Saurin Bhatt, MD/MBA Associate Staff, Cleveland ClinicMarch 6, 2012

Dizziness in the ED: It’s Enough to Make

Your Head Spin!

2.3 - 2.6 million patients representing (about 1.5% of ED visits)

over $1.6 billion in health care expenditures per year

high incidence, cost, and potentially serious underlying causes of dizziness (TIA, stroke, arrhythmia)

Dizziness

What does the patient mean? Vertigo, presyncope, syncope, weakness, anxiety, AMS

Women and geriatric populations - atypical or under recognized symptoms of MI or stroke presenting as dizziness Elderly - several factors making them risky patients for

cerebrovascular or cardiovascular disease Multiple causes of dizziness

Who needs to get involved? Neurology/Neurosurgery, ENT, Cardiology, Toxicology, ICU,

or Psychiatry

Proper Care of Your Dizzy Patient

Dizziness Subtype

Type of Sensation

Temporal Characteristics

Selected Differentials

Vertigo Spinning or Motion Sensation

Episodic or Continuous

BPPVMeniere’s DiseaseLabyrinthitisVertebrobasilar IschemiaCerebellar Infarction or Hemorrhage

Presyncope Feeling Faint, or about to pass out

Episodic, may last for seconds, may be alleviated by lying down

DehydrationAnemiaCardiac IschemiaArrhythmiaInfectionHypo/Hyperglycemia

Disequilibrium Unsteady feeling in the lower extremities

Continuous, but may vary in intensity

Multiple Sensory DeficitsPeripheral NeuropathyVision Loss

Lightheadedness

Vague complaints, nonspecific

Medication RelatedPsychiatric Disorders including Anxiety, Depression, Panic AttacksHyperventilation

Differentials of Dizziness

Obtaining a description of symptoms without using the word dizziness may be challenging at times

Focus on: Timing TriggersProgression of the symptomsAssociated symptoms

History is Key

Largely guided by history, but almost always entails a detailed neurologic examination.

Full Neurologic examinationCranial Nerves, especially CN VII and VIIIGait, truncal ataxia, strength, sensation, DTRPronator drift, FTN, Romberg tests

Ear Examination

Cardiovascular examinationCarotid bruits, irregular rhythm.

PE Essentials

Eye examinationNystagmusVestibular Ocular Reflex (Head Impulse Test)

Skew TestingConjugate gaze

PE Essentials

Pattern Type Nystagmus Characteristic Cause

Peripheral Upbeat Torsional Nystagmus with Dix Hallpike Maneuver

Benign Paroxysmal Positional Vertigo

Peripheral Unidirectional Spontaneous Nystagmus

Vestibular Neuritis

Central Vertical Nystagmus Strokes, Chiari Malformation, MS

Central Direction Dependent Changes Medications (antiepileptic), Stroke, MS

Central Downbeating with Dix Hallpike Chiari Malformation or cerebellar space occupying lesion

Central Intranuclear Opthalmoplegia MS, Stroke

Physiologic Unsustained Gaze Dependent Nystagmus

Nystagmus Evaluation

Head Thrust Maneuver

Patient moves the head back and forth 20 degrees in each direction while gazing on a fixed object (your nose)

Disruption during vertigo suggests peripheral cause

Normal response in the setting of dizziness is suggestive of cerebellar stroke

Vestibular Ocular Reflex

Head impulse Testing

Skew Testing

In an article published in Stroke September 2009, the HINTS examination (Head Impulse, Nystagmus testing, and Testing of Skew) was more sensitive than DWI MRI within the first 48 hours of symptoms.

These three tests together take at most 2 minutes to perform and should be included in the examination of anyone complaining of persistent or constant dizziness.

Examination is better Than MRI!

Sensitivity of CT for identifying any stroke in the acute setting in 2007 data is 26%.

MRI is more sensitive (83%), but not many of emergency physicians have this access acutely

Even then, sensitivity is lowest within 24 hours of onset and when the lesion is in the brainstem or cerebellum.

A Word about Imaging

Best way to rule out central disorder is to rule in a specific peripheral vestibular disorder

Peripheral vs. Central

Characteristic Peripheral Central

Onset Sudden Gradual

Frequency Episodic, Recurrent

Constant, Progressive

Duration Seconds, Minutes

Weeks, Months

Nystagmus Horizontal Vertical

Triggered by Movement?

Yes Symptoms may worsen, but generally are not triggered with movement.

Isolated Hearing Loss?

Yes Other Neurologic findings are usually present.

