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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.

- 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

- 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

- 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

- Cerebellar infarction - Cerebellar hemorrhage: - Neurosurgical emergency - Sudden onset of headache, vertigo, vomiting, and ataxia - Visual paralysis to affected side - Ipsilateral CN VI paralysis

- 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.

- 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

- 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

- 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)

- Cardiac auscultation - Full neurologic exam, common stroke findings: - Unilateral limb weakness - Gait ataxia - Unilateral limb ataxia and/or sensory deficit - Dysarthria

- Administer medication to control vertiginous symptoms and/or nausea: - Antihistamines - Benzodiazepines - Antiemetics

  • Dizziness, 3 " ô4% of ED visits, difficult symptom to diagnose, describes a variety of experiences, including:VertigoWeakness, faintingLightheadednessUnsteadiness
  • Vertigo, a hallucination of movement:Spinning or turningSensation of movement between the patient and the environmentOscillopsia (illusion of an unstable visual world)Most patients have an organic etiology.
  • Maintenance of equilibrium depends on interaction of 3 systems:VisualProprioceptiveVestibular
  • Any disease that interrupts the integrity of above systems may give rise to vertigo.
  • Peripheral vertigo:Often, severe symptomsIntermittent episodes lasting seconds to minutes, occasionally hoursHorizontal or horizontal " ôtorsional nystagmus (also positional, fatigues, and suppressed by fixation)Normal neurologic examSometimes associated hearing loss or tinnitus
  • Central vertigo:Usually mild continuous symptomsAll varieties of nystagmus (horizontal, vertical, rotatory)No positional associationPresence of neurologic findings most of the time

Etiology

Peripheral

  • Acute peripheral vestibulopathy (APV):Vestibular neuritis (most common):Single acute attack continuous rotational vertigoConstant for several daysPresent even when stillNo hearing deficitsHighest incidence in 3rd " ô5th decadeAcute labyrinthitis:Similar to vestibular neuritis but:Associated with hearing deficitMay be viral (common), serous, acute suppurative, toxic, or chronic
  • Benign paroxysmal positional vertigo (BPPV):Most common cause recurrent vertigoPosterior canal, 85 " ô95% of BPPV casesLateral semicircular less commonProbable cause is loose particles (otoliths) in semicircular canalsCan be secondary to other entities including trauma and APV
  • Ototoxic drugs:AminoglycosidesAntimalarialsErythromycinFurosemide
  • 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 causeProgressive unilateral hearing deficits and tinnitusMay 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 emergencySudden onset of headache, vertigo, vomiting, and ataxiaVisual paralysis to affected sideIpsilateral CN VI paralysis
  • Multiple sclerosis:Onset between 20 " ô40 yrAll forms of nystagmusMay have abrupt onset of severe vertigo and vomitingHistory of other vague and varying neurologic signs or symptoms
  • Brainstem hypertensive encephalopathy
  • Trauma:Vertiginous symptoms common after whiplash injuryPostconcussive syndrome or damage to labyrinth or CN VIII secondary to basilar skull fractureVertebral artery injury has been seen after chiropractic manipulation.
  • Temporal lobe epilepsy:Associated with hallucinations, aphasia, trancelike states, or convulsionsMore common in younger patients
  • Vertebrobasilar migraines:Prodrome of vertigo, dysarthria, ataxia, visual disturbances, or paresthesias followed by headacheOften 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 syncopeSecondary to a stenotic subclavian arteryDiminished 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 neuritisSudden and fixed symptoms (seconds " ôminutes) consider stroke (but see BPPV below)Multiple prodromal episodes in months, especially weeks prior (TIAs): Stroke more likelyRepeated intense episodes provoked/exacerbated by head movements: BPPV more likely but could be TIAEpisodic 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 strokeNeurologic symptoms (central cause):Unilateral limb weaknessDysarthriaHeadacheAtaxiaNumbness of the faceHemiparesis, headacheDiplopia/visual disturbancesHas there been head or neck trauma?
  • Past medical history/ROS:
  • 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 likelyBilateral 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 handsPatient to look at your nose (or camera)Rapidly rotate head 10 " ô20 é ░ then back to midline:Normal: Maintains gazeAbnormal: Lag in maintaining gaze and corrective saccade back to nose/cameraRotation to left, tests left vestibular apparatus
  • Skew deviation testing (predicts central pathology):Face patientPatient to look at your noseAlternately cover each eyeNormal: Eyes motionlessAbnormal: 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 weaknessGait ataxiaUnilateral limb ataxia and/or sensory deficitDysarthria

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 bleedSymptomatic treatment for peripheral vertigo with appropriate follow-up
  • Administer medication to control vertiginous symptoms and/or nausea:AntihistaminesBenzodiazepinesAntiemetics
  • 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.

See Also (Topic, Algorithm, Electronic Media Element)

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)