Dizziness

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

2. 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

3. Agenda • Definitions • Faintness • Spinning • Other Syndromes Dizziness

4. 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

5. Dizziness • Harrison’s textbook of IM refers to as having disturbed ambulation Dizziness

6. Other associated symptoms • Changes in vision • Orthostasis • Just about anything else Dizziness

7. 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

8. 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

9. Orthostasis • Iatrogenic (done by med prof.) is common form • Blood pressure meds • May use mineralcorticoids to treat • Cause fluid retention • Hydrocortisone Dizziness

10. Fainting • Loss of buffers to remain conscious • What comes before syncope referred to as prodrome Dizziness

11. Syncope • Large differential • Cardiac syncope • Later slide • Neurological • Simply fainting • Probably the most common • Anxiety • Stress • Let history guide you-next slide Dizziness

12. Syncope-guided by history • History of heart disease • ?CardiomyopathyThink 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

13. Syncope-Cardiac causes • Arrythmia/dysrrhythmia • Heart block • May require pacemaker • Aortic stenosis (severe) • Also think meds (orthostasis) Dizziness

14. Vertigo • Impaired vestibular system • May be due to disturbance of inner ear • Altered head position in space, via alteration of CN VIII Dizziness

15. Normal balance maintenance • Visual input • Somatosensory input • Skin • Joints • Muscles • Spinal cord • Cerebellum • Cerebrum Dizziness

16. Nystagmus • Alteration of eye movement • Oscillation to lateral gaze • Normal 2-3 beats • If more, consider abnormal Dizziness

17. Vertigo-Types • Physiologic • Pathologic Dizziness

18. Vertigo-Physiologic • Abnormal input to stabilize • i.e.: Car sickness • Unfamiliar head position • Sea sickness • Unusual head position • Painting ceiling • Spinning Dizziness

19. 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

20. Vertigo patterns • Fast phase of nystagmus goes away from lesion (affected side) • Rotation goes away from affected side • Falling toward side of lesion Dizziness

21. Etiologies • Idiopathic • Acute labyrnthitis • Vestibular neuritis • Infection • Herpes simplex I implicated • Trauma • Ischemia • Often have nausea/vomiting • Drugs • Alcohol • Aminoglycoside antibiotics • Others Dizziness

22. Special syndromes • Mèniére’s • Cranial nerve VIII problems • Benign positional vertigo Dizziness

23. Mèniére’s disease • Cochlear disease • Progressive hearing loss • Low frequency • Tinnitus • Dizziness • Etiology • Not known • ?Infection, autoimmune, inflammatory, demyelization, tumor, trauma Dizziness

24. Mèniére’s-Treatment • Diuretics • Hydrochlorothiazide • Very low salt restriction • <1 g per day Dizziness

25. 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

26. 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

27. 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

28. 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

29. Treatment • Treat cause if known • Bed rest • Vestibular rehabilitation • Medications (next slides) Dizziness

30. Medications • Vestibular suppressants • Meclizine (Antivert®)-Antihistamine • Dimenhydrinate (Dramamine®) • Promethazine • Benzodiazepines • Diazepam (Valium®) • Others • Steroids • Epley maneuver (BPV) Dizziness

31. 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

32. Summary • Broadly dizziness is either spinning or non spinning • Most of the time it resolves • If not, image for tumor, stroke • Reassure patient Dizziness

33. Where to Get More Information • Any Medicine Textbook covers these topics • Braunwald Heart Disease, Textbook of Cardiovascular Medicine Dizziness