Rosen & Barkin's 5-Minute Emergency Medicine Consult (768 page)

• Acute peripheral vestibulopathy (APV):
  
  • Vestibular neuritis (most common):
    
    • Single acute attack continuous rotational vertigo
      
    • Constant for several days
      
    • Present even when still
      
    • No hearing deficits
      
    • Highest incidence in 3rd–5th decade
      
  • Acute labyrinthitis:
    
    • Similar to vestibular neuritis but:
      
      • Associated with hearing deficit
        
      • May be viral (common), serous, acute suppurative, toxic, or chronic
        
• Benign paroxysmal positional vertigo (BPPV):
  
  • Most common cause recurrent vertigo
    
  • Posterior canal, 85–95% of BPPV cases
    
  • Lateral semicircular less common
    
  • Probable cause is loose particles (otoliths) in semicircular canals
    
  • Can be secondary to other entities including trauma and APV
    
• Ototoxic drugs:
  
  • Aminoglycosides
    
  • Antimalarials
    
  • Erythromycin
    
  • Furosemide
    
• Ménière disease:
  
  • Episodic vertigo, hearing loss, and tinnitus
    
• Acoustic neuroma:
  
  • Tumor of Schwann cells enveloping the 8th cranial nerve (CN VIII)
    
  • Develops into central cause
    
  • Progressive unilateral hearing deficits and tinnitus
    
  • May also involve CN V, VII, or X
    
• Trauma:
  
  • Rupture of tympanic membrane, round window, labyrinthine concussion, or development of perilymphatic fistula can all have severe symptoms.
    
• Otitis media and serous otitis with effusion
  
• Foreign body in ear canal
  

• Vertebrobasilar artery insufficiency:
  
  • Disturbances may be transient or exacerbated by movement of the neck.
    
• Cerebellar infarction
  
• Cerebellar hemorrhage:
  
  • Neurosurgical emergency
    
  • Sudden onset of headache, vertigo, vomiting, and ataxia
    
  • Visual paralysis to affected side
    
  • Ipsilateral CN VI paralysis
    
• Multiple sclerosis:
  
  • Onset between 20–40 yr
    
  • All forms of nystagmus
    
  • May have abrupt onset of severe vertigo and vomiting
    
  • History of other vague and varying neurologic signs or symptoms
    
• Brainstem hypertensive encephalopathy
  
• Trauma:
  
  • Vertiginous symptoms common after whiplash injury
    
  • Postconcussive syndrome or damage to labyrinth or CN VIII secondary to basilar skull fracture
    
  • Vertebral artery injury has been seen after chiropractic manipulation.
    
• Temporal lobe epilepsy:
  
  • Associated with hallucinations, aphasia, trancelike states, or convulsions
    
  • More common in younger patients
    
• Vertebrobasilar migraines:
  
  • Prodrome of vertigo, dysarthria, ataxia, visual disturbances, or paresthesias followed by headache
    
  • Often a family history of migraines or similar attacks
    
• Tumor
  
• Subclavian steal syndrome:
  
  • Exercise of an arm causing shunting of blood from vertebral and basilar arteries into the subclavian artery, resulting in vertigo or syncope
    
  • Secondary to a stenotic subclavian artery
    
  • Diminished unilateral radial pulse or differential systolic BP between arms
    
• Hypoglycemia
  

DIAGNOSIS

Sensation of motion, spinning, disorientation in space, or disequilibrium

• Does true vertigo exist?
  
• Timing of onset:
  
  • Gradual (hours–days): Probably neuritis
    
  • Sudden and fixed symptoms (seconds–minutes) consider stroke (but see BPPV below)
    
  • Multiple prodromal episodes in months, especially weeks prior (TIAs): Stroke more likely
    
  • Repeated intense episodes provoked/exacerbated by head movements: BPPV more likely but could be TIA
    
  • Episodic attacks with auditory symptoms: Consider Ménière
    
• Stroke risk factors including age >50 and vascular risks
  
• Severity of symptoms: Imbalance out of proportion to vertigo, consider stroke
  
• Modifiers: Head movement, BPPV more likely
  
• Associated symptoms:
  
  • Hearing loss (new unilateral): Labyrinthitis, Ménière (with tinnitus), rarely, but possibly stroke
    
  • Neurologic symptoms (central cause):
    
    • Unilateral limb weakness
      
    • Dysarthria
      
    • Headache
      
    • Ataxia
      
    • Numbness of the face
      
    • Hemiparesis, headache
      
    • Diplopia/visual disturbances
      
  • Has there been head or neck trauma?
    