Fatigable Yes No

Associated Symptoms Tinnitus, N/V Neurologic/Visual Symptoms

Postural Instability No (may lean towards lesion)

Yes

Peripheral vs. Central Characteristics

Dix-Hallpike Maneuver

Dix-Hallpike test for BPPVPerson from sitting to supine position, head turned 45 o to one side and extended about 20 o backward

Once supine, eyes typically observed for about 30 seconds.

If no nystagmus ensues, the person is brought back to sitting. Delay about 30 seconds again, and then the other side is tested

Positive Dix-Hallpike tests consists of a burst of nystagmus

Have the patient sit upright

Turn the patient’s head to the symptomatic side at 45 o angle, lie on the back

Remain in this position until resolution of the nystagmus

Turn the patient’s head 90 o to the other side

Remain up to 1 minutes in this position

Roll their body further in the same direction, so that the patient has their head facing nose down

Remain up to 1 minute in this position.Go back to the sitting position and remain up to 30 seconds in this position.

During every step of this procedure the patient may experience some dizziness

Epley Maneuver

Benefit of Residents…

Decision TreeFor Dizziness

Use history and physical exam to determine category

Are there any migraine symptoms?

Diagnoses to not miss!Cerebellar strokeVertebrobasilar strokeSpace occupying LesionsNPHHypoperfusion statesMS (not emergent), but can be found on examination

The ones to not send home…

20,000 of total strokes

HINTS may be diagnostic

Caution with negative neuroimaging; maintain a high index of suspicion.

Cerebellar Stroke

Often nonspecific findings (N,V, unsteady gait, or HA) and subtle neurologic findings (ataxia, dysarthria, and nystagmus)

more neurologic abnormalities than cerebellar strokes due to involvement of the posterior circulation

HA, dizziness, vertigo, or confusion may be complaints

PE findings include pupillary abnormalities, abnormal ocular movements, facial palsy, hemi/quadriplegia

Vertebrobasilar Stroke

Cerebellopontine angle tumors - slow progress (weeks or months)

Symptoms = vertigo, hearing loss, tinnitus, or facial weakness/ numbness (CN 7 and 8 involvement)

Occipital HA can also be present

With progression, look for signs of increased ICP: papilledema or mental status changes

Space Occupying Lesion

Usually in 60’s or 70’s - classic triad of unsteady gait, dementia, urinary incontinence

Gait is wide based, reduced step height and length, and decreased speed

Urinary frequency and urgency are earliest manifestations

Dementia - memory impairment with decreased attention, alertness, or speed of mental processing

Ventriculomegaly can be discovered on CT or MRI

NPH

Decreased cerebral perfusion can lead to AMS or sensation of dizziness

Shock may be apparent with vital signs changes, normally hypertensive patients with normal blood pressure or having certain beta blocker/calcium channel blockers may not have the traditional changes in vital signs

Decreased cardiac output from ACS may present as hypotension, cooler skin, dyspnea, rales, confusion, AMS, or dizziness

Hypoperfusion States

Typically young adults (25-45). Vertigo is the presenting symptom for 5% of patients 50% of MS patients have vertigo

INO found during nystagmus testing indicates MLF involvement and due to heavy myelination of the MLF places MS high on the differential

Prominent symptoms may include numbness or paresthesias

As Emergency physicians we should evaluate for other disease processes and refer to neurology for workup

Multiple Sclerosis

Goal - stabilize symptoms and identify treatable disorders

BPPV can be treated with head repositioning maneuvers

Symptomatic Medication options Dimenhydrinate IV (Dramamine) Meclizine PO (Antivert) Scopolamine transdermal patch Benzodiazepines

Antinausea medication if prominent feature

Corticosteriods and valacyclovir have been used for vestibular neuritis, but viral eitiology is rarely identified.

Medical Treatment Options

HINTS examination has a great sensitivity for finding central lesions.

The Dix-Hallpike Maneuver and Epley Maneuver not only diagnose BPPV, but also treat BPPV.

Rule out a central lesion by ruling in a peripheral lesion.

Always maintain a high degree of suspicion. A negative CT or MRI especially in the acute setting does not mean that there is no stroke!

Key Lecture points

Seminars in neurology: Vertigo presentations in the emergency department

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine: Nystagmus assessments documented by emergency physicians in acute dizziness presentations: a target for decision support?

Annals of Emergency Medicine: Risk of vascular events in emergency department patients discharged home with diagnosis of dizziness or vertigo.

Emergency Medicine Clinics of North America: Dizzy and confused: a step-by-step evaluation of the clinician's favorite chief complaint

American family physician: Dizziness: a diagnostic approach Neurology: Approach to the Dizzy patient in Practical Neurology

References