1. DIZZINESS AND SYNCOPE « PAIN OR PLEASURE » Jacques Bédard MD CSPQ FRCP (C)

2. FIRST STEP IDENTIFY TYPE OF DIZZINESS Type I: Vertigo (Vestibular - Central Nervous System) Type II: Presyncope (Cardiovascular) Type III: Walking disequilibrium (Neuromuscular) Type IV: Light headedness (Plus non specific symptoms) (Hyperventilation)

3. Second step: Type I: Vertigo SYMPTONS: Diplopia – Dysarthria Bilateral loss of vision SIGNS: Hemiparesis - hypoesthesia Ataxia VESTIBULARCENTRAL NERVOUS SYSTEM Nystagmus

4. Peripherical vestibular vertigo Third Step: Type I: Peripherical vestibular vertigo Syndrome Labyrinthitis (Vest.N.) Recurrent neuronitis Meniere’s disease Positional vertigo Periodicity 0 + recurrent ++ recurrent +++ recurrent Other 0 Tinnitus  Hearing ∆ Position < 1 minute 10 min - 20hrs 2 days-2 weeks Duration

5. “Objective”: Confirms the diagnosis “ Subjective”: Suggests the diagnosis not Does not rule out the diagnosis Dix Hallpike Positive Negative HISTORY is diagnostic

6. a b c a b a b c a EPLEY’s manoeuver: ex. RIGHT EAR) (Right ear: rotation from right to left- Left ear: rotation from left to right First rotation of the HEAD of 90 degrees (B to C) and second rotation of the SHOULDERS of 90 degrees (C to D), keeping each position B - C - D during 1 1/2 minutes.

7. POSITIONAL VERTIGO: Day 1: Vertical position – sleeping, head elevated Normal activities afterward Provoque vertigo in left -right decubitus (Identifies involved ear) Repeat posterior canal manoeuver (Patient himself) Horizontal canal?: specific manoeuver Recurrence rate: 15% (Mobile otolith) Inform the Patient Recurrence

8. 1)Wrong diagnosis 2)Wrong ear 3)Wrong position: cervical arthrosis - position “D” < 4)Wrong “timing”: < 1 1/2 min each position 5)Wrong canal: horizontal canal? (other manoeuver) “We shall never surrender!” (Churchill) Epley’s manoeuver: FAILURE?

9. System Sudden Cardiovascular (90%) Neuro (epilepsy) Metabolic Type II: Presyncope Presyncope = cardiovascular syncope Syncope Onset Sudden Slow Recovery Sudden Slow

10. FIRST STEP Type II: Presyncope « MER » M echanical: Aortic Stenosis - Left atrium Myxoma E lectric: bradycardia, tachycadia ( s upra. or Ventricular) AV block, prolonged sinus pauses... R eflex: vagal - «cardiac reflex» - micturition - etc.

11. Second Step: Type II: Presyncope “Initial evaluation” History (sens. 95% - spec. 45%) Physical ECG Opinion Specific diagnosis (75 %) Normal heart / Sick heart (REFLEX: 70%) (ELECTRIC: 70%)

12. Past History - Medication Onset: Advanced age Position: Lying down Concomitant Symptoms: –Chest pains –Palpitations Past history Onset: Young age Position: Standing Activity: Micturition - cough - etc Stimulus: Pain - Discomfort Concomitant Symptoms: –Nausea - Vomiting –Yawning - Fatigue +++ Second Step: Type II History Normal Heart Reflex Cardiac Sick Heart

13. Second Step: Type II Physical BP Lying - Standing: orthostatic hypotention Diminution BP 20 mmHg standing position Carotid sinus massage Aortic murmur Heart failure signs: – Increased jugular veins - pulmonary rales – S3(+) - Legs oedema

14. Second Step: Type II Electrocardiogram Sinus bradycardia (diagnostic if 3 seconds Bifascicular bundle branch block Second degree AV block (Mobitz I) Prolong QT (> 500 milliseconds) WPW Brugada’s syndrome Supraventricular or ventricular tachycardia Myocardial infarction (old or new)

15. Normal Heart Ambulatory Monitoring Carotid Sinus Massage Loop recorder Tilt table test Sick Heart Hospit - ambul. monitoring Echo - Treadmill Loop recorder EPS Third Step: Type II « SPECIFIC EVALUATION »

16. PROVOQUE PATIENT’S HYPERVENTILATION IDENTIFICATION by the patient of the cause of his symptoms “Break vicious circle” EXPLANATION of “respiratory alcalosis” RECOGNITION of controlling the symptoms by breath holding ELABORATION of strategies for stress management Second Step: Type IV

17. INITIAL EVALUATION History - Physical - ECG DIAGNOSIS OR Normal heart - Sick heart %) (Réflex: 70%) (Electric: 70%) Presyncope (Cardiovascular) Vertigo ( ( Vestibular - CNS) Disequilibrium (Neuromuscular) Lightheadedness ( Anxiety) VESTIBULAR CNS (Focal sings - symptoms) Physical Neurological - Locomotor HYPERVENTILATION SPECIFIC EVALUATION Normal heart Sick heart Carotid sin. Massage Treadmill-Echo. Loop recorder Loop recorder Tilt table test EPS BPV Dix Hallpike-Epley Meniere’s disease Labyrinthitis (vestibular neuronitis) Acoustic neurinoma Vascular - Inflammatory - Tumoral (CT - Magnetic resonnance) Recognizes the cause of physical symptoms 1 STEP 2 STEP 3 STEP