暈厥的診斷與處理,Syncope,暈厥的診斷與處理,暈厥的概念暈厥的診斷暈厥的治療,一.暈厥的一般概念,什么是暈厥?,突發(fā)、短暫的意識(shí)喪失伴暈倒突然腦灌注不足與猝死的不同能“醒過來”,DefinitionofSyncope,Syncopeisasymptom,thedefiningclinicalcharacteristicsofwhichare:1.Transient2.Self-limitedlossofconsciousnessleadingtofalling3.Onsetisrelativelyrapid4.Recoveryisspontaneous,complete,andusuallyprompt.,癥狀四大特點(diǎn),臨床癥狀:自發(fā)的意識(shí)喪失快速性有先兆自限性、完全恢復(fù)（與猝死的差別）,暈厥的原因(暈厥門診),Orthostatic,CardiacArrhythmia,StructuralCardio-Pulmonary,*,1VasovagalCarotidSinusSituationalCoughPost-micturition,2DrugInducedANSFailurePrimarySecondary,3BradySicksinusAVblockTachyVTSVTLongQTSyndrome,4AorticStenosisHOCMPulmonaryHypertension,5,Cerebro-vascular,Neurally-Mediated,UnknownCause=18%,56%,2%,20%,3%,1%,AlboniP,etal.JACC2001;37:1921-1928,StealSyndromeTIAEpilepsy,Classificationoftransientlossofconsciousness,Syncope1.Neurally-mediatedreflexsyncopalsyndromes2.Cardiacarrhythmiaasprimarycauses3.Structuralcardiacorcardiopulmonarydiseases4.Cerebrovascular,Non-syncopalattacks1.Withimpairmentorlossofconsciousness2.Withoutlossofconsciousness,CausesofSyncope,1.Neurally-mediatedreflexsyncopalsyndromesa.Vasovagalfaintb.Carotidsinussyncopec.Situationalfaint:AcutehaemorryagingCoughing,sneezingGastrointestinalstimulation(swallowing,defacation,visceralpain)Micturation(Post-micturation)Post-exerciseOther(e.g.Brassinstrumentplaying,weighlifting,post-prandial)D.Glossopharyngealandtrigeminalneuralgia,CausesofSyncope(cont.),2.OrthostatichypotensionAutonomicfailurePrimaryautonomicfailuresyndromes(e.g.pureautonomicfailure,multiplesystematrophy,Parkisonsdiseasewithautonomicfailure)Secondaryautonomicfailuresyndrome(e.g.diabeticneuropathy,amyloidneuropathy)Post-exercise,post-prandialDrugsandalcoholVolumedepletionHaemorryaging,diarrhea,Addisonsdisease,OrthostaticSyncope,OrthostaticSyncopeisdiagnosedwhenthereisdocumentationoforthostatichypotensionassociatedwithsyncopeorpresyncope.OrthostaticBpmeasurementsarerecommendedafter5minoflyingsupine,followedbyeachminormoreoften,afterstandingfor3min.Measurementsmaybecontinuedlonger,ifBpisstillfallingat3min.Ifpatientdoesnottoleratestandingforthisperiod,thelowestSpduringtheuprightpostureshouldberecorded.AdecreaseinSp20mmHgoradecreaseofSpto600msHVinterval100ms心房起搏誘發(fā)結(jié)下阻滯,腦電圖,非一線選用鑒別暈厥和癲癇癲癇發(fā)作間期也有異常暈厥正常,頸動(dòng)脈竇按摩(CSM),先右后左按摩而不是阻斷按摩時(shí)間5-10秒立位或臥位記錄心電及血壓,3秒長(zhǎng)間隙50mmHg收縮壓下降癥狀,+,血管迷走性暈厥,可通過傾斜試驗(yàn)診斷，陽(yáng)性率為50，特異性為90，異丙腎可提高診斷率低血壓、心動(dòng)過緩、心臟停跳75%的患者為心臟抑制型和混合型已有研究顯示在部分患者起搏治療有助益,DGBenditt,UMCardiacArrhythmiaCenter,不明原因暈厥,仍然有死亡及損傷的危險(xiǎn)生活質(zhì)量下降反復(fù)就診/診斷、就診/診斷,（3）危險(xiǎn)程度評(píng)估,高危人群心臟源性獨(dú)立高危因素SCD危險(xiǎn)性高于非心臟源性、原因不明一年死亡率18-33%（非心臟0-12%、原因不明6%）合并器質(zhì)性心臟病,神經(jīng)源性預(yù)后好但反復(fù)發(fā)作/就診反復(fù)發(fā)作性并不代表預(yù)后差老年人主要看是否合并心臟病,危險(xiǎn)程度評(píng)估,三.暈厥的治療,暈厥的治療,一旦明確診斷，治療具有針對(duì)性目標(biāo)降低死亡率預(yù)防復(fù)發(fā)改善生活質(zhì)量不明原因暈厥，治療目標(biāo)不清楚有爭(zhēng)議病人教育,器質(zhì)性心臟病流出道梗阻泵衰竭心包壓塞主動(dòng)脈夾層電生理異常特殊類型神經(jīng)系統(tǒng)病變,小結(jié),暈厥在臨床常見，但在合并器質(zhì)性心臟病的患者會(huì)增加死亡率心律失常性暈厥占20%以上并具有致命性與心動(dòng)過緩相關(guān)的神經(jīng)介導(dǎo)性暈厥約占50%，預(yù)后常較好18-47%的暈厥為不明原因,FlowChatforsyncopediagnosis,AHA/ACCFScientificStatement,Syncope,History,physicalexamination,ECG,Diagnosisfororthostatichypotensionorneurocardiogenicsyncope,Unexplainedsyncope:ECG,exercisetest,ischemiaevaluation,POSITIVE:1.Structureheartdisease:Tx2.Ischemia:Tx3.Arrhythmia:EPexaminationAbalation,ICD4.MI:ICD5.EF0.3:ICD,Normal,Cont,Normal(Cont),Single,benignepisode,Evaluationcomplete,Frequentepisode,CorrelatesymptomswithrhythmwithHoltororeventm