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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

true vertigo??
Decide whether it is central or peripheral
Is it

VERTIGO
Vestibuler

Non-Vestibuler

Rasa berputar
(true vertigo)

Rasa melayang,
goyang, sempoyongan

Episodik

Kontinyu

Mual/Muntah

(++)

(+/-)

Gangguan
Pendengaran

(+/-)

(-)

Gerakan Kepala

Gerakan Objek visual

(-)

Ramai orang, lalu lintas


macet, sibuk, pasar
swalayan

Sistem Vestibular

Sistem Visual,
somatosensorik
(proprioseptif)

Sifat Vertigo
Sifat Serangan

Gerakan Pencetus
Situasi Pencetus

Letak Lesi

Vertigo Vestibuler
Perifer

Sentral

Mendadak

Lebih lambat

Berat

Ringan

Pengaruh Gerakan
Kepala

(+)

(-)

Gejala Otonom

(++)

(-)

Gangguan Pendengaran

(+)

(-)

Tanda fokal otak

(-)

(+)

Bangkitan Vertigo
Intensitas

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 ~ Bells 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


Menieres 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 Menieres
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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