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The Magic of Spells

The Magic of Spells John E Morley St Louis University St Louis VAMC Hypoglycemia Hypoxemia Hypocalcemic tetany Alkalotic tetany Acidosis Hypercapnia Low carbon dioxide (hyperventilation) SPELLS Syncope Seizures Dizziness Psychiatric Metabolic Pulmonary embolus CVA Drop attack

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The Magic of Spells

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  1. The Magic of Spells John E Morley St Louis University St Louis VAMC

  2. Hypoglycemia Hypoxemia Hypocalcemic tetany Alkalotic tetany Acidosis Hypercapnia Low carbon dioxide (hyperventilation) SPELLS • Syncope • Seizures • Dizziness • Psychiatric • Metabolic • Pulmonary embolus • CVA • Drop attack • Migraine • Narcolepsy

  3. SPELLS

  4. “Those who suffer from frequent and strong faints Without any manifest cause die suddenly” Hippocrates (460 – 375 BC) “Ubi pulsus sit rarus semper expectanda est syncope” Geronimo Mercuriale (1530 – 1606)

  5. Vasovagal Carotid sinus hypersensitivity Cardiac Dehydration Anemia Vasodilatation Autonomic dysfunction Drug induced Syncope

  6. Mechanisms of Syncope • Sudden failure of the heart as a pump – “cardiogenic syncope” • Sudden reduction of ‘venous return’ – “orthostatic syncope” • Sudden abnormal distribution of cardiac output – “inappropriate arterial vasodilatation” • Chronic arterial disease – “atherosclerosis”

  7. Cardiogenic Syncope • Tachycardia • Bradycardia • Asystole • Prolonged QT • Myxoma • Hypertrophic Obstructive Cardiac Myopathy

  8. Brugada SyndromeBrugada & Brugada J Am Coll Cardiol 1992;20:1391-1396 • Right bundle branch block • ST segment elevation in V1 to V3 • Propensity to develop sustained ventricular arrhythmias

  9. Work-up for Cardiac Syncope Greatest utility in older patient Do not do if: Carotid bruit Recent MI Recent stroke History of ventricular tachycardia POSITIVE: asystole >3 secs • Carotid sinus massage • Cardiac Enzymes • Echocardiogram • Stress test • Long term ambulatory loop electrocardiography • Tilt table

  10. Treatment of Orthostasis • Eliminate medications • Increase salt • Elevate head of bed • Bedside commode • Avoid hot showers • Get up slowly • Orthostatic training • Jobst stockings • Two cups of coffee in morning

  11. Treatment ofOrthostasis • Midodrine (alpha-1 adrenergic antagonist) • Motrin • Fludrocortisone • Erythropoetin • 3,4 Dl-threo-diphenoxyphenylserine (DOPS)

  12. Orthostatic Syncope Drugs Neuropathy Varicose veins Jacuzzi syncope • Venous pooling >20% on standing • Excessive loss of water or blood • Failed venoconstriction • Increased pressure in chest or abdomen Valsalva manevure Weight Lifting Trumpet blowing Tussive syncope Micturition syncope Deglutition syncope

  13. Valsalva Manoevure R-R interval < 1.2 Diagnostic of autonomic neuropathy

  14. Inappropriate arterial vasodilatation EXERCISE SYNCOPE : Expansion of arteries to muscle Compression of veins Diversion of blood from other organs STRESS “fright” SYNDROME : Muscular arterial vasodilatation “playing dead”

  15. POSTPRANDIAL HYPOTENSION(“BIG MAC ATTACK”) • VARIABLE • MORE COMMON IN AM • PREVALENCE 26% • falls syncope stroke myocardial infarction death • STIMULATED BY CARBOHYDRATE • DUE TO CGRP RELEASE

  16. 1.00 0.75 0.50 0.25 0.00 0 20 40 60 Postprandial hypotension predicts all-cause mortality in nursing home residents age >65yr  10 mmHg  11 - 19 mmHg ≥20 mmHg Probability of survival P=0.009 Months (n=179) (Fisher et al 2005)

  17. Effects of meal composition on postprandial blood pressure Glucose Fat Protein Water P<0.001 Mean arterial blood pressure (mmHg) Time (min) n=10 hypertensive elderly subjects Jansen et al (1990)

  18. Effect of octreotide on the blood pressure response to oral glucose (75g) P<0.05 octreotide (50µg s.c.) mean arterial blood pressure (mmHg) placebo Time (min) n=10 hypertensive older subjects Jansen et al (1989)

  19. Anorexia Delayed Gastric Emptying Inhibits hepatic glucose production GLUCAGON-LIKE PEPTIDE Stimulates insulin Decreases glucagon GLP-1 levels are reduced in diabetes

  20. Effect of acarbose (100mg) on GIP and GLP-1 GIP GLP-1 control acarbose pmol/L pmol/L * *P<0.001 *P<0.004 * * * * * * * * * * * * * * * Time (min) n=8 healthy older subjects Gentilcore et al (2005)

