医学]晕厥的诊断与处理.ppt

晕厥的诊断与处理,Syncope,晕厥的诊断与处理,晕厥的概念 晕厥的诊断 晕厥的治疗,一. 晕厥的一般概念,什么是晕厥?,突发、短暂的意识丧失伴晕倒 突然脑灌注不足 与猝死的不同能“醒过来”,Definition of Syncope,Syncope is a symptom, the defining clinical characteristics of which are: 1. Transient 2. Self-limited loss of consciousness leading to falling 3. Onset is relatively rapid 4. Recovery is spontaneous, complete, and usually prompt.,症状四大特点,临床症状: 自发的意识丧失 快速性 有先兆 自限性、完全恢复（与猝死的差别）,晕厥的原因(晕厥门诊),Orthostatic,Cardiac Arrhythmia,Structural Cardio- Pulmonary,*,1 Vasovagal Carotid Sinus Situational Cough Post- micturition,2 Drug Induced ANS Failure Primary Secondary,3 Brady Sick sinus AV block Tachy VT SVT Long QT Syndrome,4 Aortic Stenosis HOCM Pulmonary Hypertension,5,Cerebro- vascular,Neurally- Mediated,Unknown Cause = 18%,56%,2%,20%,3%,1%,Alboni P, et al. JACC 2001; 37: 1921-1928,Steal Syndrome TIA Epilepsy,Classification of transient loss of consciousness,Syncope 1.Neurally-mediated reflex syncopal syndromes 2.Cardiac arrhythmia as primary causes 3.Structural cardiac or cardiopulmonary diseases 4.Cerebrovascular,Non-syncopal attacks 1. With impairment or loss of consciousness 2. Without loss of consciousness,Causes of Syncope,1. Neurally-mediated reflex syncopal syndromes a. Vasovagal faint b. Carotid sinus syncope c. Situational faint: Acute haemorryaging Coughing, sneezing Gastrointestinal stimulation(swallowing, defacation, visceral pain) Micturation(Post-micturation) Post-exercise Other(e.g. Brass instrument playing, weighlifting, post- prandial) D. Glossopharyngeal and trigeminal neuralgia,Causes of Syncope( cont.),2. Orthostatic hypotension Autonomic failure Primary autonomic failure syndromes(e.g. pure autonomic failure, multiple system atrophy, Parkisons disease with autonomic failure) Secondary autonomic failure syndrome(e.g. diabetic neuropathy, amyloid neuropathy) Post-exercise, post-prandial Drugs and alcohol Volume depletion Haemorryaging, diarrhea, Addisons disease,Orthostatic Syncope,Orthostatic Syncope is diagnosed when there is documentation of orthostatic hypotension associated with syncope or presyncope. Orthostatic Bp measurements are recommended after 5 min of lying supine, followed by each min or more often, after standing for 3 min. Measurements may be continued longer, if Bp is still falling at 3 min. If patient does not tolerate standing for this period, the lowest Sp during the upright posture should be recorded. A decrease in Sp 20mmHg or a decrease of Sp to 90 mmHg is defined as orthostatic hypotension regardless of whether or not symptoms occure,Causes of Syncope( cont.),3. Cardiac arrythmias as primary cause 1.Sinus node disfunction 2.Atrioventricular conduction system disease 3.PSVT and VT 4.Inherited syndromes(long QT syndrome, Brugada syndrome) 5.Implanted device(pacemaker, ICD) malfunction or drug-induced proarrythmias,Causes of Syncope( cont.),4. Structural cardiac or cardiopulmonary diseases Cardiac valvular disease a.AMI/ischemia b.Obstructive cardiomyopathy c.Atrial myxoma d.Acute aortic dissection e.Pericardial disease/tamponade f.Pulmonary embolus/pulmonry hypertension g.Obstructive cardiac disease 5. Cerebrovascular Vascular steal syndromes,Causes of Non-syncope Attacks (Commonly misdiagnosed as syncope),1.Disorders with impairment or loss of consciousness a.Metabolic disorders(hypoglycaemia, hypoxia, hyperventilation with hypocapnia b.Epilepsy c.Intoxication d.Vertebro-basilar TIA 2. Disorders resembling syncope without loss of consciousness a.Cataplexy b.Drop attacks c.Psychogenic “syncope”(somatization disorders) d.TIA of carotid origin,二. 