Approach to Dizziness and Vertigo in Emergency Department

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how to approach vertigo in ED and how to differentiate between central and peripheral lesion

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Approach to Dizziness and Vertigo in Emergency Department

  1. 1. Approach to dizziness and vertigo in ED Faez Baherin MBBS MMed (Emergency) Training Programme USM Supervisor : Dr Zikri
  2. 2. Outline • Introduction and Definition • Pathophysiology of the disease • Classification • Approach : History • Approach : Physical Examination • HINTS to INFARCT • Management • Conclusion / Take-home message
  3. 3. Introduction • Very common presentation • It is one of the most common chief complaints in the emergency department.(1) • The lifetime prevalence of vertigo in adults aged 18 to 79 years is 7.4%, with a clear increase in prevalence with age. 1. Karatas M. Central Vertigo and dizziness, epidemiology, differential diagnosis and common causes. Neurologist 2008; 14(6);355-64
  4. 4. Definition
  5. 5. Pathophysiology of vertigo • CNS coordinates and integrates sensory input from the visual, vestibular and proprioceptive system. • 1) Visual inputs provide spatial orientation • 2) Proprioceptors help relate body movement and indicate the position of the head relative to that of the body • 3) Vestibular establishes the body’s orientation with respect to gravity Tintinalli 7th Edition
  6. 6. Vestibular system Movement of endolymph in the canals sense orientation to movement (via movement of specialized hair cells)  afferent vestibular impulse  8th CN Vertigo : mismatch of information from the involved senses Eg : aging, otoconia, increased endolymph production
  7. 7. Classification • True Vertigo vs Non-vertiginous Giddiness • Peripheral vs Central Vertigo
  8. 8. Non Vertiginous Dizziness
  9. 9. Central vs Peripheral Vertigo Kulstad Dizzy and Confused : A step-by-step evaluation of the clinician’s favorite chief complaint, Emerg Med Clin N Am 28 (2010)
  10. 10. Vertigo approach : History • What does the patient mean by dizziness • Is it true vertigo or non vertiginous dizziness • Rule out any life threatening conditions that could manifest as vertigo – ACS, arrythmias, hypoxia, hypoperfusion. Exclude possible head trauma or space occupying lesion • True vertigo should be further evaluated – central versus peripheral. URTI, hearing loss etc
  11. 11. Vertigo approach : History • Peripheral vertigo – described as rotational or spinning sensation when patient changes head position in relative to gravity (2) • Patient with peripheral vertigo most commonly report discrete episodic periods of vertigo lasting 1 minute or less and often report limitation of their general movement to avoid provoking the vertigo (3) • Approximately 50 percent reports subjective imbalance between episodes of vertigo (4) 2,3,4 : Bhattacharyya et all, CPG American Academy of Otolaryngology
  12. 12. Vertigo approach : History • Central vertigo is more sinister and more life threatening • It is usually accompanied by neurological sx and signs – diplopia, dysarthria, cranial nerve defect, etc • Central cause is not always absent when symptoms appear more consistent with benign peripheral etiology (5) • Drugs Tintinalli 7th Edition
  13. 13. Drugs associated with dizziness
  14. 14. Physical Examination • General condition, vital signs, ECG • Ear, neurology, vestibular examinations • External auditory canal and TM should be examined + hearing assessment • Cranial nerve examination. • Other abnormalities that point toward central lesion : corneal reflex, facial paresis, dysphagia, depressed gag reflex, ataxia. • Tandem gait and romberg testing + pronator drift
  15. 15. Physical Examination • No bedside maneuver is diagnostic but head thrust maneuver deserves special mention • It assesses the VOR (vestibular ocular reflex) and distinguishes between peripheral and central causes (6) • Abnormal response – peripheral causes – patient’s eye move with their head and then snap back to examiner’s nose • Normal response – fixed to examiner nose – central lesion – bypass the cerebellum 6. Kulstad Dizzy and Confused : A step-by-step evaluation of the clinician’s favorite chief complaint, Emerg Med Clin N Am 28 (2010)
  16. 16. Physical Examination • Diagnostic criteria for BPPV with Dix-Hallpike test (7) 1) History – episodes of vertigo with changes in head position 2) Physical exam -Vertigo associated with nystagmus is provoked By Dix-Hallpike test -There is latency period between completion of Maneuver and the onset of nystagmus (5-20 sec) -Provoked vertigo and nystagmus increase and resolve Within 60 second 7. CPG : BPPV. American Academy of Otolaryngology 2008
