THE DISCOMFORTS
I.DEFINITION
- Malaise is a feeling of unease with an imminent impression of loss of consciousness, which may or may not occur more or less completely.
- Acute pathological situation felt by the patient or those around him as a change in his previous state. The return to normal is spontaneous, rapid or progressive.
- Questioning, clinical examination, and simple paraclinical tests provide the diagnosis in 70 to 80% of cases.
- No relationship Loss of consciousness (LC) / severity of underlying pathology.
- The absence of PC does not eliminate a cardiac cause.
II. POSITIVE DIAGNOSIS
- Based on questioning the patient, those around them and any eyewitnesses.
- Collect information from paramedics, firefighters, relatives, etc.
- Circumstances of gradual, sudden onset,
Time to meal
Effort
Position changes
Prolonged standing
Emotion, pain
Urination, coughing effort, cervical compression
Fall, trauma, wound
Potential source of nitric oxide (CO)
- recovery mode, accompanying signs.
Symptoms
The malaise can present itself in different ways. It includes the inconsistent association of several symptoms such as a feeling of sudden anxiety underpinned by clinical signs, sometimes accompanied by pain, difficulty breathing , feeling of lack of air, sweating, palpitations, nausea, and tingling.
The discomfort also manifests itself through visual disturbances with black veil before the eyes, dizziness , a feeling of general weakness, abnormal movements and imminent loss of consciousness.
III. DIFFERENTIAL DIAGNOSIS
- acute, regressive with impaired vigilance
- Pathological conditions of gradual onset
- Pathological conditions where symptoms do not resolve:
Disturbances of consciousness, persistence of chest or abdominal pain, palpitations, headache, dyspnea, neurological deficit, signs of infection or psychiatric disorders.
- Discomfort is an associated sign and often a sign of severity.
IV. ETIOLOGICAL DIAGNOSIS
Questioning, clinical = diagnostic orientation in 50 to 70% of cases
Complete clinical examination:
• Careful cardiology and neurology
• Traumatic injuries?
Questioning and examinations:
- ECG = only mandatory examination.
- Vasovagal: 50%
- Cardiac: 5 to 20%
- Orthostatic hypotension: 10%
- Other causes:
– Epilepsy
– Alcohol poisoning
– CO
– psychiatric
- Cardiac
• Syncope suggests a cardiac cause (neither sensitive nor specific) as well as:
• Cardiac history
• Occurrence during exercise
• Taking antiarrhythmic medication
• Chest pain
• Palpitations
• Dyspnea
Questioning and clinical examination provide immediate guidance
1- Obstructive heart disease
• aortic stenosis (AS)
• obstructive cardiomyopathy (OCM)
2- Conduction disorders
• Safe: complete atrioventricular block (AVB)
•Possible: right bundle branch block (LBB) and left posterior hemi block (LPHB)
3- Heart rhythm disorders
• Sinus dysfunction, atrial rhythm disease.
• Paroxysmal tachycardias.
• Long QT (antiarrhythmic treatment, hypokalemia).
4 – syncopal angina
• Myocardial infarction
b) Orthostatic hypotension
- Wanted in principle:
– at least 5 minutes.
– 30 mm Hg decrease in PAS (systolic), 20mmHg PAD (diastolic).
– Reproduction of symptoms.
- Iatrogenic
– Diuretics
– Antihypertensives
– Antidepressants, neuroleptics
– Nitrates
– Beta blockers
- True or relative hypovolemia
- Peripheral neuropathy, Parkinson’s
- neurocardiogenic = vasovagal discomfort
- Vasovagal discomfort: 50% of etiologies
– Often typical
• Favoring circumstances, prodromes
• PC 1 time out of 2
• Asthenia
• Young subject
• History of discomfort
• Tilt test
– Sometimes less typical: angina, etc.
- Neurological
- Epilepsy:
– Generalized: problem if there are no eyewitnesses
– Partial: more difficult diagnosis
- EEG without clinical orientation has little value
• Neurovascular accident: exceptionally
e) Various diagnostics
- Metabolic
1) Hypoglycemia always drug-induced Deep, not reversible without treatment.
2) Ionogram disorders
- Poisoning
- To carbon monoxide
Syncope, headache, dizziness, vomiting
Collective, family context
Faulty heating
- Acute alcoholic +++
Systematic research in the event of any unexplained discomfort
- Psychiatric
Depressive syndromes
Panic attacks, somatization
V. SUPPORT
- Contact emergency services (the fall may have caused trauma).
- Lay the person down in a quiet place.
- You can also loosen his clothes to help him breathe better.
- Adequate water intake.
- wearing support stockings may be considered.
- If the patient remains unconscious for more than 5 minutes: secure lateral position.
VI. CONCLUSION
- Vagueness of the term discomfort.
- Wide variety of possible diagnoses.
- Clinic and ECG are usually sufficient.