  21. Effect of acarbose on blood pressure and heart rate Systolic BP Heart rate control acarbose mmHg BPM P<0.0001 P<0.05 Time (min) n=8 healthy elderly subjects Gentilcore et al (2005)

  22. *** **** *** ***** EFFECT OF MIGLITOL Lee et al Diab Ob & Metab 4:329, 2002 Glucagon-Like Peptide Satiety Satiety (cm) Glucagon – Like Peptide – 1 (GLP-1)(pmol/L) Time (minutes) Test + Treatment Meal Time (hour)

  23. Post Prandial hypotension Treatment • Coffee in am • Small meals • Decrease carbohydrate • Fiber with meal • Alpha-1 glucosidase inhibitors • Octreotide (somatostatin)

  24. Of Black Swans And Zebras

  25. Systemic Mastocytosis • Increased gastric acid • Diarrhea • Dermatographia • Urticaria pigmentosum • Syncope • Diagnostic test : Tryptase

  26. Addison’s Disease • Orthostasis • Weight loss • Abdominal symptoms • Increased K • Decreased Na • Eosinophillia

  27. Eagle Syndrome(Elongated Styloid Process) • I. Pharyngeal pain • II. Carotid artery syndrome Carotodynia Headaches Tinnitus Monocular blindness Syncope

  28. Other Zebras • VIPoma (Verner-Morrison Syndrome) • Swallowing (Hiatal hernia and achlasia) • Vagal paraganglioma • Paraplegic induced cerebral syncope • Giant Cell Arteritis

  29. Acupuncture Induced Syncope“Yan-Cheng” phenomenon More common in old

  30. Incidence of Epilepsy 1.7 years to diagnosis

  31. SEIZURES

  32. Complex Partial Seizures • Ecstasy • Anguish • Convulsions Fyodor Dostoyevski (1821 – 1881)

  33. Complex Partial Seizures HALLUCINATIONSVisual Auditory Olfactory TEMPORAL Memory Dreamy State Affective Déjà vu Fear PSYCHOMOTOR Dysphasia Chewing Undoing clothes

  34. Prevalence of Seizures

  35. Seizures : Laboratory • Prolactin increased at 20 min and decreased at 60 min; 90% in generalized motor seizures and 70 % in partial complex seizures • CPK (MM) elevated by 24 hours in 10% motor seizures • Elevated lactate in first hour

  36. Dizziness (vertigo) “ the external world seems to revolve around the individual or in which the individual seems to revolve in space ”

  37. Causes of dizziness • Acoustic neuroma • Arteriosclerosis • Benign Paroxysmal Positional Vertigo • Meniere’s Disease • Labyrinthitis • Vestibular neuronitis • Ototoxicity • Osteoarthritis

  38. Benign Paroxymal Positional Vertigo • 20% of all cases • Fifth to seventh decades • Bilateral in 10% • Associated with head trauma, vestibular neuritis and Meniere’s disease

  39. BPPV • 1921 Barany – positioning vertigo • 1952 Dix & Hallpike • 1969 Schuknecht - culpolithiasis • 1979 Hall, Ruby & McClure – canalithiasis

  40. Menieres’s Disease :A condition in which the inner ear cannot drain endolymph • Fluctuations in sensorineural hearing • Episodes of dizziness • Tinnitis • A feeling of pressure in the ear

  41. Meniere’s Disease • Hydrochlorthiazide and low salt diet • Vestibular suppressants • Surgery: Endolymphatic Sac Surgery Vestibular Nerve Sectioning Labyrinthectomy Gentamicin Chemical Labyrinthectomy

  42. Vestibular Supressants • Antihistamines – diphenhydramine • Piperazine derivatives – meclizine • Phenothiazine – promethazine • Anticholinergic – scopolamine • Butyrophenone – droperidol • Benzodiazepines – lorazepam • Robinul Fort - glycopyrolate

  43. Superior Semicircular Canal Dehiscence • Described by Minor in 1998 • Incidence 0.4% to 1.5% • Chronic Dysequilibrium, Noise evoked, Pressure evoked (nose blowing), Gaze evoked • Vertical and torsional nystagmus • CT shows superiot canal dehiscence in Poschi or stenver’s views • Visual evoked myogenic potential (lower threshold)

  44. Superior Semicircular Canal Dehiscence :TREATMENT • Avoid inciting stimuli • Pressure equalization tube • Surgical Repair (limited experience) • Counseling

  45. Alternative MedicineGinger (Zingiber officinale)

  46. Frenzel Glasses

  47. Exercise and Dizziness • Brandt-Daroff Habituation Exercises • Semont (Liberatory) Maneuver • Epley Maneuver • Gaze Stabilization Exercises • Crawthorne-Cooksey Exercises

  48. EXERCISES and DIZZINESS

  49. Status Post Fall is a Delirium Equivalent

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