DESCRIPTION

• Dizziness, 3–4% of ED visits, difficult symptom to diagnose, describes a variety of experiences, including:
  • Vertigo
  • Weakness, fainting
  • Lightheadedness
  • Unsteadiness
• Vertigo, a hallucination of movement:
  • Spinning or turning
  • Sensation of movement between the patient and the environment
  • Oscillopsia (illusion of an unstable visual world)
  • Most patients have an organic etiology.
• Maintenance of equilibrium depends on interaction of 3 systems:
  • Visual
  • Proprioceptive
  • Vestibular
• Any disease that interrupts the integrity of above systems may give rise to vertigo.
• Peripheral vertigo:
  • Often, severe symptoms
  • Intermittent episodes lasting seconds to minutes, occasionally hours
  • Horizontal or horizontal–torsional nystagmus (also positional, fatigues, and suppressed by fixation)
  • Normal neurologic exam
  • Sometimes associated hearing loss or tinnitus
• Central vertigo:
  • Usually mild continuous symptoms
  • All varieties of nystagmus (horizontal, vertical, rotatory)
  • No positional association
  • Presence of neurologic findings most of the time

ETIOLOGY

Peripheral

• Acute peripheral vestibulopathy (APV):
  • Vestibular neuritis (most common):
    • Single acute attack continuous rotational vertigo
    • Constant for several days
    • Present even when still
    • No hearing deficits
    • Highest incidence in 3rd–5th decade
  • Acute labyrinthitis:
    • Similar to vestibular neuritis but:
      • Associated with hearing deficit
      • May be viral (common), serous, acute suppurative, toxic, or chronic
• Benign paroxysmal positional vertigo (BPPV):
  • Most common cause recurrent vertigo
  • Posterior canal, 85–95% of BPPV cases
  • Lateral semicircular less common
  • Probable cause is loose particles (otoliths) in semicircular canals
  • Can be secondary to other entities including trauma and APV
• Ototoxic drugs:
  • Aminoglycosides
  • Antimalarials
  • Erythromycin
  • Furosemide
• Ménière disease:
  • Episodic vertigo, hearing loss, and tinnitus
• Acoustic neuroma:
  • Tumor of Schwann cells enveloping the 8th cranial nerve (CN VIII)
  • Develops into central cause
  • Progressive unilateral hearing deficits and tinnitus
  • May also involve CN V, VII, or X
• Trauma:
  • Rupture of tympanic membrane, round window, labyrinthine concussion, or development of perilymphatic fistula can all have severe symptoms.
• Otitis media and serous otitis with effusion
• Foreign body in ear canal

Central

• Vertebrobasilar artery insufficiency:
  • Disturbances may be transient or exacerbated by movement of the neck.
• Cerebellar infarction
• Cerebellar hemorrhage:
  • Neurosurgical emergency
  • Sudden onset of headache, vertigo, vomiting, and ataxia
  • Visual paralysis to affected side
  • Ipsilateral CN VI paralysis
• Multiple sclerosis:
  • Onset between 20–40 yr
  • All forms of nystagmus
  • May have abrupt onset of severe vertigo and vomiting
  • History of other vague and varying neurologic signs or symptoms
• Brainstem hypertensive encephalopathy
• Trauma:
  • Vertiginous symptoms common after whiplash injury
  • Postconcussive syndrome or damage to labyrinth or CN VIII secondary to basilar skull fracture
  • Vertebral artery injury has been seen after chiropractic manipulation.
• Temporal lobe epilepsy:
  • Associated with hallucinations, aphasia, trancelike states, or convulsions
  • More common in younger patients
• Vertebrobasilar migraines:
  • Prodrome of vertigo, dysarthria, ataxia, visual disturbances, or paresthesias followed by headache
  • Often a family history of migraines or similar attacks
• Tumor
• Subclavian steal syndrome:
  • Exercise of an arm causing shunting of blood from vertebral and basilar arteries into the subclavian artery, resulting in vertigo or syncope
  • Secondary to a stenotic subclavian artery
  • Diminished unilateral radial pulse or differential systolic BP between arms
• Hypoglycemia

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

Sensation of motion, spinning, disorientation in space, or disequilibrium

History

• Does true vertigo exist?
• Timing of onset:
  • Gradual (hours–days): Probably neuritis
  • Sudden and fixed symptoms (seconds–minutes) consider stroke (but see BPPV below)
  • Multiple prodromal episodes in months, especially weeks prior (TIAs): Stroke more likely
  • Repeated intense episodes provoked/exacerbated by head movements: BPPV more likely but could be TIA
  • Episodic attacks with auditory symptoms: Consider Ménière
• Stroke risk factors including age > 50 and vascular risks
• Severity of symptoms: Imbalance out of proportion to vertigo, consider stroke
• Modifiers: Head movement, BPPV more likely
• Associated symptoms:
  • Hearing loss (new unilateral): Labyrinthitis, Ménière (with tinnitus), rarely, but possibly stroke
  • Neurologic symptoms (central cause):
    • Unilateral limb weakness
    • Dysarthria
    • Headache
    • Ataxia
    • Numbness of the face
    • Hemiparesis, headache
    • Diplopia/visual disturbances
  • Has there been head or neck trauma?
• Past medical history/ROS:
  • Stroke risk factors
• Medication history