• Past medical history/ROS:
  
  • Stroke risk factors
    
• Medication history
  

• Extraocular movements:
  
  • Nystagmus (direction defined by fast component)
    
  • Unilateral, horizontal, some rotational component in (unilateral) APV, worse with gaze in the direction of nystagmus (fast away from lesion, linear slow phase)
    
  • Worse with occlusive ophthalmoscopy (cover 1 eye, examine optic disc with ophthalmoscope): APV more likely
    
  • Bilateral direction suggests central etiology, as does pure vertical or torsional nystagmus. If direction changes with gaze, central cause.
    
• Head impulse test (HIT) for unilateral vestibular loss (smartphone with slow motion video app promising aide for such testing):
  
  • Face patient, grasp head with both hands
    
  • Patient to look at your nose (or camera)
    
  • Rapidly rotate head 10–20° then back to midline:
    
    • Normal: Maintains gaze
      
    • Abnormal: Lag in maintaining gaze and corrective saccade back to nose/camera
      
  • Rotation to left, tests left vestibular apparatus
    
• Skew deviation testing (predicts central pathology):
  
  • Face patient
    
  • Patient to look at your nose
    
  • Alternately cover each eye
    
  • Normal: Eyes motionless
    
  • Abnormal: Refixation saccade after uncovered, (refixation upward, ipsilateral medullary stroke, refixation downward, contralateral stroke)
    
• Dix–Hallpike test for posterior canal BPPV
  
• Supine Roll test for lateral canal BPPV
  
• Auscultation of the carotid and vertebral arteries for bruits
  
• Pulses and pressures in both arms
  
• Inspection of the ears:
  
  • Evaluation of hearing (Weber and Rinne tests)
    
  • Ocular assessment (pupils, fundi, visual acuity, nystagmus)
    
• Cardiac auscultation
  
• Full neurologic exam, common stroke findings:
  
  • Unilateral limb weakness
    
  • Gait ataxia
    
  • Unilateral limb ataxia and/or sensory deficit
    
  • Dysarthria
    

• Ask patient to describe the sensation without using the word “dizzy.”
  
• Determine whether the cause is a peripheral or a central process using patient’s clinical presentation (see above).
  

Electrolytes, BUN, creatinine, glucose

• EKG for any suspicion of cardiac etiology
  
• Head CT/MRI for evaluation of suspected tumor, or post-traumatic cause
  
• MRI/MRA for suspected vertebrobasilar insufficiency (CT poor sensitivity)
  

Audiology or electronystagmography often helpful in outpatient follow-up

More likely other cause when “dizziness” actually is lightheadedness or malaise:

• DM
  
• Hypothyroidism
  
• Drugs (e.g., alcohol, barbiturates, salicylates)
  
• Hyperventilation
  
• Cardiac (i.e., arrhythmia, MI, or other etiologies of syncope); peripheral vascular disease (i.e., HTN, orthostatic hypotension, vasovagal)
  
• Infection/sepsis
  

TREATMENT

Treatment and medication per EMS protocol based on symptoms

• IV access for dehydration/vomiting
  
• Monitor
  
• Trauma evaluations as indicated
  
• Finger-stick blood glucose
  

• Based on accurate diagnosis:
  
  • Central etiologies require more aggressive workup than peripheral.
    
  • Neurosurgical intervention for cerebellar bleed
    
  • Symptomatic treatment for peripheral vertigo with appropriate follow-up
    
• Administer medication to control vertiginous symptoms and/or nausea:
  
  • Antihistamines
    
  • Benzodiazepines
    
  • Antiemetics
    
• Initiate IV antibiotics for acute bacterial labyrinthitis (rare).
  
• Repositioning maneuvers such as Epley and Semont for posterior BPPV. Roll or Lempert maneuver for lateral BPPV
  

• Diazepam (Valium): 2.5–5 mg IV q8h or 2–10 mg PO q8h
  
• Dimenhydrinate (Dramamine): 25–50 mg IV, IM or PO q6h
  
• Diphenhydramine (Benadryl): 25–50 mg IV, IM, or PO q6h
  
• Lorazepam (Ativan): 1 mg IV, IM or 1–2 mg PO q4–6h
  
• Meclizine (Antivert): 25 mg PO q6h PRN
  
• Promethazine (Phenergan): 12.5 mg IV q6h or 25–50 mg IM, PO, or PR q6h
  

FOLLOW-UP