晕厥的诊断,神经科医生,心脏科医生,Initial evaluation important historical features,1、Questions about circumstances just to attack Position(supine,sitting or standing) Activity(supine,during or after exercise) Situation(urination,defecation,cough or swallowing) Predisposing factors(e.g.,crowded or warm places,prolonged standing,post-prandial period) Precipitating events(e,g.,fear,intense pain,neck movements) 2、 Questions about onset of attack Nausea,vomiting,feeling of cold,sweating,aura,pain in neck or shoulders 3、 Questions about attack(eyewitness) Skin colour(pallor,cyanotic) Duration of loss of consciousness Movements(tonic-clonic,etc) Tongue biting,5、 Questions about end of attack Nausea,vomiting,diaphoresis,feeling of cold,confusion,muscle aches,skin colour,wounds 6、 Questions about background Number and duration of syncopes Family history of arrhyhmogenic disease Presence of cardiac disease Neurological history(parkinsonism,epilepsy,narcolepsy) Internal history(diabetes,etc.) Medication(hypotensive and antidepressant agents),Initial evaluation important historical features,Initial evaluation Diagnostic criterion,Vasovagal syncope is diagnosed if precipitating events such as fear,severe pain,emotional distress,instrumentation and prolonged standing are associated with typical prodromal symptoms. Situational syncope is diagnosed if syncope occurs during or immediately after urination,defecation,cough or swallowing. Orthostatic syncope in diagnosed when there is a documentation of orthostatic hypotension associated with syncope or presyncope.,Initial evaluation ECG diagnostic criteria,Syncope due to cardiac arrhythmia is diagnosed in case of: Symptomatic sinus bradycardia3s Mobitz II 2nd or 3rd degree atrioventricular block Alternating left and right bundle branch block Rapid paroxysmal tachycardia Pacemaker malfunction with cardiac pauses,Initial evaluation ECG diagnostic criteria,Syncope due to cardiac ischemia is diagnosed when symptoms are present with ECG evidence of acute myocardial ischaemia with or without myocardial infarction.,Clinical and ECG features Suggesting Cardiac Syncope,Syncope during exertion or supine Palpitations at the time of syncope Suspected VT(e.g. heart failure or NSVT) BBB Mobitz 1 second degree AVB Sinus bradycardia50bpm WPW Long QT ARVD or Brugada S.,Clinical and ECG features Suggesting Neurally-mediated Syncope,After sudden unexpected unpleasant sight,sound,or smell Prolonged standing or crowded,warm places. Nausea,vomiting associated with syncope. Within one hour of a meal(post-prandial). After exertion. Syncopal with throat or facial pain (glossopharyngeal or trigeminal neuralgia). With head rotation,pressure on carotid sinus(spontaneous carotid sinus syncope),Laboratory investigations,Certain or suspected heart disease,yes,no,Cardiac evaluation -Echocardiogram -ECG monitoring -Exercise test -EP study -ILR,NM evaluation -Carotid sinus massage -Tilt testing -ATP test -ILR,Laborarory investigations,Useful (when indicated),Almost never useful,Carotid sinus massage Tilt testing Echocardiogram Holter/loop monitoring Electrophysiological test Exercise stress testing Implantable loop recorder EEG CT scan & MNR Carotid Doppler sonography Ventricular SAECG Coronary angiograhpy Pulmonary scintigraphy,初步诊断 病史、体检、ECG 、BP 实验室检查 Holter、Loop、HUT 危险性评价,诊断及评价,晕厥症状,真晕厥,诊断明确,病史 + 体检 + 心电图,除外诊断,治疗,诊断不明确,详细病史、家族史 查体,心脏病诊断程序,晕厥诊断程序,?,（ 1 ）诊断及鉴别诊断,晕厥过程描述 本人及目击者 发作方式 发作持续时间 姿势 伴随症状 后果,病史问什么 12-导 ECG,正常与否? AMI 严重心动过缓及长间隙 AV 及束支阻滞 心动过速(SVT, VT) WPW, LQT, Brugada,诊断的“金标准” 在自发症状时记录到症状相关 ECG 可做出初步诊断,诊断及鉴别 诊断,（ 2 ） Holter/ILR,*Medtronic data on file,21%因晕厥查Holter 2%有心律失常+晕厥 15%有晕厥但无心律失常,用于间隔较长的复发者常规检查不能确诊,心脏电生理检查,有用有限的评价方法 对器质性心脏病更有意义 SHD 50-80% 无 SHD 18-50% 对心动过缓意义不大 ACC/AHA/NASPE: Class I 指征: 合并器质性心脏病不明原因晕厥,有意义的指标,诱发出单形室速 诱发出 SVT 伴低血压 SNRT 3000 ms or CSRT 600 ms HV interval 100 ms 心房起搏诱发结下阻滞,脑 电 图,非一线选用 鉴别晕厥和癫痫 癫痫 发作间期也有异常 晕厥正常,颈动脉窦按摩(CSM),先右后左 按摩而不是阻断 按摩时间5-10秒 立位或卧位 记录心电及血压,3秒长间隙 50mmHg收 缩压下降 症状,+,血管迷走性晕厥,可通过倾斜试验诊断，阳性率为50，特异性为90 ，异丙肾可提高诊断率 低血压、心动过缓、心脏停跳 75% 的患者为心脏抑制型和混合型 已有研究显示在部分患者起搏治疗有助益,DG Benditt, UM Cardiac Arrhythmia Center,不明原因晕厥,仍然有死亡及损伤的危险 生活质量下降 反复就诊/诊断、就诊/诊断,（ 3 ）危险程度评估,高危人群 心脏源性 独立高危因素 SCD危险性高于非心脏源性、原因不明 一年死亡率18-33% （非心脏0-12%、原因不明6% ） 合并器质性心脏病,神经源性预后好但反复发作/就诊 反复发作性并不代表预后差 老年人主要看是否合并心脏病,危险程度评估,三. 晕厥的治疗,晕厥的治疗,一旦明确