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

1. Approach to dizziness and
vertigo in ED
Faez Baherin MBBS
MMed (Emergency) Training Programme USM
Supervisor : Dr Zikri

2. Outline
• Introduction and Definition
• Pathophysiology of the disease
• Classification
• Approach : History
• Approach : Physical Examination
• HINTS to INFARCT
• Management
• Conclusion / Take-home message

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. Definition

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. 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. Classification
• True Vertigo vs Non-vertiginous Giddiness
• Peripheral vs Central Vertigo

8. Non Vertiginous Dizziness

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. 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. 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. 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. Drugs associated with dizziness

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. 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. 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. Physical Examination

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. 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. A guide to Management of Peripheral Vestibular Disorder, Malaysian Society of Otorhinolaryngologists 2012

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. 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. Radiological Imaging
• History and PE findings compatible with
central causes
• In HINT-INFARCT +ve test

24. Management
A guide to Management of Peripheral Vestibular Disorder, Malaysian Society of Otorhinolaryngologists 2012

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. 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. 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. 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. Repositioning maneuvers
• Epley maneuver
• Semont maneuver
• 80-98 % effective in BPPV
Evidence profile grade B

30. Epley’s Maneuver

31. Sermont Maneuver

32. Guideline approach to vertigo
Tintinalli 7th Edition

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. 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
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