Dizziness in the ED:
It’s Enough to Make Your
Head Spin!
Saurin Bhatt,
MD/MBA
Associate
Staf f,
Cleveland
Clinic
March 6, 201 2
Dizziness
 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)
Proper Care of Your Dizzy Patient
 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
Differentials of Dizziness
Dizziness Subtype Type of Sensation
Temporal
Characteristics
Selected Differentials
Vertigo
Spinning or Motion
Sensation
Episodic or
Continuous
BPPV
Meniere’s Disease
Labyrinthitis
Vertebrobasilar Ischemia
Cerebellar Infarction or
Hemorrhage
Presyncope
Feeling Faint, or
about to pass out
Episodic, may last for
seconds, may be
alleviated by lying
down
Dehydration
Anemia
Cardiac Ischemia
Arrhythmia
Infection
Hypo/Hyperglycemia
Disequilibrium
Unsteady feeling in
Continuous, but may
the lower extremities vary in intensity
Multiple Sensory Deficits
Peripheral Neuropathy
Vision Loss
Lightheadedness
Vague complaints,
nonspecific
Medication Related
Psychiatric Disorders including
Anxiety, Depression, Panic
Attacks
Hyperventilation
History is Key
 Obtaining a description of symptoms without using
the word dizziness may be challenging at times
 Focus on:
 Timing
 Triggers
 Progression of the symptoms
 Associated symptoms
PE Essentials
 Largely guided by history, but almost always
entails a detailed neurologic examination.
 Full Neurologic examination
 Cranial Nerves, especially CN VII and VIII
 Gait, truncal ataxia, strength, sensation, DTR
 Pronator drift, FTN, Romberg tests
 Ear Examination
 Cardiovascular examination
 Carotid bruits, irregular rhythm.
PE Essentials
Eye examination
Nystagmus
Vestibular Ocular Reflex (Head Impulse Test)
Skew Testing
Conjugate gaze
Nystagmus Evaluation
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
Vestibular Ocular Reflex
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
HEAD IMPULSE TESTING
SKEW TESTING
EXAMINATION IS BETTER THAN MRI!
 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.
A Word about Imaging
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.
Peripheral vs. Central
Best way to rule out central disorder is to rule
in a specific peripheral vestibular disorder
Peripheral vs. Central Characteristics
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
Dix-Hallpike Maneuver
Dix-Hallpike test for BPPV
Person 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
Epley Maneuver
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
Benefit of Residents…
Decision Tree
For Dizziness
Use history and
physical exam to
determine
category
Are there any
migraine
symptoms?
The ones to not send home…
Diagnoses to not miss!
Cerebellar stroke
Vertebrobasilar stroke
Space occupying Lesions
NPH
Hypoperfusion states
MS (not emergent), but can be found on
examination
Cerebellar Stroke
 20,000 of total strokes
 Often nonspecific findings
(N,V, unsteady gait, or HA)
and subtle neurologic
findings (ataxia, dysarthria,
and nystagmus)
 HINTS may be diagnostic
 Caution with negative neuroimaging; maintain a
high index of suspicion.
Vertebrobasilar Stroke
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
Space Occupying Lesion
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
NPH
 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
Hypoperfusion States
 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
Multiple Sclerosis
 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
Medical Treatment Options
 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.
KEY LECTURE POINTS
 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!
References
 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