Approach to dizziness and vertigo in ED

Faez Baherin MBBSMMed (Emergency) Training Programme USM

Supervisor : Dr Zikri

Outline

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

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

Definition

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

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

Classification

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

Non Vertiginous Dizziness

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)

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

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

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)

• DrugsTintinalli 7th Edition

Drugs associated with dizziness

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

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 cerebellum6. Kulstad Dizzy and Confused : A step-by-step evaluation of the clinician’s favorite chief complaint, Emerg Med

Clin N Am 28 (2010)

Physical Examination

• Diagnostic criteria for BPPV with Dix-Hallpike test (7)

1) History – episodes of vertigo with changes in head position2) Physical exam-Vertigo associated with nystagmus is provokedBy Dix-Hallpike test-There is latency period between completion ofManeuver and the onset of nystagmus (5-20 sec)-Provoked vertigo and nystagmus increase and resolveWithin 60 second

7. CPG : BPPV. American Academy of Otolaryngology 2008

Physical Examination

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

Differential diagnosis

• Peripheral vs central

• Peripheral :BPPV : 42%Vestibular Neuritis : 41 %Meniere’s Disease : 10 %Vascular and other causes (6%)

• CentralCerebellar infarctVertebrobasilar insufficiencyCNS lesion

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

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 verticalocular misalignment exclude 91 percent of stroke (8)

8. Edlow JA, Newman Toker . Diagnosis and initial management of cerebellar infarction. Lancet Neurol 2008

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

Radiological Imaging

• History and PE findings compatible with central causes

• In HINT-INFARCT +ve test

Management

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

Medical pharmacotherapy

• For peripheral vertigo , short term treatment with pharmacotherapy is the mainstay rx

• Prolonged treatment may exacerbate sx• Goal1) Reduction / elimination of vertigo2) Enhancement of vestibular compensation3) Reduction of accompanying sx like nausea

and vomiting

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

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

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

Repositioning maneuvers

• Epley maneuver• Semont maneuver

• 80-98 % effective in BPPV

Evidence profile grade B

Epley’s Maneuver

Sermont Maneuver

Guideline approach to vertigo

Tintinalli 7th Edition

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)

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