David A. Marcus@EMIMDoc

LIJ Emergency Medicine – 12/2/2015

Dizzying HiNTS in the E.D.

Oh Doc, I’m dizzy…

28 y/o F non contributory PMHxdizzy for one day, nausea and vomiting.

Oh Doc, I’m dizzy…

85 y/o M h/o Diabetesp/w mild dizziness for 2 days, nausea.

Oh Doc, I’m dizzy…

52 y/o FHealthy“My head is light” (not heavy) x 6 hoursNeeds help walking

Oh Doc, I’m dizzy…

65 y/o M DM, CAD/CABGDizziness x 24 hrsPhotophobia, mild headache.

Oh Doc, I’m dizzy…

38 y/o FNon contributory PMHx Vertigo x 36 hoursNausea and vomiting, reduced hearing

The Plan

Spinning, dizziness, lightheadedness, oh my! Central vs Peripheral – Is that a thing? Taking it to the bedside A neuro-ophthalmologist says what?

We will not be discussing the place of CT in vertigo evaluation.

Spinning, dizziness, lightheadedness, oh my!One man’s tree is another man’s bush…

15-20% of people with vertigo will describe it using other terms, even with repeat questioning, and may use different terms for same Sx within 1 encounter.

I’m Dizzy One of the most common ED complaints

Tremendous DDx

Central vs Peripheral – Is That a Thing?

Yes. But first:Benign Parox. Positional Vertigo

• N/V, Nystagmus, Head motion intolerance • Paroxysmal• Positional• Triggered by movement (vertical)• < 1 minute• Able to walk

• Dx: Dix Hallpike Maneuver

Torsional/Vertical Nystagmus

• Tx: Epley Maneuver/Meds

Acute Vestibular Syndrome

• N/V, Nystagmus, Head motion intolerance• Usually, acute onset• Extended duration• Unsteady gait

CENTRAL PERIPHERAL

Central vs Peripheral – Is That a Thing?

3% of all isolated vertigo = stroke

20% of posterior CVA have no neuro deficits

10% of cerebellar infarcts have only vertigo

Central vs Peripheral – Is That a Thing?

Acute Vestibular Syndrome (not BPPV)

Peripheral AVS:

1. Vestibular Neuritis/Labyrinthitis (most)

2. Menierre’s Disease (uncommon)- Vertigo + Cochlear Sx

3. Trauma/Post Op

4. Schwannoma

Central AVS:

1. Cerebellar Infarct/Hemorrhage

2. Migrainous Vertigo

3. Meds/Tox

4. Demyelinating Disease (MS, etc)

5. Trauma/Post Op

6. Masses (CPA tumors, etc)

Taking it to the Bedside

1. Sudden, maximal at onset (though may not seem as severe as BPPV)

2. Unable to ambulate without assistance due to ataxia

3. Focal neuro deficits4. New, acute occipital headache5. Direction changing nystagmus6. Intact Head Impulse Test

Red flags for Acute Vestibular Syndrome

Taking it to the Bedside

If:

Then:

Taking it to the Bedside

If no:

Then:

A neuro-ophthalmologist says what? Originally published by Dr. David

Newman-Toker et al.

Proponents argue that the HiNTS Exam can help differentiate central vertigo from peripheral vertigo in AVS.

Use for patient with AVS without red flags, who are at moderate-high risk of stroke

A neuro-ophthalmologist says what? Hi – Head Impulse (VOR intact)

Normal is ABNORMAL (central)

N – NystagmusBidirectional or gaze evoked is ABNORMAL

(central)

TS – Test of SkewVertical skew is ABNORMAL (central)

Video on: http://emcrit.org/?powerpress_pinw=765-podcast

A neuro-ophthalmologist says what?

A neuro-ophthalmologist says what? The data:

Kattah: ED; Vertigo, N/V, Gait Ataxia, +/- Nystagmus; At least 1 risk factor

Chen: ED; Vertigo, N/V; At least 1 risk factorNewman-Toker HiNTS vs ABCD2: ED; Vertigo,

Nystagmus, N/V, Gait imbalance, head motion intolerance; At least 1 risk factor.

Newman-Toker HiNTS: Specialized, small. Same inclusions; At least 1 risk factor.

ALL exams done by trained Neuro, or Neuro-Ophth.

Mostly on admitted pts.

A neuro-ophthalmologist says what?

•Up to 100% sensitive and 96% specific for CVA•Better than MRI < 48 hours of Sx

•Methodological concerns•Unclear how fits into practice• Can’t rule out CVA

Taking it to the bedside

Head Impulse testing can be difficult – here’s a Trick of the Trade from Dr. Scott Weingart: http://emcrit.org/procedures/iphone-hit/

The Bottom Line BPPV vs AVS Central vertigo may have less nausea and vomiting, may be

better tolerated. Red flags for AVS MRI

Sudden, maximal at onsetUnable to ambulate without assistance d/t AtaxiaFocal neuro deficitsNew, acute occipital headacheAbnormal HiNTS exam

HiNTS for symptomatic AVS without red flagsApply in “at risk” populationNot a “rule-out” tool yet, extension of neuro examAbnormal? MRINormal? Decision based on clinical picture

Recommended Reading Cohn, B. Can Bedside Oculomotor (HINTS) Testing

Differentiate Central From Peripheral Causes of Vertigo? Ann Emerg Med. 2014;64:265-268. http://www.ncbi.nlm.nih.gov/pubmed/24530107

Spiegel, R. The Adventure of the Veiled Lodger. Posted on EMNerd, Oct 21, 2013. http://emnerd.com/adventure-veiled-lodger

Seemungal, BM, Bronstein AM. A practical approach to acute vertigo. Pract Neurol 2008; 8: 211–221. http://pn.bmj.com/content/8/4/211.abstract

Additional Citations Nelson, JA, Viirre, E. The Clinical Differentiation of

Cerebellar Infarction from Common Vertigo Syndromes. West J Emerg Med. 2009;10(4):273-277. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791733/

Petrosoniak, A. Boring Question: Dizzy, need a few HINTS? Posted on BoringEM, 8/11/14.