12.11.13 Autonomic dysfunction

Conditions

• • Acute

    • GBS

      • DANGEROUS! Watch out

  • Chronic

    • Diabetes

    • Parkinsonism (multi-system atrophy)

    • Shy-Drager syndrome

Symptoms

• • CVS

    • Postural dizziness

  • GI

    • Upper - Vomiting

    • Lower - Nocturnal diarrhoea

  • Sweating

    • Gustatory, in response to tyramines

  • GUS

    • Erectile dysfunction (early sign)

    • Trouble voiding

Examination

• • Pulse

    • < 20 BPM change after 6 deep breaths

    • < 15 BPM change after standing

  • BP

    • > 15/10 mmHg postural drop

      • But wait 3 MINS before measuring

      • Keep arm at heart level

  • ECG RR ratio

    • Changes after valsava (breathe into manometer + maintain 40 mmHg pressure)

Postural hypotension management

• • Conservative

    • Sit on bed for 3 mins before standing

    • Fluids (3 L per day)

    • Salt

    • Stockings

    • Sleep head-up

    • Physical countermeasures

      • Buttock tensing

      • Stand on toes

      • Tense arms and shoulders

  • Medication

    • Fludrocortisone

      • But keep an eye on [Na]

    • Alpha agonist

      • Midodrine

    • Erythropoietin

Gaits

• • Cerebellar

    • Wide-based

    • Drunken

    • With slurred speech

  • Stroke

    • Circumduction

  • Spastic paraparesis

    • Stiff knees

  • Parkinsons

    • Shuffling

    • Fenestrating (accelerating)

  • Foot slap (common peroneal palsy)