SYNCOPE
I. Introduction
- Syncope: loss of consciousness and postural tone, sudden, complete, of brief duration, with complete spontaneous recovery, linked to global and transient cerebral hypoperfusion.
- Lipothymia: same pathophysiology: cerebral ischemia, but simple obtundation, without true loss of consciousness, with more gradual onset and end and generally longer duration, the etiologies may be the same.
- They represent 3 to 5% of admissions to emergency services
- They must be recognized within brief losses of consciousness.
- We must then try to link them to a specific etiology, knowing that cardiac causes are the most threatening, but not the most frequent.
- Sometimes preceded by accompanying signs “prodromal phase”
-Obsessed.
– general malaise, feeling of weakness.
– sweats.
– drooling, nausea or even vomiting.
– ringing in the ears, “bell” noise.
-empty head impression.
-visual disturbances: fog, veil before the eyes sometimes
- Recovery + slow, with in order: hearing, then sight, then postural tone.
II. INTERROGATION (patient and entourage)
Questions about the context
- Family history of sudden death, arrhythmogenic congenital heart disease, or fainting.
- of heart disease.
- neurological (Parkinson’s, epilepsy).
- Metabolic disorders (diabetes, etc.)
Most often, the doctor does not attend the syncope , and it is therefore necessary to try to get the patient and those around them to clarify:
- start and end: abrupt or gradual
- PC reality
- duration ?
- amnesia?
- the circumstances just before the episode: Position (lying, sitting or standing) Activity (resting, during or after exercise)
III. CLINICAL EXAMINATION
-cardiovascular time:
TA lying down and standing up,
Pulse taking, cardiac and vascular auscultation,
ECG, ± sino-carotid massage after elimination of a murmur, massage of the carotid sinus under control of blood pressure and continuous ECG for 5 seconds, first on the right then 30 seconds later on the left.
– neurological time:
Ex of motor, sensitive, sensory functions; signs in focus?
– general examination.
THE DISCOMFORTS
IV. PARACLINICAL EXAMINATIONS
- biological: blood sugar, blood ionogram, FNS, cardiac enzymes, calcemia.
- ECG if not done, looking for signs of sinus bradycardia, sinoatrial block, bi or tri fascicular bundle branch block, AV block), threatening ventricular extrasystoles (ESV).
- Other additional examinations will be guided by the initial findings:
– Holter.
-late potentials.
– stress test
– echocardiogram
- Complete neurological side:
-EEG baseline, ± after sleep deprivation.
– echo-Doppler of the neck vessels.
V. ETIOLOGY
A°SYNCOPES OF CARDIAC ORIGIN
Not the most frequent: 1/10 but serious, because of the risk of sudden death.
1° rhythm and conduction disorders:
-Paroxysmal bradycardia, AV block, atrial rhythm disease.
-Malfunction of a pacemaker or defibrillator.
– Supraventricular tachycardia, Ventricular tachycardia.
2° coronary insufficiency
3° obstacles to ventricular ejection or filling
-aortic stenosis (AOS): during exercise.
– tamponade.
4° advanced heart failure, particularly dilated cardiomyopathies.
B°SYNCOPES OF ORTHOSTATIC HYPOTENSION : Occurs upon waking due to failure to readjust blood pressure, significant and persistent drop ≥ 20 mm Hg for systolic ≥ 10 mm Hg for diastolic.
HYPOVOLEMIA
- 1 TRUE
– dehydration: diarrhea, vomiting, fever.
Iatrogenic: diuretics in the elderly ++
– hemorrhage: internal, digestive ++, spoliation anemia.
Iatrogenic: NSAIDs.
2 RELATIVE
- – varicose veins (–> elastic support)
Iatrogenic: nitrate derivatives, potassium channel activators, too high doses.
- alcohol
C°SYNCOPES -VASOVAGAL most frequent in practice, also called “neurocardiogenic”
D° IN AROUND 40% OF CASES NO CAUSE FOUND
- Their prognosis is not necessarily worse.
- Recurrence is more or less frequent depending on the cause.
- Cardiac causes promote sudden death.
VII. CONDUCT TO BE ADOPTED
THE DISCOMFORTS
THE DISCOMFORTS
SYNCOPE DUE TO ORTHOSTATIC HYPOTENSION
- Adequate hydration and sodium intake (2 to 3 L of fluid and 10 g NACL) should be maintained .
- Midodrine should be added if necessary (5-20 mg, 3 times/day)
- Fludrocortisone should be administered in addition if necessary (0.1 – 0.3 mg, once a day)
- Elastic support of the lower limbs and abdominal bandages may be considered to reduce venous storage.
- Sleeping with the head elevated more than 10° can help increase blood volume.
THE DISCOMFORTS
VIII. CONCLUSION
- The primary goal of syncope management is to reduce sudden death.
- It is the initial assessment that will allow risk stratification and guide additional examinations.
- Wide variety of possible diagnoses.
- Clinic and ECG are usually sufficient.
THE DISCOMFORTS
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