Syncope, Dizziness & Vertigo:

Case Review

Amy Gutman MD ~ EMS Medical Directorwww.prehospitalmd@gmail.com /

www.TEAEMS.com

Objectives

“Weak & Dizzy” is a common complaint with both benign & lethal causes

Etiologies of dizziness & syncope

Connection of cardiovascular & neurovascular disorders

Assessment & management strategies

“The only difference between syncope & sudden death is that in one you wake up”. Engel GL. Ann Intern Med

1978

Prehospital Dizziness Protocol?

No specific “dizziness” or “syncope” protocols

Protocol(s) used depends upon cause & effect(s) of symptoms

A good history & physical exam provides diagnosis in most patients

Not the patients to test how good you are at obtaining refusals!

Case Presentation 82 yo WF presents with CC of “dizziness”. States

intermittent, but persistent & unpredictable moments of dizziness that “made her head spin”. During the episodes, patient would nearly pass out, c/o dizziness & lightheadedness with some “blurred” vision. No CP, SOB, palpitations, seizure, loss of consciousness. No trauma, recent illness or other complaints

Vitals & exam unremarkable by BLS crew. Patient initially did not want to be transported to the hospital but was convinced to get checked out. ALS crew called but unavailable

What is your differential diagnosis based upon this info?

Case Continued History fairly unremarkable in otherwise

healthy patient who recently started OTC antihistamines for sinus congestion

Vitals stable but patient had at least 3 more episodes on the way to the ED in which she would lean back in stretcher & become extremely dizzy

In ED, placed on a hallway bed. During her triage, while the RN had the patient on a monitor and was checking her pulse he noted the following:

Definitions Syncope (Greek: sunkoptein / to cut short)

Sudden & self-limiting loss of consciousness with loss of postural tone & a spontaneous recovery. A symptom, not a diagnosis

Vertigo (Latin: vertere / to turn) Sensation of dizziness or abnormal motion resulting

from a disorder of the sense of balance

Dizzy Having a whirling sensation with tendency to fall;

bewildered or confused; producing giddiness

Challenges of Syncope & Dizziness

50% with no specific causes

Significant cost & time to diagnose & manage

Unpredictability leads to negative impact on quality of life

Management specific to the cause / suspected cause(s); varies significantly in effectiveness

Dizziness & Syncope

Syncope, dizziness & vertigo are generally symptoms rather than diseases

Benign to fatal causes Cardiac causes have highest

mortality rates >500,000 new patients

annually 70,000 have recurrent,

infrequent, unexplained syncope 3-6% ED visits annually 2-10% hospital admissions

0%

5%

10%

15%

20%

25%

Sync

ope

Mor

talit

y

Overall Due to Cardiac Causes

Associated Symptoms

Traumatic sequellae Fever, signs of illness Focal neurological

symptoms Prodromal or post-episodic

Palpitations / CP SOB Seizures Nausea, Vomiting Micturition Loss of continence

Pathological Risk Factors

>2 associated with 10-20% incidence of death from neurovascular or cardiovascular causes within 1 year CAD, CHF, arrhythmia Chest pain Abnormal ECG Persistent orthostatic

hypotension Age >45yrs Traumatic sequellae for any

fall

Cause Prevalence (Mean) %Reflex-Mediated:

Vasovagal 18Situational 5

Carotid Sinus 1Orthostatic hypotension 8Medications 3Psychiatric 2Neurological 10Organic Heart Disease 4Cardiac Arrhythmias 14Unknown 34

Syncope Etiology

Syncope Etiology*

Orthostatic Arrhythmia Structural

*

• Vasovagal• Carotid Sinus

• Peripheral vestibular dysfunction

• Brainstem lesion

• Situational• Cough• Micturition

• Meds

• Autonomic Failure

• Presyncope

• Brady• Sick

sinus• AV

block

• Tachy• VT• SVT

• Long QT

• Aortic Stenosis

• HOCM

• Pulmonary HTN

• Psychogenic

•Metabolic

• Neurological

Non-CVNeurological

Unknown Cause = 34%

24% 11% 14% 4% 12%

*DG Benditt, UM Cardiac Arrhythmia Center

Misdiagnosed or Associated with Dizziness

Migraine Hypoxia Hyperventilation Somatization / Psychiatric Intoxication Seizures Hypoglycemia

Sleep disorders / OSA

Subclavian steal syndrome

Basilar artery migraine (syncope + headache)

Vertebrobasilar insufficiency (syncope + vascular disease)

