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emergensi pada vertigo
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VERTIGO & DIZZINESS: IN THE EMERGENCY ROOM
Amanda Tiksnadi, MD
Department of Neurology
Faculty of Medicine University of Indonesia
Updates of Neuroemergency 2012, RSCM Jakarta
Perpective
• 7.5 mil/year in ambulatory care settings
• Study of 1000 outpatient 3rd complaint
• One of most commont CC in ED
• BPPV
• Most common
• Loose particles in the semicircular canals
• 107 cases per 100.000/yr
• Dizziness in older person
• 20% severe enough to affect ADL
• CV, neurosensory, psych, multiple medications
Dizziness In The ER
• Pts difficult to interview, time consuming
• Dizziness ~ imprecise term
Weakness, presyncope, neurologic impairment, vertigo,
visual disturbance, psychologic illness
• Reported symptoms can be vague, inconsistent, or
unreliable
• Life-threatening disorder ~ benign disorder
• Screening test often insensitive
• Problematic to diagnose and treat
Evaluation
• Often difficult & time consuming commonly referred to
medical specialists
• Neurologist, Otolaryngologist, Ophthalmologist do play
important role in the patient evaluation
• But.... In reality, most of the pts have an organic basis
for symptoms that can be successfully identified and
treated good history and focal PE in the primary care
setting
• Goal of the primary clinician
• Recognize which pts need inpatient management or
emergency intervention
Evaluation
• Basic concepts of diagnostic process
• Is it true vertigo??
• Decide whether it is central or peripheral
VERTIGO
Vestibuler Non-Vestibuler
Sifat Vertigo Rasa berputar
(true vertigo)
Rasa melayang,
goyang, sempoyongan
Sifat Serangan Episodik Kontinyu
Mual/Muntah (++) (+/-)
Gangguan
Pendengaran (+/-) (-)
Gerakan Pencetus Gerakan Kepala Gerakan Objek visual
Situasi Pencetus (-) Ramai orang, lalu lintas
macet, sibuk, pasar
swalayan
Letak Lesi Sistem Vestibular Sistem Visual,
somatosensorik
(proprioseptif)
Vertigo Vestibuler
Perifer Sentral
Bangkitan Vertigo Mendadak Lebih lambat
Intensitas Berat Ringan
Pengaruh Gerakan
Kepala (+) (-)
Gejala Otonom (++) (-)
Gangguan Pendengaran (+) (-)
Tanda fokal otak (-) (+)
In the
ER Acute severe
dizziness
Recurrent
attack of
dizziness
Recurrent
positional
dizziness
Acute Severe Dizziness
• Sudden onset, absence of prior similar episodes
• Nausea, vomiting >>. Impaired ability to walk is also >
• Vestibular neuritis • Acute lesion of vestibular nerve on one side
• Presumed viral in origin ~ Bell’s palsy of the VIIIth nerve
• True severe vertigo 1-2 days w gradual resolution over wks to mos
• Exceedingly rare to have >1 episode consider alternative D/
• PE in VN highly characteristic examination features
• Stroke within posterior fossa • Dizziness: 50% of stroke presentations
• 3% patients of dizziness had stroke as the etiology
• 1% isolated dizziness had a stroke as etiology
• Pros study of 24 pts with acute severe dizziness 25% stroke
Acute Severe Dizziness
• Stroke within posterior fossa
• Ask for other neurologic symptoms: focal numbness, focal
weakness, or slurred speech
• Mild double vision can result from a vestibular lesion not a
specific sign
• Pts stroke with isolated dizziness imblance, true vertigo, nausea,
vomitting ~ as in VN
• CT is not recommended, MRI is preferable but the sensitivity is low
and not practical in ER setting
• Key feature STROKE vs. VN : Physical Examination:
nystagmus and head thrust test
PE of Acute Severe Dizziness Vestibular Neuritis
• Spontaneous Nystagmus
• Unidirectional nystagmus
• Head-Thrust Test
• Positive with movements
toward abnormal side
Stroke
• Spontaneous Nystagmus
• Bidirectional gaze-evoked,
Pure torsional, Spontaneous
vertical nystagmus
• Head-Thrust Test
• Normal
Management of Acute Severe Dizziness
• Supportive care
• If Stroke is suspected neuroimaging
• If stroke < 3 hours of onset thrombolytic treatment
• If VN short course of corticosteroids
• After acute phase
• Resume daily activities help brain to compensate for asymmetry
of vestibular signals
• A formal vestibular therapy
Recurrent Positional Dizziness
• Symtoms triggered by certain head positions
• BPPV vs. CNS origin
• Important to recognize BPPV
