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DIZZINESS & VERTIGO. Trevor Langhan PGY-5 Resident rounds. Dizziness - Background. Dizziness = sensation of abnormal orientation in space Very common complaint in the ED Common cause for repeat physician visits Patients older than 60 years - PowerPoint PPT Presentation
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DIZZINESS & VERTIGO
Trevor Langhan PGY-5
Resident rounds
Dizziness - Background
Dizziness = sensation of abnormal orientation in space
Very common complaint in the ED
Common cause for repeat physician visits
Patients older than 60 years
20% have experienced dizziness severe enough to affect their daily activity
Case 175 year old ladyPMHx: DM, OA, GoutMeds: metformin, glyburide, Vit B, multivit, Iron
Cc: DizzyHPI: stood up after lunch in mall
+++ lightheadedEverything was fading to blackMild nausea with sweatingNeeded to sit or would have faintedLayed down on bench in mall. Now feels better
Case 1
HR 88 BP 110/70 RR 16 Sat 95% afeb
Hgb 73, platelet 410, WBC 7.5
Lytes, Creat, Gluc, troponin, U/A all normal
CXR normal
EKG normal sinus
Physical exam
Unremarkable
Neuro exam normal, gait normal
PLAN?
San Fran Syncope Rule
1-3 % of ED visits are for syncope or pre-syncope
50% of patients don’t have a diagnosis at d/c
SF rule criteria are:
Abnormal EKG
Hematocrit < 30%
History of CHF
Complaint of SOB
Systolic BP < 90 mmHg
San Fran Syncope Rule
Who will have a serious event within 7 days
Derivation and validation study
98% and 96% sensitive
External Validation study:
Prospectively enrolled syncope and near-syncope
477 patients (good f/u in 93%)
12% had significant event in 7 days
Rule 89% sensitive & 42% specific
San Fran Syncope RuleInclusion: syncope or near-syncope b/t 8am & 10pm
SF rule exclusion criteria are:
LOC related to seizure (witnessed)
LOC due to Head trauma
Ongoing confusion (including dementia)
Intoxication
Age < 18 years
Non-english or spanish speaking
DNR
Lack of follow-up contact info
Presyncopal Lightheadedness
Diagnoses not to miss
Cardiac Syncope
1 yr mortality 18-33%
Neurologic Catastrophes
Ischemia or bleed
Hemorrhage
ruptured AAA, ruptured EP
Dizzy vs. Vertigo
Key to history is trying to differentiate
‘what’s dizzy to you?’
Fading to black vs. room spinning?
Neuro Exam
Most of us can do a rudimentary exam
Finer details often lacking
Some questions to consider:
Rhomberg?
Nystagmus?
Dysmetria?
EOM exam?
Pupillary findings?
Vertigo
Vertigo – defined more clearly as a sensation of disorientation in space combined with a sensation of motion.
Usually 2o to pathological basis, but need to differentiate benign from sinister
Most NB is to differentiate peripheral and central vertigo
Vertigo
Vestibular apparatus
3 semi-circular canals with cristae
Provide info about body angles and movement
Travel by CN VIII
Enter brainstem near Pons
Travels down two paths
MLF – medial longitudinal fasciculus
Vestibulospinal tract
Peripheral vs. Central
Peripheral causes usually benign and not needing acute intervention.
Central causes may have urgently needed intervention (cerebellar hemorrhage).
Changing or rapidly progressive symptoms should raise concern of impending posterior circulation occlusion.
Peripheral vs. Central
Peripheral Central
Onset Sudden Gradual S
Position Worse No Effect P
Intensity Very Not severe I
Nystagmus One direction Hor, vert, rotary
N
Neuro Symps Usually none Usually yes N
Auditory +/- tinnitus None E
Duration Seconds to minutes
Weeks to months
D
‘Toxic’ Labyrinthitis
Medication induced vestibular toxicityAminoglycosidesAnticonvulsantsAlcoholNSAIDS
Gradually progressive SxCan get hearing loss & severe N & V No positional nystagmusTx
Stop toxic drug?steroids
Peripheral
Benign Positional Peripheral Vertigo – BPPV
Due to canulith settling against cristae
+++ severe acute vertigo symptoms
Dix-Hallpike Test
Dix-Hallpike Test
Particle Repositioning Maneuvers
Cochrane (2005) – ”some evidence that the Epley manoeuvre is a safe effective treatment for posterior canal BPPV”
Studies vary from 66-100% success in alleviating or decreasing Sx
Effective in subjective vertigo
30-50% will have recurrence requiring repeat Tx
CASE
44 year old woman complains of ringing in her ears, needing to listen to the TV at higher volume, and the sensation that the room is spinning.
