Practical Emergency Medicine Dizziness and vertigo Dr. H K Tong Consultant A&E Dept Queen Mary Hospital Hon Associate Prof. HKU
Introduction Dizziness Common And Challenging: Too many possible diagnoses Too difficult to get a clear history Physical exam is often non-contributory Too many pitfalls
Many causes:- 15% Spectrum of Dizziness Visits to US Emergency Departments Mayo Clin Proc. 2008;83(7):765-775
Case scenario Triage F 65 dizziness today vomited once PH-- HT, DM FU GOPD BP 150/90 P 65/min Temp 37 C Category III (Stretcher case)
Dizziness Targeted history Nature Duration and previous episode Provoking factors associated symptoms PMH, Drug, Allergy
What do you understand by the term : dizziness? Vertigo? Disequilibrium (tend to fall)? Lightheadedness? (pre-syncope) Blackout? (syncope) Unwell? Headache? Weakness? Unhappy..??
Some more history... Need to clarify dizziness your understanding on dizziness may not be the same as the patient s.
Try not to use the word 暈 to describe your feeling 天旋地轉 睜不開眼 好想睏 暈船浪 想暈倒 Vertigo Dysequilibrium Lightheadedness Near syncope
Martin A. Samuels THE DIZZY PATIENT: A CLEAR-HEADED APPROACH
Pitfall Rely too much on assigning a dizziness category in limiting the DDx.
Symptom description is not precise
Common DDx of Vertigo CNS problem Cerebellar stroke Brain stem stroke TIA (vertebro-basilar insufficiency) CP angle tumor Demyelination disease Vestibular migraine Peripheral Labyrinthitis Vestibular neuronitis BPPV (otoconia) Meniere s disease Concussion (labyrinthine) Acoustic neuroma Drugs can cause both types of vertigo
Central Peripheral Vertigo less intense Constant symptom Imbalance: severe Hearing loss and tinnitus less common CNS / Cerebellar sign +ve More intense Paroxysmal acute relapse Imbalance: milder Hearing loss and tinnitus more common No cerebellar sign These are NOT INVARIABLE!!!
Otogenic vertigo: DDx matrix
Duration of illness Long history Really? Or just recurrent episodes Persisting e.g. multiple sensory deficits Recurrent e.g. Menieres BPPV Short history 1-2 days Never before Implication: look for acute sinister problem
Duration of symptoms Short (minutes) Long (hours) BPPV Near-syncope TIA Vestibular neuronitis Menieres Ds Initial Evaluation of Vertigo. Am Fam Physician 2006;73:244-51.
Provoking/Precipitating factors Triggered by certain head position e.g. looking up Positional vertigo (e.g.bppv) Triggered by change in head position Likely peripheral vestibular Worsen while getting up and lying down Equivalent to change head position Worsen while getting up only Think orthostatic hypotension, autonomic neuropathy Only while walking Likely neurological deficit During exercise Perfusion problem due to CV causes
Vertigo provoked or aggravated by head motion? Overreliance on symptom quality in diagnosing dizziness: Stanton VA - Mayo Clin Proc --2007; 82(11): 1319-28
Pitfall Vertigo aggravated (NOT triggered) by head movement may still be due to CENTRAL causes
Associated symptoms are useful in pointing to other DDx General Fever (URI) Nausea Depression / anxiety CNS headache diplopia weakness/numbness unsteady gait CVS/Resp palpitation chest pain SOB, cough ENT earache, fullness hearing loss tinnitis GI Vomiting/ Diarrhea Abd pain tarry stool
Drug related dizziness Hypotension All anti HT drugs (especially recently added) postural hypotension: alpha-blockers Hypoglycemia: Long acting DM drug: Daonil for age>70 Toxic action at reticular activating system Anticonvulsant e.g. phenytoin + nystagmus Drugs that disturb electrolytes: Natrilix Ototoxic drugs: lasix, salicylates
Physical exam may help in pin pointing the cause. CNS? Peripheral vestibular? Perfusion problems?
