DIZZINESS AND SYNCOPE PAIN OR PLEASURE Jacques Bdard

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 VESTIBULAR CENTRAL NERVOUS SYSTEM SYMPTONS: Diplopia – Dysarthria Bilateral loss of vision SIGNS: • Hemiparesis - hypoesthesia • Ataxia Nystagmus

Third Step: Type I: Peripherical vestibular vertigo Syndrome Duration Periodicity Other Labyrinthitis (Vest. N. ) 2 days-2 weeks 0 0 Recurrent neuronitis 10 min - 20 hrs + recurrent 0 Meniere’s disease 10 min - 20 hrs Positional vertigo < 1 minute Tinnitus ++ recurrent Hearing +++ recurrent ∆ Position

Dix Hallpike Positive “Objective”: Confirms the diagnosis “ Subjective”: Suggests the diagnosis Negative Does not rule out the diagnosis not HISTORY is diagnostic

EPLEY’s manoeuver: ex. RIGHT EAR) (Right ear: rotation from right to left- Left ear: rotation from left to right a a b a c b b c a 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: Inform the Patient Day 1: Vertical position – sleeping, head elevated Normal activities afterward Recurrence rate: 15% (Mobile otolith) Recurrence Provoque vertigo in left -right decubitus (Identifies involved ear) Repeat posterior canal manoeuver (Patient himself) Horizontal canal? : specific manoeuver

Epley’s manoeuver: FAILURE? 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)

Type II: Presyncope = cardiovascular syncope Syncope Onset Recovery Sudden • Neuro (epilepsy) Slow • Metabolic Slow System Sudden • Cardiovascular (90%)

FIRST STEP Type 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%)

Second Step: Type II History Sick Heart Normal Heart Reflex • Past history • Onset: Young age • Position: Standing • Activity: Micturition - cough - etc • Stimulus: Pain - Discomfort • Concomitant Symptoms: – Nausea - Vomiting – Yawning - Fatigue +++ Cardiac • Past History - Medication • Onset: Advanced age • Position: Lying down • Concomitant Symptoms: – Chest pains – Palpitations

Second Step: Type II Physical • BP Lying - Standing: orthostatic hypotention Diminution BP < 90 mm. Hg or change BP >20 mm. Hg standing position Carotid sinus massage • Aortic murmur • Heart failure signs: – Increased jugular veins - pulmonary rales – S 3(+) - 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)

Third Step: Type II « SPECIFIC EVALUATION » Normal Heart Sick Heart • Ambulatory • Hospit - ambul. Monitoring monitoring • Carotid Sinus Massage • Echo - Treadmill • Loop recorder • Tilt table test • EPS

Second Step: Type IV 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

1 STEP 2 STEP 3 STEP VESTIBULAR Vertigo (Vestibular - CNS) CNS (Focal sings - symptoms) BPV Dix Hallpike-Epley Meniere’s disease Labyrinthitis (vestibular neuronitis) Acoustic neurinoma Vascular - Inflammatory - Tumoral (CT - Magnetic resonnance) SPECIFIC EVALUATION INITIAL EVALUATION Presyncope (Cardiovascular) Disequilibrium (Neuromuscular) Carotid sin. Massage Treadmill-Echo OR Normal heart - Sick heart Loop recorder (Réflex: 70%) (Electric: 70%) %) Tilt table test EPS DIAGNOSIS Physical Neurological - Locomotor Lightheadedness HYPERVENTILATION ( Anxiety) Normal heart Sick heart History - Physical - ECG Recognizes the cause of physical symptoms