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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
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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
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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
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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
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Evaluation
• Basic concepts of diagnostic process
• Is it true vertigo??
• Decide whether it is central or peripheral
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VERTIGO
Vestibuler Non-Vestibuler
Sifat Vertigo Rasa berputar
(true vertigo)
Rasa melayang,
goyang, sempoyongan
Sifat Serangan Episodik Kontinyu
Mual/Muntah (++) (+/-)
Gangguan
Pendengaran (+/-) (-)
Gerakan Pencetus Gerakan Kepala Gerakan Objek visual
Situasi Pencetus (-) Ramai orang, lalu lintas
macet, sibuk, pasar
swalayan
Letak Lesi Sistem Vestibular Sistem Visual,
somatosensorik
(proprioseptif)
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Vertigo Vestibuler
Perifer Sentral
Bangkitan Vertigo Mendadak Lebih lambat
Intensitas Berat Ringan
Pengaruh Gerakan
Kepala (+) (-)
Gejala Otonom (++) (-)
Gangguan Pendengaran (+) (-)
Tanda fokal otak (-) (+)
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In the
ER Acute severe
dizziness
Recurrent
attack of
dizziness
Recurrent
positional
dizziness
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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 ~ Bell’s 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
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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
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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
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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
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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
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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
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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
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Positional Testing – Dix-Hallpike test
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Particle Repositioning – Epley Maneuver
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Home Program – Brandt-Darroff Exc
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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
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Recurrent Attacks of Dizziness
• Report of prior similar episodes
• Duration: highly variable but can be helpful in
discriminating potential causes
• Meniere’s 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
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Recurrent Attacks of Dizziness
• Transient Ischemic Attack
• New-onset recurrent spontaneous attacks of dizziness
• Last for minutes, less than typical Meniere’s
• 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
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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
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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
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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
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Summary
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`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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