Syncope DiagnosisHistory & Physical Exam

Including ECG

Neurological Testing

• Head CT / MRI / MRA

• Carotid Doppler• EEG

Cardiovascular

• Ambulatory• Tilt Table•

Echocardiogram

• EPS • Angiogram• Stress

TestingPsychological Evaluation

ENT Evaluation• Sinus CT• Otolith

evaluation• Hearing exam

Metabolic• Laboratory

SAMPLE History & OPQRST Assessment

SSX: Associated symptoms Sequelae

Allergies: +/- & what is the reaction

Medications: Include OTCs & topicals

PMH: Cardiovascular, neurovascular

diseases, migraine, prior similar episodes

Last Oral Intake:

Events

Onset & Duration

Provocation or Palliation Position Medications Temperature

Quality

Region & Radiation

Severity Loss of consciousness

Time Time of day, duration of event

History & physical exam leads to cause identification in nearly half of patients

Family History Sudden death

Deafness

Arrhythmias

Congenital heart disease

Heart attack or CVA at young age

Seizures

Metabolic disorders

Physical Exam Serial vitals

Focus on cardiac & neurologic exams Stroke scale Glucose Monitor / ECG

If syncope + fall, presume a spinal injury present until proven otherwise

Stroke Scales

Vasovagal

Carotid Sinus

Neuralgic or

Migranous

Situational

TIA / CVA

Subclavian Steal

Episodes after pain, fear, excitation, exertion; standing w/ locked knees “i.e. “at attention”

Micturition, cough, swallowing

Facial Pain or headache

Head rotation or pressure on carotid sinus

Post exercise

Seizure

Murmur

Seizure activity, LOC >5 mins with post-ictal period

Presence of heart murmur on exam or echocardiogram

Arrhythmia

Psychogenic

Focal neurological symptoms that persist (CVA) or resolve within 1-72 hours (TIA); positive stroke

scale

Intermittent or persistent irregularity of rhythm or regularity

Anxiety, hyperventilating, personal gain

Other Syndromes Vertebral-Basilar Stroke

Diplopia, dysarthria, dysphagia, weakness, numbness

Meniere’s Aural fullness, deafness,

tinnitus Brainstem evoked audiometry

95% sensitive for detecting acoustic neuromas

Multiple Sclerosis Vertigo preceded by other

neurologic dysfunction

Nonspecific Dizziness

Psychiatric disorders Depression 25% Anxiety or panic disorder

25% Somatization Alcohol / drug abuse Personality disorder Hyperventilation

Syncope & presyncope overlap CAD, CHF, PE,

dysrhythmias

Disequilibrium Multisensory disorder

Peripheral neuropathy Visual impairment Musculoskeletal disorder interfering

with gait Vestibular disorder Cervical spondylosis

Symptoms worsened with antidepressants & anticholinergics

May occur while sitting, driving or position change

Peripheral vs Central Vertigo (Vestibular

Dysfunction)PERIPHERAL VERTIGO

CAUSES Vestibular neuronitis Labyrinthitis Meniere’s syndrome Head trauma Drug-induced

Aminoglycosides, phenytoin, phenobarbital, carbamazepine, salicylates, quinine

CENTRAL VERTIGO CAUSES Cerebellar infarction or

hemorrhage Lateral medullary infarction

(Wallenberg’s syndrome) Brainstem infarction or

hemorrhage Multiple sclerosis Vertebrobasilar

insufficiency

Central vertigo associated with poor outcomes while peripheral vertigo is often “benign”. Can have overlap in

symptoms, therefore difficult to differentiate

Nystagmus: Characteristics

CENTRAL ORIGIN Vertical, horizontal or

rotary

May change direction with gaze

Not diminished by fixation

Does not significantly worsen with head movement

PERIPHERAL ORIGIN Horizontal, torsional Does not change

direction with gaze change

Diminished by fixation May fatigue (if elicited

by head movement)

Cerebellar Infarction

CEREBELLAR INFARCTION

Nystagmus + dizziness

Nausea & vomiting

Ataxia & ipsilateral asynergia

No focal weakness or motor abnormality

LATERAL MEDULLARY INFARCTION: WALLENBERG SYNDROME

Nystagmus + dizziness Nausea & vomiting Ataxia & ipsilateral

asynergia No focal weakness or motor

abnormality Hoarseness Horner’s syndrome Ipsilateral facial analgesia;

contralateral body analgesia

Horner’s Syndrome:Ptosis, Miosis,

Anhidrosis

Carotid or Vertebral Artery Dissection

Often spontaneous Acute dizziness after neck

trauma / manipulation Presents with posterior

circulatory infarction symptoms

MRA may reveal double-lumen, but full angiography has higher yield

Neurally-Mediated Reflex Syncope (NMS)

