DESCRIPTION

• Patients' descriptions of symptom quality (vertigo, lightheadedness, disequilibrium, or "other") are frequently misleading and should not be the basis of clinical decision making.
• An approach based on associated symptoms, timing and triggers of the dizziness followed by a targeted physical exam looking for telltale signs is less prone to subjective errors of language and possibly more likely to yield a specific diagnosis.
• There are 4 "timing and triggers" categories:
  • Acute vestibular syndrome (AVS)
  • Abrupt onset of persistent dizziness
  • Episodic vestibular syndrome (EVS)
  • Spontaneous episodes of dizziness lasting many minutes to hours
  • Positional vestibular syndrome (PVS)
  • Very brief episodes (usually lasting 20–50 sec) that are triggered by head or body position movement
  • Chronic vestibular syndrome (CVS)
  • Gradual onset of dizziness lasting weeks to months or longer

ETIOLOGY

• General medical (49%):
  • Arrhythmia
  • Hypoglycemia and other toxic metabolic causes
  • Hypovolemia of any cause
  • Sepsis and infections
  • Low cardiac output states of any cause
• Otologic/vestibular (33%):
  • Benign paroxysmal positional vertigo (BPPV)
  • Labyrinthitis and vestibular neuritis
• Neurologic (11%):
  • Stroke and transient ischemic attack (TIA)
  • Vestibular migraine
• Psychiatric (7%):
  • Anxiety and depression

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

History

Define the timing and triggers category and determine if the ROS suggests a particular serious diagnosis:

• Is the dizziness abrupt or gradual in onset?
• Is the dizziness intermittent or persistent?
• If intermittent, how long do episodes last?
• If intermittent, are the episodes triggered by head or body position movement?
• Are there any hearing or neurologic symptoms?
• Has the patient had recent head injury or started any new medications?
• Does the ROS suggest an acute medical issue; not an encyclopedic list, but examples include:
  • Headache – stroke, dissection, or tumor
  • Ear pain – mastoiditis, otitis media
  • Hearing changes – Ménière disease or labyrinthitis
  • Neck pain – vertebral dissection
  • Fever – systemic infection
  • Dyspnea – pulmonary embolism, pneumonia, or anemia
  • Chest pain – ACS or pulmonary embolism
  • Fluid losses – orthostatic hypotension, hypovolemia
  • Pregnancy – ectopic pregnancy, pre-eclampsia

ALERT

Physical Exam

• Vital signs
• Stand patient to test for clinical signs of orthostatic hypotension
• Otoscopic evaluation
• Cardiac exam – is there a murmur or S3?
• Neurologic exam
  • CN II-XII. In particular, is there nystagmus, and if so, what type (see below)?
  • Observe gait
  • Cerebellar exam (finger to nose/heel to shin)
  • Dix-Hallpike maneuver only for intermittent symptoms
• HINTS exam (only for patients with AVS)
  • This is a 3-part more detailed oculomotor exam (head impulse test, nystagmus testing, and test for skew deviation)
  • For acute (< 48 hr) of symptoms this exam has been shown to be more sensitive than MRI. If exam is concerning obtain MRI or neurology consultation.
• Head impulse testing (vestibulo-ocular reflex)
  • Patient fixes gaze on examiner's nose
  • Move patient's heads rapidly about 20° in the horizontal plane
• If reflex is intact their eyes will stay fixed on your nose (vestibulo-ocular reflex is intact) and a central cause such as cerebellar stoke may be at play. If there is a corrective saccade (eye moves with head and then snaps back toward your nose), this suggests a peripheral cause (vestibular neuritis or labyrinthitis)
• Nystagmus
  • Have patient track your finger to all visual fields.
    • Does the direction of horizontal nystagmus change with change in direction of gaze? (i.e., when patient looks left, is fast component beating to left; when patient looks right, is fast component toward the right)?
    • Direction-changing, vertical or torsional nystagmus (in a patient with the AVS) strongly suggests a central cause.
    • Direction-fixed nystagmus (always in same direction independent of direction of gaze) suggests peripheral cause.
• Tests of skew
  • Alternating cover test
    • Have the patient look at your nose and cover one of their eyes with your hand
    • Rapidly uncover the 1st eye; cover the other one and observe if there is a rapid vertical eye movement (the amplitude can be quite small).
    • Continue to alternately cover and uncover each eye (focusing on 1 eye) in rapid succession.
  • A rapid vertical corrective saccade (up or down) strongly suggests a central process.

ALERT

ESSENTIAL WORKUP

The only mandatory workup is history and physical exam. Using these, one can often make a specific diagnosis.

