VERTIGO & DIZZINESS: IN THE EMERGENCY ROOM

Amanda Tiksnadi, MD

Department of Neurology

Faculty of Medicine University of Indonesia

Updates of Neuroemergency 2012, RSCM Jakarta

Perpective

• 7.5 mil/year in ambulatory care settings

• Study of 1000 outpatient 3rd complaint

• One of most commont CC in ED

• BPPV

• Most common

• Loose particles in the semicircular canals

• 107 cases per 100.000/yr

• Dizziness in older person

• 20% severe enough to affect ADL

• CV, neurosensory, psych, multiple medications

Dizziness In The ER

• Pts difficult to interview, time consuming

• Dizziness ~ imprecise term

Weakness, presyncope, neurologic impairment, vertigo,

visual disturbance, psychologic illness

• Reported symptoms can be vague, inconsistent, or

unreliable

• Life-threatening disorder ~ benign disorder

• Screening test often insensitive

• Problematic to diagnose and treat

Evaluation

• Often difficult & time consuming commonly referred to

medical specialists

• Neurologist, Otolaryngologist, Ophthalmologist do play

important role in the patient evaluation

• But.... In reality, most of the pts have an organic basis

for symptoms that can be successfully identified and

treated good history and focal PE in the primary care

setting

• Goal of the primary clinician

• Recognize which pts need inpatient management or

emergency intervention

Evaluation

• Basic concepts of diagnostic process

• Is it true vertigo??

• Decide whether it is central or peripheral

VERTIGO

Vestibuler Non-Vestibuler

Sifat Vertigo Rasa berputar

(true vertigo)

Rasa melayang,

goyang, sempoyongan

Sifat Serangan Episodik Kontinyu

Mual/Muntah (++) (+/-)

Gangguan

Pendengaran (+/-) (-)

Gerakan Pencetus Gerakan Kepala Gerakan Objek visual

Situasi Pencetus (-) Ramai orang, lalu lintas

macet, sibuk, pasar

swalayan

Letak Lesi Sistem Vestibular Sistem Visual,

somatosensorik

(proprioseptif)

Vertigo Vestibuler

Perifer Sentral

Bangkitan Vertigo Mendadak Lebih lambat

Intensitas Berat Ringan

Pengaruh Gerakan

Kepala (+) (-)

Gejala Otonom (++) (-)

Gangguan Pendengaran (+) (-)

Tanda fokal otak (-) (+)

In the

ER Acute severe

dizziness

Recurrent

attack of

dizziness

Recurrent

positional

dizziness

Acute Severe Dizziness

• Sudden onset, absence of prior similar episodes

• Nausea, vomiting >>. Impaired ability to walk is also >

• Vestibular neuritis • Acute lesion of vestibular nerve on one side

• Presumed viral in origin ~ Bell’s palsy of the VIIIth nerve

• True severe vertigo 1-2 days w gradual resolution over wks to mos

• Exceedingly rare to have >1 episode consider alternative D/

• PE in VN highly characteristic examination features

• Stroke within posterior fossa • Dizziness: 50% of stroke presentations

• 3% patients of dizziness had stroke as the etiology

• 1% isolated dizziness had a stroke as etiology

• Pros study of 24 pts with acute severe dizziness 25% stroke

Acute Severe Dizziness

• Stroke within posterior fossa

• Ask for other neurologic symptoms: focal numbness, focal

weakness, or slurred speech

• Mild double vision can result from a vestibular lesion not a

specific sign

• Pts stroke with isolated dizziness imblance, true vertigo, nausea,

vomitting ~ as in VN

• CT is not recommended, MRI is preferable but the sensitivity is low

and not practical in ER setting

• Key feature STROKE vs. VN : Physical Examination:

nystagmus and head thrust test

PE of Acute Severe Dizziness Vestibular Neuritis

• Spontaneous Nystagmus

• Unidirectional nystagmus

• Head-Thrust Test

• Positive with movements

toward abnormal side

Stroke

• Spontaneous Nystagmus

• Bidirectional gaze-evoked,

Pure torsional, Spontaneous

vertical nystagmus

• Head-Thrust Test

• Normal

Management of Acute Severe Dizziness

• Supportive care

• If Stroke is suspected neuroimaging

• If stroke < 3 hours of onset thrombolytic treatment

• If VN short course of corticosteroids

• After acute phase

• Resume daily activities help brain to compensate for asymmetry

of vestibular signals

• A formal vestibular therapy

Recurrent Positional Dizziness

• Symtoms triggered by certain head positions

• BPPV vs. CNS origin

• Important to recognize BPPV

• Can be readily treated at the bedside

• Most effective way to exclude CNS positional dizziness

BPPV

• Episodes < 1 min

• Pts are normal in between episodes

• Nausea or a mild lightheadedness sometimes > 1 min

need exploration for other potential cause

• Dizziness at any cause will feel worse with certain

position, BPPV has dizziness triggered by positional

changes AND THEN returns to normal between attacks

• VN often misclassified as BPPV, symp improve when pts

remain still and worsen with movements different w

BPPV who returns to normal at rest

BPPV

• Ca carbonate debris dislodge from otoconial membrane in

the inner ear semicircular canal free floating head

movement trigger the symp

• Most common trigger

• Extending the head back to look up

• Turning over in bed

• Getting in and out of bed

Positional Testing – Dix-Hallpike test

Particle Repositioning – Epley Maneuver

Home Program – Brandt-Darroff Exc

Central Positional Dizziness

• Stems from a lession of the cerebellum or the brainstem

• Chiari malformation, cerebellar tumor, MS, migrain

vertigo, degenerative ataxia disoder

• Central vs. Peripheral: pattern of nystagmus

• Pure down-beating nystagmus lasts as long as the position is held

• Pure torsional nystagmus

• Nystagmus is refractory to repositoning maneuvers

Recurrent Attacks of Dizziness

• Report of prior similar episodes

• Duration: highly variable but can be helpful in

discriminating potential causes

• Meniere’s disease

• Recurrent spontaneous episodes

• Severe true vertigo, nausea, vomiting, imbalance

• Unilateral auditory features: hearing loss, very loud tinnitus, ear

fullness

• Nystagmus may not follow the rule of nystagmus VN but red flag

for CNS nystagmus apply

• Head thrust generally normal since N.VIII is intact

Recurrent Attacks of Dizziness

• Transient Ischemic Attack

• New-onset recurrent spontaneous attacks of dizziness

• Last for minutes, less than typical Meniere’s

• Impending basilar artry occlusion

• Main consideration if the attacks are increasing in freq (crescendo

pattern)

• Auditory symp may present AICA involvement

• CTA or MRA are the test to consider

Recurrent Attacks of Dizziness

• Migraine

• Great mimicker of all causes of dizziness

• Acute severe attack, positional episodes, or recurrent spontaneous

attacks

• PE: can suggest a peripheral or central process

• Strong genetic component, environmental fx, food, lifestyle

• Light, sound, motion, can trigger or aggravate the symp

• Diagnosis of migraine vertigo remains a diagnosis of exclusion

• If the symp is new in onset & not fit for peripheral consider first

as stroke or TIA before diagnosing as migraine vertigo

• Headache not always reported

• Triptan do not generally improve symp

Recurrent Attacks of Dizziness

• Panic disorder

• Show any other typical symp of panic disorder

• If general history and PE not clear exclude the other potential

cause

• General medical cause

• Usually not in form of true vertigo

• If nystagmus present involvement of peripheral or central

components of the vestibular syst

Nystagmus rules out most general medical disorders

• Cardiac arrhytmia or myocardial infarction should be considered in

the appropriate setting

Symptomatic Treatment

• Severe nausea & vomiting IV fluids during ER stay

• Drug to reduce symptoms

• Vestibular supressants

(antihistamines, benzodiazepines, anticholinergics)

• Antiemetics

• These drugs can be effective for acute attacks, not

effective as prophylactic agents

• If taken as daily regular basis side effects >> or reduce

the brain ability to compensate

Summary

`Summary

• The most effective way to “rule out” a serious case is to

“rule-in” a benign inner ear disorder

• When the features are atypical or other red flag appear

consider sinister causes

• Acute severe dizziness atypical for VN

• Recurrent attacks of dizzienss when attacks are recent in onset

and last only minutes

• Recurrent positional dissiness central positional pattern of

nystagmus is seen or when no respond to particle repositining

technique

Generally central positional nystagmus is caused by disorder that

require a less urgent evaluation than acute severe dizziness or

recurrent attacks of dizziness