Neurally mediated reflex mechanism with cardioinhibitory (bradycardia) & vasodepressor (hypotension) components Vasovagal syncope (VVS) Carotid sinus syndrome (CSS) Situational syncope

Loss of the normal balance between sympathetic & parasympathetic nervous system

Triggered by stretch & mechanoreceptors (carotid sinus, bladder, esophagus, respiratory tract)

Peripheral venous pooling causes sudden decreased venous return Pallor, nausea, sweating, palpitations common

Carotid Sinus Syndrome (CSS)

Rare except in elderly “Falls after losing balance”

Sensory nerves in carotid sinus walls respond to stimulation increasing afferent signals to brain stem

Reflexive increase in efferent vagal activity & decreased sympathetic tone results in bradycardia & vasodilation

Different syndrome than carotid sinus hypersensitivity, similar management

Other Forms of VVS Drug-induced

Often from diuretics, vasodilators

Primary autonomic failure Deconditioning, parkinsonism

Secondary autonomic failure Diabetes +/- neuropathy,

amyloidoisis

Alcohol Orthostatic intolerance +/-

neuropathy

Orthostatic Hypotension

Decline of >20mmHg SBP or 10mmHg DBP from supine to standing

Elderly vulnerable due to decreased baroreceptor sensitivity, decreased cerebral blood flow, increased renal sodium wasting, decreased thirst response with aging

Peripheral sympathetic tone impairment due to diabetic neuropathy, anti-HTN medication

Radiologic Imaging Non-contrast CT helps r/o

acute hemorrhage (but not 100% accurate)

MRI more sensitive than CT for hypoxic injury or cerebellar & brain-stem infarctions PET scan may improve

diagnostic accuracy CT angiography or MRA

useful within 24 hours

Carotids often included in evaluation

Electroencephalogram (EEG)

Not 1st line testing Differentiates syncope from seizures

Head - Tilt Test

Evaluates NMS predisposition Specificity of negative test 90%

Nystagmus & vertigo with peripheral lesions when diseased side turned downward Peripheral nystagmus may fatigue with

repeated maneuvers

Central lesions not significantly changed with position change

Symptoms of peripheral nystagmus dramatically worsened with head movement & tends to fatigue with repeated maneuvers

Dix Hallpike Diagnosis

PERIPHERAL VERTIGO

CENTRAL VERTIGO

Time before onset of nystagmus

2-20 secs 0 secs

Duration of nystagmus

<1 min >1 min

Fatiguability Yes with repetitiion Non-fatiguiing

Direction of nystagmus

Upbeat & torsional May change direction

Intensity of vertigo severe Minimal to moderate

Epley Maneuver Particle-Repositioning

• Potential consequence is carotid occlusion / clot resulting in stroke

Cardiovascular Syncope LOC often w/o prodrome

Significant injury risk

Structural heart disease is most important risk factor for predicting risk of death from syncope or dizziness

Acute MI / Ischemia Hypertrophic cardiomyopathy Aortic dissection Pericarditis Pericardial tamponade Pulmonary embolus Pulmonary HTN Aortic stenosis Atrial myxoma Bradyarrhythmias Tachyarrhythmias

12 Lead EKG & Monitor

Normal or abnormal? Normal “now” does not

equal normal “always”

Fast or slow?

Pauses?

Pacemaker?

Ambulatory ECG Holter

24-48 hours symptoms w/ arrhythmia (5%) v.

symptoms without arrhythmia (17%)

External Loop Event Recorder Weeks to months Limited value in sudden LOC

Loop Recorder Months Implantable type more convenient Provided diagnosis in 55% of pts

with unexplained syncope compared to conventional methods

What’s My Rhythm? All Seen in Dizziness & Syncope

From the files of DG Benditt, UM Cardiac Arrhythmia Center

So…Back to Our Patient

Bradyarrhythmic Syncope

Wide, weird & slow Sinus brady Symptomatic 1st degree HB 3rd degree HB

Cause often correctible with medication adjustment

Indication for atrial pacemaker implantation

Ventricular pacing indicated in atrial fibrillation with slow ventricular response

