Syndrome 0.4

70
San Francisco Syncope Rules

• 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

71
San Francisco Syncope Rules

• the rule can not and should not be strictly
  applied without judgmentrather, 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 20079174-175)

72
Summary

• 4 types of dizziness
• 4 vertigos
• 4 syncope
• Hx, Px, ECG, Hb
• CT ? rarely helpful
• Syncope tools limited value
• Clinical dominates