Transcript Document
Dizziness University of New England Physician Assistant Program 27 AUG 2009 Jeffrey T. Reisert, DO Dizziness 1 7/17/2015 Contact Information Jeffrey T. Reisert, DO Tenney Mountain Internal Medicine 251 Mayhew Turnpike Plymouth, NH 03264-3026 603-536-6355 (office) 603-536-6356 (fax) [email protected] Dizziness 2 7/17/2015 Agenda Definitions Faintness Spinning Other Syndromes Dizziness 3 7/17/2015 Multiple sensations Lightheadedness/Faint/Presynope – Feel like going to pass out Spinning/Vertigo – Sensation of abnormal movement Other – Hyperventilation – Hyperglycemia – Depression Syncope – Loss of consciousness – Covered only briefly today-Often a topic under cardiology Dizziness 4 7/17/2015 Dizziness Harrison’s textbook of IM refers to as having disturbed ambulation Dizziness 5 7/17/2015 Other associated symptoms Changes in vision Orthostasis Just about anything else Dizziness 6 7/17/2015 Orthostasis AKA orthostatic hypotension Change in blood pressure and cerebral blood flow due to transient low blood pressure – Alteration in normal response to standing – Often occurs with aging due to loss of vasoconstriction (With standing, blood falls to feet, and you get dizzy or pass out) Dizziness 7 7/17/2015 Orthostasis Several definitions – Lie for 10 minutes, stand for at least 2 minutes though response in worst case may last 10 minutes – Fall in systolic BP >20mmHg – Fall in diastolic BP >10 mmHg – Increase in heart rate 10-25 beats per minute – Symptoms of cerebral hypoperfusion (dizzy) – 24% of old people have this! Dizziness 8 7/17/2015 Orthostasis Iatrogenic (done by med prof.) is common form – Blood pressure meds May use mineralcorticoids to treat – Cause fluid retention – Hydrocortisone Dizziness 9 7/17/2015 Fainting Loss of buffers to remain conscious What comes before syncope referred to as prodrome Dizziness 10 7/17/2015 Syncope Large differential Cardiac syncope – Later slide Neurological Simply fainting – Probably the most common – Anxiety – Stress Let history guide you-next slide Dizziness 11 7/17/2015 Syncope-guided by history History of heart disease – ?CardiomyopathyThink arrhythmia Medications – Anti-hypertensives – All medications???? (Read labels….Ugh!) Seizure-Could they have had one? – Loss of bowel/bladder control – Bite tongue – Note many with true syncope have shaking as part of syndrome – More to be covered under seizure talk Dizziness 12 7/17/2015 Syncope-Cardiac causes Arrythmia/dysrrhythmia Heart block – May require pacemaker Aortic stenosis (severe) Also think meds (orthostasis) Dizziness 13 7/17/2015 Vertigo Impaired vestibular system May be due to disturbance of inner ear Altered head position in space, via alteration of CN VIII Dizziness 14 7/17/2015 Normal balance maintenance Visual input Somatosensory input – – – – Skin Joints Muscles Spinal cord Cerebellum Cerebrum Dizziness 15 7/17/2015 Nystagmus Alteration of eye movement Oscillation to lateral gaze Normal 2-3 beats If more, consider abnormal Dizziness 16 7/17/2015 Vertigo-Types Physiologic Pathologic Dizziness 17 7/17/2015 Vertigo-Physiologic Abnormal input to stabilize – i.e.: Car sickness Unfamiliar head position – Sea sickness Unusual head position – Painting ceiling Spinning Dizziness 18 7/17/2015 Vertigo-Pathological Disturbance of vision Disturbance of somatosensory system Disturbance of vestibular system CNS tries to correct – Change in frequency of normal firing (homeostasis is disrupted), unequal signal results, abnormal head sensation Worse with rapid head movement Often nausea and ataxia Dizziness 19 7/17/2015 Vertigo patterns Fast phase of nystagmus goes away from lesion (affected side) Rotation goes away from affected side Falling toward side of lesion Dizziness 20 7/17/2015 Etiologies Idiopathic – Acute labyrnthitis – Vestibular neuritis Infection – Herpes simplex I implicated Trauma Ischemia – Often have nausea/vomiting Drugs – Alcohol – Aminoglycoside antibiotics – Others Dizziness 21 7/17/2015 Special syndromes Mèniére’s Cranial nerve VIII problems Benign positional vertigo Dizziness 22 7/17/2015 Mèniére’s disease Cochlear disease Progressive hearing loss – Low frequency Tinnitus Dizziness Etiology – Not known – ?Infection, autoimmune, inflammatory, demyelization, tumor, trauma Dizziness 23 7/17/2015 Mèniére’s-Treatment Diuretics – Hydrochlorothiazide Very low salt restriction – <1 g per day Dizziness 24 7/17/2015 Cranial nerve VIII Sound and balance Acoustic neuroma – Unilateral hearing loss – Tinnitus – Schwannoma or meningioma MRI for diagnosis – Preferred test – Special protocol for acoustic neuromas and CN VIII problems Dizziness 25 7/17/2015 Benign Positional Vertigo Due to changes in head position No clear known cause May last months Epley maneuver (see handout) – Works – You “can try this at home!” Dizziness 26 7/17/2015 Evaluation of dizzy patient H&P should guide you Orthostatic vital signs Swivel chair Cardiac testing (next slide) Other provocative tests – Head shaking – Special glasses (Frenzel glasses) – In the realm of specialty clinics Dizziness 27 7/17/2015 Cardiac testing for syncope EKG – Rules out heart block Echocardiogram – Rules out structural heart disease (cardiomyopathy) Holter monitor – 24 hour hear monitor – Tape recording device – Good for symptomatic evaluation (palpitations) and tachycardia Event monitor – Wear up to a month – Trans-telephonic transmission of data Exercise stress testing (low yield) Electrophysiologic study (EP study) – Looks for risk for Ventricular tachycardia Dizziness 28 7/17/2015 Treatment Treat cause if known Bed rest Vestibular rehabilitation Medications (next slides) Dizziness 29 7/17/2015 Medications Vestibular suppressants – Meclizine (Antivert®)-Antihistamine – Dimenhydrinate (Dramamine®) – Promethazine Benzodiazepines – Diazepam (Valium®) – Others Steroids Epley maneuver (BPV) Dizziness 30 7/17/2015 Sea sickness/Motion sickness Occurs with movement….Allows body to know you are in motion Alteration is when the vestibular sense, visual sense, and somatosensory sense are not congruent (conflict in clues) Principle symptom is nausea/vomiting Other symptoms include dizziness, salivation, diaphoresis, and malaise. May look pale. Physiologic (not a disease, per se) Treated with antihistamines such as dimenhydrinate (Dramamine®) or anti-cholinergics such as scopalamine (Transderm Scop® patch). Both are sedating Dizziness 31 7/17/2015 Summary Broadly dizziness is either spinning or non spinning Most of the time it resolves If not, image for tumor, stroke Reassure patient Dizziness 32 7/17/2015 Where to Get More Information Any Medicine Textbook covers these topics Braunwald Heart Disease, Textbook of Cardiovascular Medicine Dizziness 33 7/17/2015