• Can be readily treated at the bedside
• Most effective way to exclude CNS positional dizziness
BPPV
• Episodes < 1 min
• Pts are normal in between episodes
• Nausea or a mild lightheadedness sometimes > 1 min
need exploration for other potential cause
• Dizziness at any cause will feel worse with certain
position, BPPV has dizziness triggered by positional
changes AND THEN returns to normal between attacks
• VN often misclassified as BPPV, symp improve when pts
remain still and worsen with movements different w
BPPV who returns to normal at rest
BPPV
• Ca carbonate debris dislodge from otoconial membrane in
the inner ear semicircular canal free floating head
movement trigger the symp
• Most common trigger
• Extending the head back to look up
• Turning over in bed
• Getting in and out of bed
Positional Testing – Dix-Hallpike test
Particle Repositioning – Epley Maneuver
Home Program – Brandt-Darroff Exc
Central Positional Dizziness
• Stems from a lession of the cerebellum or the brainstem
• Chiari malformation, cerebellar tumor, MS, migrain
vertigo, degenerative ataxia disoder
• Central vs. Peripheral: pattern of nystagmus
• Pure down-beating nystagmus lasts as long as the position is held
• Pure torsional nystagmus
• Nystagmus is refractory to repositoning maneuvers
Recurrent Attacks of Dizziness
• Report of prior similar episodes
• Duration: highly variable but can be helpful in
discriminating potential causes
• Meniere’s disease
• Recurrent spontaneous episodes
• Severe true vertigo, nausea, vomiting, imbalance
• Unilateral auditory features: hearing loss, very loud tinnitus, ear
fullness
• Nystagmus may not follow the rule of nystagmus VN but red flag
for CNS nystagmus apply
• Head thrust generally normal since N.VIII is intact
Recurrent Attacks of Dizziness
• Transient Ischemic Attack
• New-onset recurrent spontaneous attacks of dizziness
• Last for minutes, less than typical Meniere’s
• Impending basilar artry occlusion
• Main consideration if the attacks are increasing in freq (crescendo
pattern)
• Auditory symp may present AICA involvement
• CTA or MRA are the test to consider
Recurrent Attacks of Dizziness
• Migraine
• Great mimicker of all causes of dizziness
• Acute severe attack, positional episodes, or recurrent spontaneous
attacks
• PE: can suggest a peripheral or central process
• Strong genetic component, environmental fx, food, lifestyle
• Light, sound, motion, can trigger or aggravate the symp
• Diagnosis of migraine vertigo remains a diagnosis of exclusion
• If the symp is new in onset & not fit for peripheral consider first
as stroke or TIA before diagnosing as migraine vertigo
• Headache not always reported
• Triptan do not generally improve symp
Recurrent Attacks of Dizziness
• Panic disorder
• Show any other typical symp of panic disorder
• If general history and PE not clear exclude the other potential
cause
• General medical cause
• Usually not in form of true vertigo
• If nystagmus present involvement of peripheral or central
components of the vestibular syst
Nystagmus rules out most general medical disorders
• Cardiac arrhytmia or myocardial infarction should be considered in
the appropriate setting
Symptomatic Treatment
• Severe nausea & vomiting IV fluids during ER stay
• Drug to reduce symptoms
• Vestibular supressants
(antihistamines, benzodiazepines, anticholinergics)
• Antiemetics
• These drugs can be effective for acute attacks, not
effective as prophylactic agents
• If taken as daily regular basis side effects >> or reduce
the brain ability to compensate
Summary
`Summary
• The most effective way to “rule out” a serious case is to
“rule-in” a benign inner ear disorder
• When the features are atypical or other red flag appear
consider sinister causes
• Acute severe dizziness atypical for VN
• Recurrent attacks of dizzienss when attacks are recent in onset
and last only minutes
• Recurrent positional dissiness central positional pattern of
nystagmus is seen or when no respond to particle repositining
technique
Generally central positional nystagmus is caused by disorder that
require a less urgent evaluation than acute severe dizziness or
recurrent attacks of dizziness
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