Vertigo, Emergency Medicine

Basics

Description

Dizziness, 3 " ô4% of ED visits, difficult symptom to diagnose, describes a variety of experiences, including:
- Vertigo
- Weakness, fainting
- Lightheadedness
- Unsteadiness
Vertigo, a hallucination of movement:
- Spinning or turning
- Sensation of movement between the patient and the environment
- Oscillopsia (illusion of an unstable visual world)
- Most patients have an organic etiology.
Maintenance of equilibrium depends on interaction of 3 systems:
- Visual
- Proprioceptive
- Vestibular
Any disease that interrupts the integrity of above systems may give rise to vertigo.
Peripheral vertigo:
- Often, severe symptoms
- Intermittent episodes lasting seconds to minutes, occasionally hours
- Horizontal or horizontal " ôtorsional nystagmus (also positional, fatigues, and suppressed by fixation)
- Normal neurologic exam
- Sometimes associated hearing loss or tinnitus
Central vertigo:
- Usually mild continuous symptoms
- All varieties of nystagmus (horizontal, vertical, rotatory)
- No positional association
- Presence of neurologic findings most of the time

Etiology

Peripheral

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 " ô5th 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 " ô95% 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
Meni â Ęre 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

Central

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 " ô40 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

Signs and Symptoms

Sensation of motion, spinning, disorientation in space, or disequilibrium é á
History

Does true vertigo exist?
Timing of onset:
- Gradual (hours " ôdays): Probably neuritis
- Sudden and fixed symptoms (seconds " ôminutes) 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 Meni â Ęre
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, Meni â Ęre (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

Physical Exam

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 " ô20 é ░ 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 " ôHallpike 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

Essential Workup

Ask patient to describe the sensation without using the word "dizzy. " Ł
Determine whether the cause is a peripheral or a central process using patients clinical presentation (see above).

Diagnosis Tests & Interpretation

Lab
Electrolytes, BUN, creatinine, glucose é á
Imaging

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)

Diagnostic Procedures/Surgery
Audiology or electronystagmography often helpful in outpatient follow-up é á

Differential Diagnosis

More likely other cause when "dizziness " Ł actually is lightheadedness or malaise: é á

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

Pre-Hospital

Treatment and medication per EMS protocol based on symptoms é á

Initial Stabilization/Therapy

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

Ed Treatment/Procedures

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

Medication

Diazepam (Valium): 2.5 " ô5 mg IV q8h or 2 " ô10 mg PO q8h
Dimenhydrinate (Dramamine): 25 " ô50 mg IV, IM or PO q6h
Diphenhydramine (Benadryl): 25 " ô50 mg IV, IM, or PO q6h
Lorazepam (Ativan): 1 mg IV, IM or 1 " ô2 mg PO q4 " ô6h
Meclizine (Antivert): 25 mg PO q6h PRN
Promethazine (Phenergan): 12.5 mg IV q6h or 25 " ô50 mg IM, PO, or PR q6h

Follow-Up

Disposition

Admission Criteria

Cerebellar infarct/hemorrhage
Vertebrobasilar insufficiency
Acute suppurative labyrinthitis
Intractable nausea/vomiting
Inability to ambulate

Discharge Criteria
Patient with peripheral etiology and stable é á
Issues for Referral
Otolaryngology follow-up for suspected acoustic neuroma or perilymphatic fistula é á

Follow-Up Recommendations

Primary care, neurology, or otolaryngology follow-up for all
Epley and Semont maneuvers are extremely effective in treating BPPV.

Pearls and Pitfalls

Isolated vertigo can be the sole symptom of stroke or bleed
Central cause clues: Imbalance and/or ataxia out of proportion to vertigo
Learn the specialized exam and repositioning techniques

Additional Reading

Bhattacharyya é áN, Baugh é áRF, Orvidas é áL, et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139:S47 " ôS81.
Chawla é áN, Olshaker é áJS. Diagnosis and management of dizziness and vertigo. Med Clin North Am. 2006;90(2):291 " ô304.
Kattah é áJC, Talkad é áAV, Wang é áDZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: Three-step oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40:3504 " ô3510.
Kerber é áKA. Vertigo and dizziness in the emergency department. Emerg Med Clin North Am. 2009;27(1):39 " ô50.
Olshaker é áS. Vertigo. In: Marx é áJ, et al., eds. Rosens Emergency Medicine: Concepts and Clinical Practice. St. Louis, MO: CV Mosby; 2010:93 " ô100.

Codes

ICD9

386.10 Peripheral vertigo, unspecified
386.11 Benign paroxysmal positional vertigo
780.4 Dizziness and giddiness
386.2 Vertigo of central origin
386.12 Vestibular neuronitis
386.30 Labyrinthitis, unspecified

ICD10

H81.10 Benign paroxysmal vertigo, unspecified ear
H81.399 Other peripheral vertigo, unspecified ear
R42 Dizziness and giddiness
H81.49 Vertigo of central origin, unspecified ear
H81.20 Vestibular neuronitis, unspecified ear
H83.09 Labyrinthitis, unspecified ear

SNOMED

399153001 Vertigo (finding)
103284002 Positional vertigo (finding)
50438001 peripheral vertigo (disorder)
38403006 Vertigo of central origin
103292006 Constant vertigo
186738001 Epidemic vertigo
433631000124103 Acute labyrinthitis (disorder)

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