Speaker Disclosures: 12/4/2015 DIZZINESS AND NEAR SYNCOPE. I have no relevant commercial relationships to disclose

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1 DIZZINESS AND NEAR SYNCOPE Bernard Gran, M.D. Neurologist, Co-Chief, Department of Neuroscience Baptist Health Neuroscience Center Speaker Disclosures: I have no relevant commercial relationships to disclose We guarantee that by the end of this lecture, each and every one of you will be able to differentiate between the benign and malignant causes of dizziness and near syncope... 1

2 Most of the time Dizziness Vertigo Lightheaded Near Syncope Syncope Decrease Balance Disequilibrium Almost 50% of the time no further history is obtained in the E.R. 2

3 Precipitating Factors: Position when episode occurred Prior vomiting or diarrhea Tinnitus Hearing deficit Differential Diagnosis: Cerebral Hypoperfusion Peripheral Lesion Central Lesion Cerebral Hypoperfusion: Arrythmias Aortic Stenosis Orthostatic Hypotension 3

4 Peripheral Lesion: BPPV Meniere s Central Lesion: Ischemic-VBI Mass Lesion DO NOT MISS Stroke Tumor Cardiac 4

5 Cost: Dizziness as presenting symptom in E.R $3.9 billion 2015 $4.4 billion ER E.R. visits million million A 97% increase Johns Hopkins We can save an estimated $1 billion by cutting out indiscriminate use of Cat Scans (CTs) Cat Scan miss almost 80% of strokes in the early stages Imaging tests on dizziness as presenting symptom has quadrupled since 1995 Johns Hopkins No real reliable, validated protocols for dizziness 5

6 Take Syncope Predictors: San Francisco Syncope Rules Boston Syncope Rules San Francisco Syncope Rules: History of CHF Hematocrit less than 30% EKG abnormalities SOB Systolic BP less than 90mm hg at triage 2-5% negative predictive value Ann Emergency Med 11/05 J Quinn Boston Syncope Rules: CP, SOB ABN EKG Worrisome cardiac hx Family Hx of sudden death Significant heart murmur Signs of conduction disease Volume depletion Persistent abnormal vs Primary CNS event 1% negative predictive value J emergency Med 10/07 S Grossman 6

7 With syncope, the cause is identified 48.3% of time Postural BP changes has a 58.7% yield History taken has a 19.7% yield Only 1.7% of money spent effectively Southern Ned Journal 11/14 P Johnson Evaluation of Dizziness: History Orthostatic blood pressure Physical exam Orthostatic Hypotension: Defined as a drop in systolic BP 20mm hg or more Drop in diastolic BP 10mm hg or more within 3 minutes of standing Arch Int Med 1992 Streeten & Anderson 7

8 DOH Delayed Orthostatic Hypotension: Orthostatic hypotension after 3 minutes DOH will progress to oh over time Similar disease mechanisms Similar long term complications Neurology 2015 C Gibbons, R Freeman Physical Exam: Look at the eyes Horizontal head impulse test Dix-hallpike maneuvers 8

9 Horizontal Head Impulse Test: Ask the patient to focus on a spot on the wall as clinician moves the patient's head from side to side. The clinician focuses their attention on the patient's eyes. If the patient is making fast, corrective eye adjustments in response to the head movements, that would indicate the patient experiencing a benign form of dizziness rather than a stroke D Newman-Toker, MD Johns Hopkins iphone App: SLOW MO $0.99 9

10 Dix-Hallpike Maneuver: Patient sits on exam table. Clinician turns patient s head degrees to one side and quickly tilts patient back with head hanging 20 degrees over the end of the exam table. Repeat procedure with head turned to the other side. If no vertigo or nystagmus, bpv less likely 5-10 second latency rotatory nystagmus, likely positive for BPV Fast phase of rotatory nystagmus is toward the affected ear (ear closest to the ground) Proc Royal Soc Med 1952 Dix, Hallpike Evidence-based Efficient Cost Effective vs. Risk Litigation Baptist Rules for Dizziness/Vertigo: Sx for at lest 72 hours No history of prior stroke No history of cancer No cardiac history or symptoms Normal neurological exam Orthostatic hypotension Positive hallpike Normal labs - CBC, Chem profile 10

11 Questions Comments Complaints 11

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