Dizziness University of New England Physician Assistant Program

Dizziness University of New England Physician Assistant Program 27 AUG 2009 Jeffrey T. Reisert, DO Dizziness 1 6/12/2021

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) Jeffrey. T. Reisert@hitchcock. org Dizziness 2 6/12/2021

Agenda Definitions l Faintness l Spinning l Other Syndromes l Dizziness 3 6/12/2021

Multiple sensations l Lightheadedness/Faint/Presynope – Feel like going to pass out l Spinning/Vertigo – Sensation of abnormal movement l Other – Hyperventilation – Hyperglycemia – Depression l Syncope – Loss of consciousness – Covered only briefly today-Often a topic under cardiology Dizziness 4 6/12/2021

Dizziness l Harrison’s textbook of IM refers to as having disturbed ambulation Dizziness 5 6/12/2021

Other associated symptoms Changes in vision l Orthostasis l Just about anything else l Dizziness 6 6/12/2021

Orthostasis AKA orthostatic hypotension l Change in blood pressure and cerebral blood flow due to transient low blood pressure l – 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 6/12/2021

Orthostasis l 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 >20 mm. Hg – Fall in diastolic BP >10 mm. Hg – Increase in heart rate 10 -25 beats per minute – Symptoms of cerebral hypoperfusion (dizzy) – 24% of old people have this! Dizziness 8 6/12/2021

Orthostasis l Iatrogenic (done by med prof. ) is common form – Blood pressure meds l May use mineralcorticoids to treat – Cause fluid retention – Hydrocortisone Dizziness 9 6/12/2021

Fainting Loss of buffers to remain conscious l What comes before syncope referred to as prodrome l Dizziness 10 6/12/2021

Syncope l l Large differential Cardiac syncope – Later slide l l Neurological Simply fainting – Probably the most common – Anxiety – Stress l Let history guide you-next slide Dizziness 11 6/12/2021

Syncope-guided by history l History of heart disease – ? Cardiomyopathy Think arrhythmia l Medications – Anti-hypertensives – All medications? ? (Read labels…. Ugh!) l 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 6/12/2021

Syncope-Cardiac causes Arrythmia/dysrrhythmia l Heart block l – May require pacemaker Aortic stenosis (severe) l Also think meds (orthostasis) l Dizziness 13 6/12/2021

Vertigo Impaired vestibular system l May be due to disturbance of inner ear l Altered head position in space, via alteration of CN VIII l Dizziness 14 6/12/2021

Normal balance maintenance Visual input l Somatosensory input l – Skin – Joints – Muscles – Spinal cord Cerebellum l Cerebrum l Dizziness 15 6/12/2021

Nystagmus Alteration of eye movement l Oscillation to lateral gaze l Normal 2 -3 beats l If more, consider abnormal l Dizziness 16 6/12/2021

Vertigo-Types Physiologic l Pathologic l Dizziness 17 6/12/2021

Vertigo-Physiologic l Abnormal input to stabilize – i. e. : Car sickness l Unfamiliar head position – Sea sickness l Unusual head position – Painting ceiling l Spinning Dizziness 18 6/12/2021

Vertigo-Pathological l l 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 l l Worse with rapid head movement Often nausea and ataxia Dizziness 19 6/12/2021

Vertigo patterns Fast phase of nystagmus goes away from lesion (affected side) l Rotation goes away from affected side l Falling toward side of lesion l Dizziness 20 6/12/2021

Etiologies l Idiopathic – Acute labyrnthitis – Vestibular neuritis l Infection – Herpes simplex I implicated l l Trauma Ischemia – Often have nausea/vomiting l Drugs – Alcohol – Aminoglycoside antibiotics – Others Dizziness 21 6/12/2021

Special syndromes Mèniére’s l Cranial nerve VIII problems l Benign positional vertigo l Dizziness 22 6/12/2021

Mèniére’s disease l l Cochlear disease Progressive hearing loss – Low frequency l l l Tinnitus Dizziness Etiology – Not known – ? Infection, autoimmune, inflammatory, demyelization, tumor, trauma Dizziness 23 6/12/2021

Mèniére’s-Treatment l Diuretics – Hydrochlorothiazide l Very low salt restriction – <1 g per day Dizziness 24 6/12/2021

Cranial nerve VIII l l Sound and balance Acoustic neuroma – Unilateral hearing loss – Tinnitus – Schwannoma or meningioma l MRI for diagnosis – Preferred test – Special protocol for acoustic neuromas and CN VIII problems Dizziness 25 6/12/2021

Benign Positional Vertigo Due to changes in head position l No clear known cause l May last months l Epley maneuver (see handout) l – Works – You “can try this at home!” Dizziness 26 6/12/2021

Evaluation of dizzy patient H&P should guide you l Orthostatic vital signs l Swivel chair l Cardiac testing (next slide) l Other provocative tests l – Head shaking – Special glasses (Frenzel glasses) – In the realm of specialty clinics Dizziness 27 6/12/2021

Cardiac testing for syncope l EKG – Rules out heart block l Echocardiogram – Rules out structural heart disease (cardiomyopathy) l Holter monitor – 24 hour hear monitor – Tape recording device – Good for symptomatic evaluation (palpitations) and tachycardia l Event monitor – Wear up to a month – Trans-telephonic transmission of data l l Exercise stress testing (low yield) Electrophysiologic study (EP study) – Looks for risk for Ventricular tachycardia Dizziness 28 6/12/2021

Treatment Treat cause if known l Bed rest l Vestibular rehabilitation l Medications (next slides) l Dizziness 29 6/12/2021

Medications l Vestibular suppressants – Meclizine (Antivert®)-Antihistamine – Dimenhydrinate (Dramamine®) – Promethazine l Benzodiazepines – Diazepam (Valium®) – Others l l Steroids Epley maneuver (BPV) Dizziness 30 6/12/2021

Sea sickness/Motion sickness l l l 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 6/12/2021

Summary Broadly dizziness is either spinning or non spinning l Most of the time it resolves l If not, image for tumor, stroke l Reassure patient l Dizziness 32 6/12/2021

Where to Get More Information Any Medicine Textbook covers these topics l Braunwald Heart Disease, Textbook of Cardiovascular Medicine l Dizziness 33 6/12/2021