• Triage: Identify abnormal vital signs, changes in mentation or gross focal deficits in primary survey
  • Focused history to elicit other complaints such as chest pain, headache, and change in hearing that will guide evaluation
• Timing: Distinguish between intermittent and chronic symptoms considering relevant conditions for each
• Triggers: For intermittent symptoms consider the immediate context of episodes
• Telltale signs: HINTS exam for acute dizziness

DIAGNOSIS TESTS & INTERPRETATION

Lab

• Serum glucose
• Hematocrit, if suspected anemia/blood loss
• Electrolytes and renal function
  • VBG if considering CO poisoning or CO₂ narcosis
• UA to evaluate for infection
• Toxicologic screen, if suspected exposure

Imaging

• CT head if acute bleed suspected
  • CT only ~40% sensitive for ischemic posterior circulation stroke
• MRI if no other etiology found and HINTS exam concerning in a patient with the AVS

Diagnostic Procedures/Surgery

• Dix-Hallpike maneuver, head thrust maneuver, and test for skew deviation.
• EKG to detect arrhythmia, MI
• Lumbar puncture in setting of unexplained infectious signs or headache

DIFFERENTIAL DIAGNOSIS

Each of the timing and triggers categories has its own differential diagnosis. Here are the common and the dangerous causes:

• AVS – acute vestibular syndrome
  • Benign
    • Viral labyrinthitis (hearing involved)
    • Vestibular neuritis (hearing not involved
  • Dangerous
    • Stroke, particularly brainstem or cerebellar
    • Occasionally low cardiac output state (e.g., PE, ACS)
• EVS – episodic (spontaneous) vestibular syndrome
  • Benign
    • Vestibular migraine
  • Dangerous
    • TIA
    • Rarely, brief low cardiac output state (e.g., arrhythmia, PE that breaks up and migrates)
• PVS – positional (triggered) vestibular syndrome
  • Benign
    • BPPV
    • Orthostatic hypotension (if benign cause)
  • Dangerous
    • Orthostatic hypotension (if serious cause)
    • Rarely, CPPV (central paroxysmal positional vertigo) caused by a posterior fossa mass
• CVS – chronic vestibular syndrome
  • Benign
    • Psychiatric causes (anxiety and depression)
    • Benign medication side effects
  • Dangerous
    • Rarely a posterior fossa mass

[Outline]

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

INITIAL STABILIZATION/THERAPY

• Abnormal vital signs clinically managed
• Stabilization should be determined by more specific classification of dizziness based on the history, physical exam, and ancillary studies.

ED TREATMENT/PROCEDURES

Symptomatic control until diagnosis established

If BPPV suspected perform Epley maneuver

MEDICATION

• Ondansetron: 4 mg IV or ODT
• Diazepam: 2.5–5 mg IV or 2–10 mg PO
• Diphenhydramine: 25–50 mg IV, IM, or PO
• Meclizine: 25 mg PO (no more than 2–3 days)
• Promethazine: 12.5 mg IV q6h or 25–50 mg PO, IM, or PR q6h

Note: These medications are for symptom relief; response has no etiologic implications.

[Outline]

• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

Admission or discharge of patients with dizziness should be based on the underlying etiology or associated symptoms.

Discharge Criteria

• Admission or discharge of patients with dizziness should be based on the underlying and the patient's ability to function safely at home.
• If patient has isolated complaint of dizziness with normal neurologic and oculomotor testing as described above, consider discharge with follow-up instructions

Issues for Referral

Refer for completion of workup as an outpatient to a primary care physician, ENT, or neurologist depending upon likely cause.

FOLLOW-UP RECOMMENDATIONS

• The patient should be instructed:
  • Not to drive or operate machinery if he is feeling dizzy
  • To get up slowly after sitting or lying down
• Patient should return to the ED or see his doctor right away if:
  • Symptoms of neurologic problem (worsening headache, confusion, memory loss, new motor or sensory loss)
  • Symptoms of an infection (stiff neck, fevers, or chills)
  • Symptoms of acute cardiovascular or pulmonary problem (new acute abdominal chest or back pain, new dyspnea, or hemoptysis)
  • Symptoms of fluid losses (intractable emesis or stools, GI or vaginal bleeding)

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• Use the "timing and triggers" technique to diagnose dizzy patients.
• Advanced age and traditional stroke risk factors increase the likelihood of acute stroke as cause of dizziness.
• Noncontrast CT is NOT sensitive for acute cerebellar stroke.
• Patients with cerebellar stroke can present with isolated dizziness.
• It is a "negative" head impulse test (lack of corrective saccade) that is worrisome; a "positive" test suggests a peripheral vestibular etiology.
• The treatment for BPPV is an Epley maneuver, NOT meclizine.

ICD9

• 386.11 Benign paroxysmal positional vertigo
• 386.30 Labyrinthitis, unspecified
• 780.4 Dizziness and giddiness

ICD10

• H81.10 Benign paroxysmal vertigo, unspecified ear
• H83.09 Labyrinthitis, unspecified ear
• R42 Dizziness and giddiness

[Outline]

• ICD9
• ICD10

• Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol. 2008;7:951–964.
• Hwang DY, Silva GS, Furie KL, et al. Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting acute posterior fossa infarct. J Emerg Med. 2012;42:559–565.
• Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: Three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40:3504–3510.
• Newman-Toker DE, Cannon LM, Stofferahn ME, et al. Imprecision in patient reports of dizziness symptom quality: A cross-sectional study conducted in an acute care setting. Mayo Clin Proc. 2007;82:1329–1402.
• Newman-Toker DE, Hsieh YH, Camargo CA Jr, et al. Spectrum of dizziness visits to US emergency departments: Cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008;83(7):765–775.

See Also (Topic, Algorithm, Electronic Media Element)

Vertigo

Michael Bouton

Jonathan A. Edlow