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2/19/2014
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Basic Stroke CareAirway ManagementElevate Head of Bed 30 DegreesNPOBedrails UpFever ControlBlood Sugar ControlASA 160-325mg PO (if no blood on CT)Reverse AnticoagulantsDVT Prophylaxis (ward) tPA NOT given tPA given
Liang B, et al. Annals of EM (2008)Thiess D, et al. Neurol Clin (2010)
tPA Lawsuits
ACEP/AAN Policy 2013Level A recommendations. In order to improve functional outcomes, IV tPA
should be offered to acute ischemic stroke patients who meet National Institute of Neurological Disorders and Stroke (NINDS) inclusion/exclusion criteria and can
be treated within 3 hours after symptom onset.*
Level B recommendations. In order to improve functional outcomes, IV tPA should be considered in acute ischemic stroke patients who meet European
Cooperative Acute Stroke Study (ECASS) III inclusion/exclusion criteria and can be treated between 3 to 4.5 hours after symptom onset.*
* The effectiveness of tPA has been less well established in institutions without the systems in place to safely administer the medication.
Note: Within any time window, once the decision is made to administer IV tPA, the patient should be treated as rapidly as possible. As of this writing, tPA for acute ischemic stroke in the 3- to 4.5-hour
window is not FDA approved.
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Vertigo2014
Stuart Swadron MD FRCPC FAAEM FACEP
University of Southern CaliforniaLos Angeles County/USC Medical Center
Not Missing Something BAD
DizzinessDizziness
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DizzinessDizziness
VertigoVertigoLightheadednessLightheadedness DysequilibriumDysequilibrium DysequilibriumDysequilibrium
DizzinessDizziness
VertigoVertigoLightheadednessLightheadedness
DysequilibriumDysequilibrium
DizzinessDizziness
VertigoVertigoLightheadednessLightheadedness
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83 4 5 6
6
79 10
Cerebellum
Central Peripheral
12
TinnitisHearing Loss
83 4 5 6
6
79 10
Cerebellum
Central Peripheral
12
The 5 D’s and Crossed Findings
Dizziness (vertigo)
Dysphagia
Diploplia
Dysmetria
DysarthriaLong tract findings
Any of these = CENTRAL = BAD
(motor/sensory) Walk
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Vertigo2014
1. Make sure that it’s isolated31,000 patientsDischarged with diagnosis of vertigo or dizziness
Stroke in only 1 in 500 in the first month
ACUTE VESTIBULAR SYNDROME
BPPV CEREBELLAR STROKE
Et Viral Otolith debris Vascular
Sx Gradual onset < 1 minute episodes Sudden onset
Dx PositiveHead ImpulsetestPositiveDix-Hallpiketest
NegativeHead Impulsetest
Rx Suppression meds
CorticosteroidsEpley
maneuverAdmission
ASA
Isolated Vertigo
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Delayed onset
Fatiguable
Decreases with fixation
Nystagmus in Peripheral Vertigo
QuickTime™ and a decompressor
are needed to see this picture.
ACUTE VESTIBULAR SYNDROME
BPPV CEREBELLAR STROKE
Et Viral Otolith debris Vascular
Sx Gradual onset < 1 minute episodes Sudden onset
Dx PositiveHead ImpulsetestPositiveDix-Hallpiketest
NegativeHead Impulsetest
Rx Suppression meds
CorticosteroidsEpley
maneuverAdmission
ASA
Isolated Vertigo The Head Impulse Test
Negative(normal)
Positive
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Negative (normal) Head Impulse Test
QuickTime™ and a decompressor
are needed to see this picture.
Postive (R-sided) Head Impulse Test
QuickTime™ and a decompressor
are needed to see this picture.
Postive (bilateral) Head Impulse Test
QuickTime™ and a decompressor
are needed to see this picture.
CENTRAL!!!
QuickTime™ and a decompressor
are needed to see this picture.
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SKEW! SKEW!
QuickTime™ and a decompressor
are needed to see this picture.
SKEW!
QuickTime™ and a decompressor
are needed to see this picture. HINTSHead Impulse Test of Skew
Central Nystagmus
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ACUTE VESTIBULAR SYNDROME
BPPV CEREBELLAR STROKE
Et Viral Otolith debris Vascular
Sx Gradual onset < 1 minute episodes Sudden onset
Dx PositiveHead ImpulsetestPositiveDix-Hallpiketest
NegativeHead Impulsetest
Rx Suppression meds
CorticosteroidsEpley
maneuverAdmission
ASA
Isolated Vertigo Vertigo2014
1. Make sure that it’s isolated2. Consider:
Acute Vestibular NeuritisBPPVCerebellar stroke
DizzinessDizziness DizzinessDizziness
VertigoVertigoLightheadednessLightheadedness DysequilibriumDysequilibrium
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DysequilibriumDysequilibrium
DizzinessDizziness
VertigoVertigoLightheadednessLightheadedness LightheadednessLightheadedness DysequilibriumDysequilibrium
DizzinessDizziness
VertigoVertigo
Is it isolated? Is it isolated?
LightheadednessLightheadedness DysequilibriumDysequilibrium
DizzinessDizziness
VertigoVertigo
YESYES5D’s
Long Tract SignsCT scan
5D’sLong Tract Signs
CT scan
NONO
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MRI / AdmitMRI / Admit YESYES5D’s
Long Tract SignsCT scan
5D’sLong Tract Signs
CT scan
NONO
BPVBPV CerebellarStroke
CerebellarStroke
Acute VestibularNeuritis
Acute VestibularNeuritis
Abrupt onset- Head Impulse
Gradual onset+ Head Impulse
Brief episodes+ Dix-Hallpike
Thank you!
Vertigo2014