Focus your exam GC--pallor CNS cranial N nystagmus cerebellar signs limb: motor, sensory ENT hearing T M Neck rigidity bruit CVS/Resp GI BP/P; Postural BP JVP; HS; M AE, added sounds abdomen PR tarry stool Test Gait at some point
Investigation Unnecessary if diagnosis is obvious from history or physical exam: Peripheral vertigo due to BPPV, Meniere s disease, vasovagal attack No routine set of Ix for dizziness
Useful investigations for dizziness ECG: suspected silent MI ( usually in diabetic and old female ) or arrhythmia Blood glucose: hyper/hypo in DM patients CBP: suspected anemia Electrolytes: maybe useful in pt with nonspecific dizziness and risk factors e.g. on diuretics CT brain
Consider urgent CT Age >50 Abrupt onset of symptoms Prior history of stroke/tia Risk factors for stroke Head/ Neck injury (MVC, neck manipulation? Dissection) Headache (sudden, severe, persistent) Nausea/vomiting disproportionate to dizziness
Wait 24-48 h before CT Isolated vertigo Nystagmus of peripheral type Can still walk though unstable If symptoms improve over time vestibular disease and no need for CT
Three categories of ED dizzy pt Acute severe dizziness Recurrent attacks of dizziness Recurrent positional dizziness
Acute severe dizziness (not near syncope pattern) Kerber. Emerg Med Clin N Am 27 (2009) 39 50
Recurrent dizziness Kerber. Emerg Med Clin N Am 27 (2009) 39 50
Emerg Med Clin N Am 27 (2009) 39 50
Scenario A--F/65, DM, HT Onset Provoke Today, gradual Hx of URI recently Quality Spinning sensation + Relief Severity Time Better with eyes closed, worse with neck movement Cannot get up for a few hours already Associated symptoms: Nausea + vomiting; no tinnitus/hearing loss Exam: essentially normal
Vestibular sedatives Prochlorperazine (Stemetil) Anti-emetic, phenothiazine group CNS acting Not for children Caution in young adults (dyskinesia) Dimenhydrinate (Gravol) First generation antihistamine Anti-motion sickness (unknown mechanism) Betahistine(Merislon) antivertigo/selective vasodilator Diazepam (Valium) BZD Not For Brief Episodes Beware: not useful if not vestibular ds.
Any special test for vestibular ds? Hallpike test (For BPPV only) Head Thrust Test
Hallpike test positional testing using the head-hanging technique sit patient up head turn to one side lower body and head to a level lower than bed patients with benign positional vertigo will show a burst of upbeating nystagmus after a delay of 5 to 10 seconds, the nystagmus lasts about 30 seconds
Dix Hallpike: Traditional and Sideway Position Barraclough, Kevin; Bronstein, Adolfo. Vertigo. BMJ. 339:b3493, September 26, 2009
Hallpike test & Epley manoevre
Nystagmus? Central Central Horizontal; vertical Change direction with gaze No fatigue Peripheral Horizontal Fixed direction Fatiguable Fixation has no effect Disappear with fixation
Effect of fixation Hotson et al. Acute Vestibular Sx. NEJM 1998;339 (10)
Alexander law Nystagmus due to peripheral vestibular disease increases in intensity when the eyes are turned in the direction of the saccade (fast phase)
Down beating nystagmus
Vertical nystagmus Pitfall Overreliance on symptom quality in diagnosing dizziness: Stanton VA - Mayo Clin Proc --2007; 82(11): 1319-28
Bidirectional nystagmus
Any other features to suggest central origin? Vascular risk factors e.g. HT, smoker Headache, neck rigidity Focal signs e.g. double vision Cerebellar sign e.g. truncal ataxia < 50% pts with cerebellar infarct have nystagmus
Stroke e.g. cerebellar should be suspected CT scan Consult Neuro PRN
Any other specific points you want to ascertain in the history and physical? LMP in younger patient Drugs e.g. NSAID, Po Chai pill Omit meal (other features of hypoglycemia) Palpitation (arrhythmia) BP postural changes Tarry stool (melena PR)
How do you check postural BP BP lying repeat BP after patient stands for ~ 1min SBP > 20 mmhg is significant may reproduce dizziness This patient has SBP drop ~ 20 mmhg + recurrence of dizziness on standing up
PR shows no melena. Is GIB ruled out? It takes hours for melena to reach rectum.
Sources of bleeding/anemia Gut bleeding peptic ulcer bleeding colon cancer Bleeding hemorrhoid GU tract menorrhagia ectopic pregnancy hematuria Concealed bleeding AAA Blood disorders hemolysis e.g. drug induced leukemia Hemodilution takes time.
Summary We have covered: Different types of dizziness Important causes of dizziness Vertigo: stroke, vestibular ds non-vertigo: inadequate CNS perfusion, anemia Evaluation of dizzy patients
Evaluation of dizziness History O Onset P Provoking factor Q Quality or nature R Relief/Aggravate Factor S Severity T Time Course/ Duration Associated symptoms Physical Exam Cranial N Nystagmus Cerebellar signs Gait/Balance ENT (Head Thrust ) CVS (postural BP) GI (tarry stool) Neuro
Diagnosis not to miss: Stroke (cerebellar) GIB Cardiac causes
Safe management of dizziness Precise history Repeated physical exam Choice of investigation Reassessment Discharge only if: symptom free while walking +/- referral
End
Psychiatric dizziness Definition: a subjective sensation of dizziness associated with other anxiety / depression / obsession symptom Non-vertigo Persistent or frequent relapsing Presence of dizziness despites normal neurology and gait Can happen in relative young patients
Head Thrust Test Test vestibulo-occular reflex Abnormal eye movements associated with unilateral loss of vestibular function. N Engl J Med 2006;355(24):e26.
Initial Evaluation of Vertigo. Am Fam Physician 2006;73:244-51.
Initial Evaluation of Vertigo. Am Fam Physician 2006;73:244-51.
Initial Evaluation of Vertigo. Am Fam Physician 2006;73:244-51.