Physical Exam

• Extraocular movements:
  • Nystagmus (direction defined by fast component)
  • Unilateral, horizontal, some rotational component in (unilateral) APV, worse with gaze in the direction of nystagmus (fast away from lesion, linear slow phase)
  • Worse with occlusive ophthalmoscopy (cover 1 eye, examine optic disc with ophthalmoscope): APV more likely
  • Bilateral direction suggests central etiology, as does pure vertical or torsional nystagmus. If direction changes with gaze, central cause.
• Head impulse test (HIT) for unilateral vestibular loss (smartphone with slow motion video app promising aide for such testing):
  • Face patient, grasp head with both hands
  • Patient to look at your nose (or camera)
  • Rapidly rotate head 10–20° then back to midline:
    • Normal: Maintains gaze
    • Abnormal: Lag in maintaining gaze and corrective saccade back to nose/camera
  • Rotation to left, tests left vestibular apparatus
• Skew deviation testing (predicts central pathology):
  • Face patient
  • Patient to look at your nose
  • Alternately cover each eye
  • Normal: Eyes motionless
  • Abnormal: Refixation saccade after uncovered, (refixation upward, ipsilateral medullary stroke, refixation downward, contralateral stroke)
• Dix–Hallpike test for posterior canal BPPV
• Supine Roll test for lateral canal BPPV
• Auscultation of the carotid and vertebral arteries for bruits
• Pulses and pressures in both arms
• Inspection of the ears:
  • Evaluation of hearing (Weber and Rinne tests)
  • Ocular assessment (pupils, fundi, visual acuity, nystagmus)
• Cardiac auscultation
• Full neurologic exam, common stroke findings:
  • Unilateral limb weakness
  • Gait ataxia
  • Unilateral limb ataxia and/or sensory deficit
  • Dysarthria

ESSENTIAL WORKUP

• Ask patient to describe the sensation without using the word "dizzy."
• Determine whether the cause is a peripheral or a central process using patient's clinical presentation (see above).

DIAGNOSIS TESTS & INTERPRETATION

Lab

Electrolytes, BUN, creatinine, glucose

Imaging

• EKG for any suspicion of cardiac etiology
• Head CT/MRI for evaluation of suspected tumor, or post-traumatic cause
• MRI/MRA for suspected vertebrobasilar insufficiency (CT poor sensitivity)

Diagnostic Procedures/Surgery

Audiology or electronystagmography often helpful in outpatient follow-up

DIFFERENTIAL DIAGNOSIS

More likely other cause when "dizziness" actually is lightheadedness or malaise:

• DM
• Hypothyroidism
• Drugs (e.g., alcohol, barbiturates, salicylates)
• Hyperventilation
• Cardiac (i.e., arrhythmia, MI, or other etiologies of syncope); peripheral vascular disease (i.e., HTN, orthostatic hypotension, vasovagal)
• Infection/sepsis

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

Treatment and medication per EMS protocol based on symptoms

INITIAL STABILIZATION/THERAPY

• IV access for dehydration/vomiting
• Monitor
• Trauma evaluations as indicated
• Finger-stick blood glucose

ED TREATMENT/PROCEDURES

• Based on accurate diagnosis:
  • Central etiologies require more aggressive workup than peripheral.
  • Neurosurgical intervention for cerebellar bleed
  • Symptomatic treatment for peripheral vertigo with appropriate follow-up
• Administer medication to control vertiginous symptoms and/or nausea:
  • Antihistamines
  • Benzodiazepines
  • Antiemetics
• Initiate IV antibiotics for acute bacterial labyrinthitis (rare).
• Repositioning maneuvers such as Epley and Semont for posterior BPPV. Roll or Lempert maneuver for lateral BPPV

MEDICATION

• Diazepam (Valium): 2.5–5 mg IV q8h or 2–10 mg PO q8h
• Dimenhydrinate (Dramamine): 25–50 mg IV, IM or PO q6h
• Diphenhydramine (Benadryl): 25–50 mg IV, IM, or PO q6h
• Lorazepam (Ativan): 1 mg IV, IM or 1–2 mg PO q4–6h
• Meclizine (Antivert): 25 mg PO q6h PRN
• Promethazine (Phenergan): 12.5 mg IV q6h or 25–50 mg IM, PO, or PR q6h

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• Cerebellar infarct/hemorrhage
• Vertebrobasilar insufficiency
• Acute suppurative labyrinthitis
• Intractable nausea/vomiting
• Inability to ambulate

Discharge Criteria

Patient with peripheral etiology and stable

Issues for Referral

Otolaryngology follow-up for suspected acoustic neuroma or perilymphatic fistula

FOLLOW-UP RECOMMENDATIONS

• Primary care, neurology, or otolaryngology follow-up for all
• Epley and Semont maneuvers are extremely effective in treating BPPV.

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• Isolated vertigo can be the sole symptom of stroke or bleed
• Central cause clues: Imbalance and/or ataxia out of proportion to vertigo
• Learn the specialized exam and repositioning techniques

ICD9

• 386.10 Peripheral vertigo, unspecified
• 386.11 Benign paroxysmal positional vertigo
• 780.4 Dizziness and giddiness

ICD10

• H81.10 Benign paroxysmal vertigo, unspecified ear
• H81.399 Other peripheral vertigo, unspecified ear
• R42 Dizziness and giddiness

[Outline]

• ICD9
• ICD10

• Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139:S47–S81.
• Chawla N, Olshaker JS. Diagnosis and management of dizziness and vertigo. Med Clin North Am. 2006;90(2):291–304.
• Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: Three-step oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40:3504–3510.
• Kerber KA. Vertigo and dizziness in the emergency department. Emerg Med Clin North Am. 2009;27(1):39–50.
• Olshaker S. Vertigo. In: Marx J, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. St. Louis, MO: CV Mosby; 2010:93–100.

See Also (Topic, Algorithm, Electronic Media Element)

• Dizziness
• Labyrinthitis

William E. Baker