  17. 17. Physical Examination
  18. 18. Physical Examination • Dix-Hallpike test is considered the gold standard test for the diagnosis of BPPV. • 82 percent sensitivity and 71 percent specificity (Lopez-Escamez et al) • 83 percent positive predictive value, 53 percent of negative predictive value (Hanley and O’Dowd) • Depends on speed and angle of plane. • Should be avoided in certain circumstances
  19. 19. Differential diagnosis • Peripheral vs central • Peripheral : BPPV : 42% Vestibular Neuritis : 41 % Meniere’s Disease : 10 % Vascular and other causes (6%) • Central Cerebellar infarct Vertebrobasilar insufficiency CNS lesion
  20. 20. A guide to Management of Peripheral Vestibular Disorder, Malaysian Society of Otorhinolaryngologists 2012
  21. 21. HINTS TO INFARCT • HINTS to Diagnose Stroke in the Acute Vestibular Syndrome AHA Stroke Journal 2009 : “Screening patients with AVS for one of 3 dangerous oculomotor signs (normal h-HIT, direction-changing nystagmus, skew deviation) appears to be more sensitive than MRI in detecting acute stroke in the first 24 to 48 hours after symptom onset. These “HINTS” to “INFARCT” could help reduce frontline misdiagnosis of patients with stroke in AVS” Abnormal head thrust + horizontal nystagmus + absence of vertical ocular misalignment exclude 91 percent of stroke (8) 8. Edlow JA, Newman Toker . Diagnosis and initial management of cerebellar infarction. Lancet Neurol 2008
  22. 22. When vertigo is not benign HINTS TO INFARCT • H – head I - Impulse • I - impulse N - Normal • N – nystagmus F - Fast-phase • T – test of A - Alternating • S - skew R - Refixation on C - Cover T - Test
  23. 23. Radiological Imaging • History and PE findings compatible with central causes • In HINT-INFARCT +ve test
  24. 24. Management A guide to Management of Peripheral Vestibular Disorder, Malaysian Society of Otorhinolaryngologists 2012
  25. 25. Medical pharmacotherapy • For peripheral vertigo , short term treatment with pharmacotherapy is the mainstay rx • Prolonged treatment may exacerbate sx • Goal 1) Reduction / elimination of vertigo 2) Enhancement of vestibular compensation 3) Reduction of accompanying sx like nausea and vomiting
  26. 26. Medical Pharmacotherapy (BPPV) • There’s no evidence in literature to suggest any of these vestibular suppressant medication are effective as a definitive, primary treatment for BPPV, or as a substitute for repositioning maneuvers. • Only used in short term and severely symptomatic patient. • In one double blind controlled trial (McClure and Willet), all group including the placebo showed a gradual decline in sx with no additional relief in the drug treatment arm. CPG : American Academy of Otolaryngology 2008
  27. 27. Medical pharmacotherapy • Drug of choice : scopolamine, transdermally • Antihistamine – most commonly prescribed drugs (H1 blocker) • Calcium channel blocker –indicated when patient is not responding to antihistamine and scopolamine • Antidopaminergic (metoclopramide, promethazine) – considered as 2nd line treatment if antihistamine and scopolamine fail. • Patient with non vertiginous dizziness shouldnt be treated with anti vertigo medication Tintinalli 7th Edition
  28. 28. Medical pharmacotherapy The review of trials did not find enough evidence to show whether Betahistine and diuretics is helpful in Meniere disease. Further research is needed. http://summaries.cochrane.org/CD001873/betahistine-for-menieres-disease-or-syndrome#sthash.chdmrzEz.dpuf
  29. 29. Repositioning maneuvers • Epley maneuver • Semont maneuver • 80-98 % effective in BPPV Evidence profile grade B
  30. 30. Epley’s Maneuver
  31. 31. Sermont Maneuver
  32. 32. Guideline approach to vertigo Tintinalli 7th Edition
  33. 33. Conclusion • Evaluating patient with dizziness is not as easy as it sounds • We should rule out life-threatening causes • We should be able to differentiate between central and peripheral causes • Good history taking and proper physical examination is mandatory (including the HINT-INFARCT)
  34. 34. Reference • A guide to Management of Peripheral Vestibular Disorder, Malaysian Society of Otorhinolaryngologists 2012 • Kulstad Dizzy and Confused : A step-by-step evaluation of the clinician’s favorite chief complaint, Emerg Med Clin N Am 28 (2010) • Clinical Practice Guideline : BPPV. American Academy of Otolaryngology 2008 • AHA Stroke Journal 2009 • Tintinalli 7th Edition • http://summaries.cochrane.org JZKK

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