ipotensione sincope...
TRANSCRIPT
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IPOTENSIONE
IPOTENSIONE
IPOTENSIONEORTOSTATICA SINCOPE
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Controllo della pressione arteriosa in ortostatismoStazione eretta
Aum.t.simpaticoRid.t.vagale
Pooling venoso
Riduz.rit.venoso
Rid.riempimento ventric. Dx e Sin
de-attivazione barocett. arteriosi e cardiopolm.Centro.vasom.ventromed.mid.allung.
Venocostriz.
compensa.rit.venoso
FLUSSO CEREBRALE
Vasocostriz arteriol.
Mantiene press.art.
Attiv.SRA
Aum ADHRitenzione Na+
Rid.portata cardiaca
ipocapnia
Aum.ventilazione
Rid.PRESSIONE ART.
Rid.fl.cerebrale
Mantiene portata cardiaca
Aum.FC& contratt.
Volemia/rit.venoso
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SINCOPE
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SINCOPE
•Perdita di coscienza totale, dovuta ad anossia cerebrale•Ad inizio brusco: SENZA ALCUN PRODROMO oppure CON PRODROMI•Responsabile della perdita del tono posturale•Con ritorno spontaneo ad uno stato di coscienza normale
Movimenti anormali, convulsioniPerdita di urine e feci
Prodromi: •Annebbiamento visivo•Ronzii auricolari/vertigini•Nausea•Sensazione di calore•Sudori•Palpitazioni•Dolori toracici•Dispnea•Senso di testa vuota
Segni post-critici: Digestivi: vomitoNeurologici: obnubilazione
amnesiadeficit sensitivo-motorioastenia
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La sincope può essere dovuta ad una lunga serie di cause, che spessosfuggono ad una identificazione precisa.
È responsabile di un gran numero di ricoveri ospedalieri e comporta unamorbilità elevata
Può avere una prognosi infausta nei pazienti con cardiopatia di base..altrimenti è solitamente a prognosi benigna
SINCOPE
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L’esame clinico del paziene affetto da sincopedeve essere sistematicamente orientato adevidenziare:
alterazioni cardiache,lesioni vascolari,ipotensione ortostatica,o una disfunzione neurologica.
SINCOPE
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alterazioni cardiache,(lesioni vascolari)(ipotensione ortostatica)(disfunzione neurologica)
SINCOPE
Forme Neuromediate
Prognosipotenzialmente
infausta(rischio di morte
improvvisa)
Conseguenzeinvalidanti(ripetizione
degli episodi ecadute)
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50%
5-%
10%
25%
IpoglicemiaIpossiaIperventilazioneGravi anemie
s.vascolari20%
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La sincope riflessa o vasovagale o neuromediataè frequente e si manifesta secondariamente a 3ordini di cause:
1- a riduzione del ritorno venoso e delriempimento cardiaco (=SVV periferiche)
2- o per stimoli al sistema nervoso centralederivanti da paura o dolore (=SVV centrali)
3- o per stimolazione diretta di afferenzeparasimpatiche/barocettori (=SVV situazionali)
SINCOPE VASOVAGALE
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Riduzione ritorno venoso e sincope vasovagale
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sincopi vasovagali situazionali e centrali
centrali
Situazionali
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Massaggio del seno carotideo,usato dagli indigeni balinesi per la cura dell’insonnia
(Schlager and Meier, 1947)
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periferiche
centrali
situazionali
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Sincope vasovagale
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Sincope vasovagale con asistolia (3 sec)
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Sincope vasovagale vasodepressoria
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Gestione della sincope
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TILT TEST
Monitoraggio simultaneo di:
ECGPressione arteriosaRespiroCO2Doppler trans-cranico
NIRS
durata 45’Event. sensibilizzato con infusione di isoproterenolo
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sincope da sforzo
Durante lo sforzo: potenzialmente gravestenosi aorticaamiloidosi
Subito dopo lo sforzo: normale ipovolemia+ tono simpatico elev.
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paediatric syncope is common
15% to 25% of children/adolescents:
at least 1 syncopal episode by young aulthood
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•Underlying cause usually benign
•Episodes may result in bodily injury
•Psychosocial morbidity (until malignant underlying condition for syncope ruled out)
•Severe activity restrictions/frequent school absenteism
•Expensive medical evaluationextensive testing due to:
-limited understanding of pediatric syncope-desire to demonstrate that no significant underlying disease is overlooked
Gordon (1987): -average 6 diagnostic tests per patient -40% pts hospitalised-total average cost 3000$ per patient-BUT: significant pathology only in 10%
PAEDIATRIC SYNCOPE: IMPORTANT PRACTICAL CONSEQUENCES
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EFFECTIVENESS OF TILT TRAININGIN NEUROCARDIOGENIC SYNCOPE IN ADOLESCENTS
Recurrence of tilt-induced and spontaneous syncope (after 18 months)
no training Tilt training p
Tilt-induced syncope 73.9% 4.2% <0.0001Spontaneous syncope 56.5% 0% <0.0001
Di Girolamo, Circulation 1999
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THERAPY
Neuro Mediated Syncope:•Education/reassurance/behavioural modification•Simple procedures:
water/salt intakepostural trainingphysical exercise training
•Medical therapycentral blood volume (fludrocortisone)SVR and venous capacitance vessels (midodrine)blunting adrenergic triggers of Bezold-Jarisch reflex (betablock.) ?
•Permanent pacemaker ?
Cardiac or systemic pathologyDose adjustments of medications that may exacerbate orthostatic intol.Invasive interventions (in severe recurrent syncope + cardiac disease):
Cardiac transplantationImplantable cardioverter-defibrillatorRadiofrequency catether ablationPermanent pacemaker
(NO!!)
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IPOTENSIONE ORTOSTATICA - MANOVRE FISICHE
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IPOTENSIONE ORTOSTATICA - MANOVRE FISICHE
BEREACQUAPRIMA DI ALZARSI !
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IPOTENSIONE ORTOSTATICA - TERAPIA
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