Dizziness and Syncope
Dizziness refers to an impairment in spatial perception and stability. Dizziness is considered imprecise.Dizziness can be used to mean vertigo, presyncope, disequilibrium, or for a non-specific feeling such as giddiness or foolishness.
Vertigo is a specific medical term used to describe the sensation of spinning or having one's surroundings spin about them. Many people find vertigo very disturbing and often report associated nausea and vomiting. It represents about 25% of cases of occurrences of dizziness.
Disequilibrium is the sensation of being off balance, and is most often characterized by frequent falls in a specific direction. This condition is not often associated with nausea or vomiting.
Presyncope is lightheadedness, muscular weakness and feeling faint as opposed to a syncope, which is actually fainting.
Non-specific dizziness is often psychiatric in origin. It is a diagnosis of exclusion and can sometimes be brought about by hyperventilation.
A stroke is the cause of isolated dizziness in 0.7% of people who present to the emergency room.
What do I do when I have a Dizzy patient?
The clinical challenge is to decide is this a cardiac cause or another cause. A cardiac cause for dizziness would result from insufficient cardiac perfusion to the brain. The initial assessment must include supine and sitting blood pressure measurements. Cardiac causes are differentiated from non-cardiac causes - this accounts for 40% of my patients with dizziness.
An ENT and Neurological evaluation as well as an ECG and a CXR must follow.
NON-CARDIAC CAUSES OF DIZZINESS
NEUROLOGICAL:
Generalised seizure is the most common cause in the absence of focal neurological signs.
Vasovagal syncope may also present with jerky movements and incontinence.
Postictal confusion differentiates generalised seizures from vasovagal syncope.
Vertebrobasilar TIA may cause dizziness in the absence of loss of conciousness.
Stroke requires a persistent neurological deficit in keeping with a defined vascular territory.
Vascular insufficiency not related to a cardiac cause but causing dizziness include migraine, subclavian steal and vertebrobasilar insufficiency - worse when looking up or turning the head.
ENT:
There is no loss of conciousness. (A loss of conciousness cannot possibly be from an isolated ear, nose or throat cause).
Vertigo may occur without nausea. Tinnitus and deafness localises the problem to the middle ear.
I now differentiate episodic from the other forms - episodic vertigo without focal neurological signs which lasts for a few moments is benign positional vertigo and is diagnosed by demonstrating nystagmus with the Hallpike manoeuvre and is treated by the Epley's manoeuvre - this may displace the otolith and give the patient relief.
Vertigo and nausea lasting for a few hours and associated with unilateral tinnitus and deafness in the middle aged and elderly is due to Menieres disease and requires no further investigation.
I treat with prochlorperazine - continuously or as required.
Progressive, chronic vertigo with Deafness and focal neurological signs requires ENT or Neurological review - after a MRI brain.
Drop Attack
The elderly and frail may have a momentary loss of postural tone causing falls without any true dizziness or any impairment of conciousness. There is usually a abrupt fall after which the patient is IMMEDIATELY able to get up. This is a self limiting condition that has no clear cause.
Generalised Anxiety Disorder
In the presence of excessive anxiety for most days for at least 6 months and at least 3 of the following:
Vertigo is a specific medical term used to describe the sensation of spinning or having one's surroundings spin about them. Many people find vertigo very disturbing and often report associated nausea and vomiting. It represents about 25% of cases of occurrences of dizziness.
Disequilibrium is the sensation of being off balance, and is most often characterized by frequent falls in a specific direction. This condition is not often associated with nausea or vomiting.
Presyncope is lightheadedness, muscular weakness and feeling faint as opposed to a syncope, which is actually fainting.
Non-specific dizziness is often psychiatric in origin. It is a diagnosis of exclusion and can sometimes be brought about by hyperventilation.
A stroke is the cause of isolated dizziness in 0.7% of people who present to the emergency room.
What do I do when I have a Dizzy patient?
The clinical challenge is to decide is this a cardiac cause or another cause. A cardiac cause for dizziness would result from insufficient cardiac perfusion to the brain. The initial assessment must include supine and sitting blood pressure measurements. Cardiac causes are differentiated from non-cardiac causes - this accounts for 40% of my patients with dizziness.
An ENT and Neurological evaluation as well as an ECG and a CXR must follow.
NON-CARDIAC CAUSES OF DIZZINESS
NEUROLOGICAL:
Generalised seizure is the most common cause in the absence of focal neurological signs.
Vasovagal syncope may also present with jerky movements and incontinence.
Postictal confusion differentiates generalised seizures from vasovagal syncope.
Vertebrobasilar TIA may cause dizziness in the absence of loss of conciousness.
Stroke requires a persistent neurological deficit in keeping with a defined vascular territory.
Vascular insufficiency not related to a cardiac cause but causing dizziness include migraine, subclavian steal and vertebrobasilar insufficiency - worse when looking up or turning the head.
ENT:
There is no loss of conciousness. (A loss of conciousness cannot possibly be from an isolated ear, nose or throat cause).
Vertigo may occur without nausea. Tinnitus and deafness localises the problem to the middle ear.
I now differentiate episodic from the other forms - episodic vertigo without focal neurological signs which lasts for a few moments is benign positional vertigo and is diagnosed by demonstrating nystagmus with the Hallpike manoeuvre and is treated by the Epley's manoeuvre - this may displace the otolith and give the patient relief.
Vertigo and nausea lasting for a few hours and associated with unilateral tinnitus and deafness in the middle aged and elderly is due to Menieres disease and requires no further investigation.
I treat with prochlorperazine - continuously or as required.
Progressive, chronic vertigo with Deafness and focal neurological signs requires ENT or Neurological review - after a MRI brain.
Drop Attack
The elderly and frail may have a momentary loss of postural tone causing falls without any true dizziness or any impairment of conciousness. There is usually a abrupt fall after which the patient is IMMEDIATELY able to get up. This is a self limiting condition that has no clear cause.
Generalised Anxiety Disorder
In the presence of excessive anxiety for most days for at least 6 months and at least 3 of the following:
- restlessness,easy fatigue, poor concentration, irritability, muscle tension, sleep disturbance without obvious cause.
The symptoms are reproduced by hyperventilation. I treat this with antidepressants.
Cardiac Syncope:
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