Her presentation is typical for:
Meniere’s Disease
Meniere’s Dz
No positional nystagmus on examAssociated tinnitus & fluctuating hearing loss (low frequency senorineural)Hearing loss may persist between episodes (need to consider acoustic neuroma in the Ddx)Tx
Low Na diet (<2 g/d)Antihistamines, diuretics, betahisitine (Serc) Chemical ablation of vestibular function (gentamicin)Surgery
Labyrinthitis & Neuronitis
Suspected viral etiology
Peak incidence in 30 to 50s
Acute severe vertigo increases rapidly in intensity (hrs) & subsides gradually (days)
Can have mild persistent positional vertigo for wks to mos
• Get N & V, but NO auditory Sx • Tx
– Prednisone for 10d may shorten course– Vestibular rehab
Acute Suppurative Labyrinthitis
• Coexisting acute exudative bacterial inner ear infection
• Vertigo, severe N & V & hearing loss• Febrile toxic pt• Tx
– Admit for IV Abx +/- surgical I & D
Central Vertigo
• May be gradual progressive symptoms over time or an acute worsening of a chronic complaint
• Cerebellar testing: – Cerebellar gait
• wide base, unsteady, irregular steps, unable to heel/toe walk
– Dysdiadochokinesia• rapid alternating movements
– Dysmetria• inability to arrest movement at desired point
(finger/nose testing)
Case
• 79 y lady c/o sudden dizziness and nausea• PMHx: a fib, hypertension, DM• Meds: Glyburide, altace, coumadin
• HR 80, BP 120/80, RR 12, Sat 97%• Unsteady gait, falling to left• Numbness to right face• Decreased sensation to left arm and leg• Right eyelid is drooped and pupil is small
Wallenberg’s Syndrome
• PICA occlusion • Hallmark is crossed findings
– Loss of pain & temp sensation on ipsilateral face
– Loss of pain & temp sensation to contralateral body
• Infarction of:– post inf cerebellum– dorsolateral medulla
• Vertigo, N & V, Nystagmus • Partial ipsilateral V, IX, X, XI CN deficits• Ipsilateral Horners syndrome
Neuroanatomy• lateral spinothalamic tract • contralateral deficits in pain
and temperature sensation from body
• spinal trigeminal nucleus • ipsilateral loss of pain and temperature sensation from face
• nucleus ambiguus • vagus and
glossopharyngeal nerves
• dysphagia, hoarseness, diminished gag reflex
• vestibular system • vertigo, diplopia, nystagmus, vomiting
• descending sympathetic fibers
• ipsilateral Horner's syndrome
Cerebellar Stroke
• Account for ~1.5% of all strokes• Sudden onset severe vertigo, H/A, N & V, ataxia• May have a “drop attack”• CT usually will not visualize posterior fossa well• If you want to r/o posterior fossa stroke you need a
MRI
• 25% of patients with RF for stroke who present to the ED with severe vertigo, nystagmus and postural instability will have a inferior cerebellar stroke
Cerebellar Stroke• What does one do in the elderly or those with
stroke RFs that appear to have peripheral vertigo?
• Tx– Antiplatelet Tx +/- warfarin, CVS RF
modification– Treatment of elevated ICP and emergent
surgical decompression may be life saving– Vestibular rehab once past acute phase
Cerebellar Hemorrhage• Similar presentation to cerebellar stroke• Often require surgical decompression and
hematoma evacuation• With appropriate surgical treatment, prognosis
is good• CN VI palsy (inability to abduct the eye) can
occur with cerebellar hemorrhage and ipsilateral nerve VI compression.
Vertebrobasilar Migraine
• Typically begins in adolescence• Multiple neuro Sx followed by headache:
– Vertigo – Dysarthria– Ataxia– Visual disturbances– Paresthesias
• Complete resolution of neuro abnormalities after attack subsides
Vertigo Ddx
• Vertigo Lasting for Seconds– BPV
• Vertigo Lasting for Minutes or Hours– Meniere’s Disease, Vertebrobasilar
Insufficiency (TIA), Migraine, Partial Sz, Perilymph fistula
• Vertigo Lasting for a Day or Longer– Vestibular Neuronitis/Labyrinthitis, Brainstem or
Cerebellar Stroke
Peripheral vs. Central DDxPeripheral Central
Acoustic neuroma A Cerbellary CVA C
Acute Otitis Media A Concussion C
BPV B Cervical Spine muscle C
Cerumen against TM C Epilepsy E
Meniere’s Disease D Multiple Sclerosis M
Vestibular Neuronitis E Migraine M
Foreign Body in canal F Tumor T
Labyrinthitis Trauma R
Neuronitis Abcess A
Trauma Vertebral basilar artery insufficiency
L
Subclavian Steal S
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