晕厥的诊断与处理

1、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. Recov

2、ery 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 b

3、lock 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-medi

4、ated 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

5、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. Glossopharyng

6、eal 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, amylo

7、id 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

8、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

9、 in Sp 20mmHg or a decrease of Sp to 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

10、 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,一旦明确诊断，治疗具有针对性 目标 降低死亡率 预防复发 改善生活质量 不明原因晕厥，治疗目标不清楚有争议 病人教育,器质性心脏病 流出道梗阻 泵衰竭 心包压塞 主动脉夹层 电

11、生理异常 特殊类型 神经系统病变,小 结,晕厥在临床常见，但在合并器质性心脏病的患者会增加死亡率 心律失常性晕厥占20%以上并具有致命性 与心动过缓相关的神经介导性晕厥约占50%，预后常较好 18-47%的晕厥为不明原因,Flow Chat for syncope diagnosis,AHA/ACCF Scientific Statement,Syncope,History, physical examination, ECG,Diagnosis for orthostatic hypotension or neurocardiogenic syncope,Unexplained syncope: ECG, exercise test, ischemia evaluation,POSITIVE: 1.Structure heart disease: Tx 2.Ischemia: Tx 3.Arrhythmia: EP examination Abalation, ICD 4.MI: ICD 5.EF0.3: ICD,Normal,Cont,Normal (Cont),Single, benign episode,Evaluation complete,Frequent episode,Correlate symptoms with rhythm with Holtor or ev