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)