Bradycardia 36%

Tachycardia 6%NSR 58%

Weird Bradyarrythmia:Idioventricular

Ventricles depolarizing on their own because of no atrial conduction

Rate between 20-40 Rate of 60-120 (all PVCs)

often called “Slow VT” Diagnostic clue: no p

waves or flipped p waves in all leads

Tachyarrhythmic Syncope

Wide, weird & fast or narrow & regular

Regular or irregular, intermittent or persistent

Cause often structural, ischemic & pathologic – not easily corrected with a simple medication change

Surgery (if related to stenosis or CAD) +/- ventricular pacing often indicated

Risk of sudden cardiac death

Atrial Fibrillation with Accessory Pathway Conduction Degenerating to

VF

Premature Ventricular Complex (PVC)

AKA: Ventricular extrasystole,

premature beat, ectopic beat, premature depolarization

Occasional monomorphic PVCs common in normal hearts but also seen in the setting of heart disease

Polymorphic VT never normal Ischemia, metabolic or

structural disorders

QT Prolongation & R on T Phenomenon

QT widens to point when a PVC occurs early in the cardiac cycle falling on the apex of preceding T wave leading to VT or torsades

Antiarrhythmics Class IA & III: Quinidine, Procainamide, Sotalol, Amiodarone

Psychoactive Agents Phenothiazines, Amitriptyline, Imipramine, Ziprasidone

Antibiotics Erythromycin, Pentamidine, Fluconazole

Antihistamines Terfenadine, Astemizole

Others Cisapride, Droperidol

VT vs VFVENTRICULAR TACHYCARDIA

Abnormal tissues in ventricles generating rapid & irregular rhythm

>3 PVCs in a row; can be sustained or unsustained

Rhythm: Regular Rate: 150-250bpm QRS Duration: Prolonged >120ms P Wave: Not seen, often dissociated

VENTRICULAR FIBRILLATION

Disorganized electrical signals cause ventricles to quiver ineffectively

Rhythm: Irregular

Rate: >250, disorganized

QRS Duration: Unrecognizable

P Wave: Not seen

VT Degenerating to VF

Case Conclusion Patient emergently trans-thoracially

paced in ED while receiving fluid boluses & amiodarone

Went to OR for permanent dual-chamber (atrial & ventricular) pacemaker

Patient’s antihistamines discontinued (unclear if contributed to symptoms)

Discharged home a few days later with no permanent sequellae

Pacemakers Ventricular > atrial >

dual chamber

Most pacemakers are “demand” type

EKG shows a “spike” when pacer fires

Beware the patient with a pacemaker, syncope / dizziness with no pacer spikes on EKG!

CV-Related Management

Recognize symptoms & avoid provocation Avoid alcohol, lack of sleep,

environmental stressors Adequate hydration & food intake Avoid drugs that lead to hypotension Avoid activities that precipitate syncope

Preventing LOC or Injury Supine position upon onset of prodrome Avoid driving or other activities that

could lead to injury

Cardiovascular / neurovascular interventions Routine follow-up Take prescribed medications as

prescribed!

References Dubin’s Guide to EKGs. Images: Wikipedia, Google, Bing searches. www.UpToDate.com. “Dizziness”, “Syncope”,

“Ventricular Tachyarrythmias”. 2013. D. Okorn MD. “Approach to Dizziness”. Swedish

Family Medicine. Dec 2009 G. Bergey MD. “Acute Dizziness & Vertigo:

Diagnosis, Assessment and Management”. 2001 M. Lehmann MD. “Tacchyarrythmias”. 2010 E. Veiga, M.D, 2008 WN Kapoor. Syncope. NEJM 2000; 343: 1856-62 Freeman, R. “Neurogenic Orthostatic

Hypotension” NEJM 2008; 358: 615-624 Soteriades, et al. Incidence and Diagnosis of

Syncope. NEJM 2002; 347:878-885 Grubb, B. Neurocardiogenic Syncope. NEJM

2005; 1004-1010 DG Benditt. “Syncope - A Diagnostic & Treatment

Strategy”. Royal Brompton Hospital, London, UK Kapoor W, Med. 1990;69:160-175 JJ Blanc, et al. Eur Heart J, 2002; 23: 815-820 WN Kapoor. “Evaluation and outcome of patients

with syncope”. Medicine 1990;69:160-175

Summaryprehospitalmd@gmail.com / www.TEAEMS.com

History & exam important in providing or eliminating a diagnosis

Most causes benign & self-limited but almost impossible to make a prehospital diagnosis

Serious causes suspected by abnormal CV or neuro exam

Recognize stroke syndromes that may present with dizziness as a prominent feature