DIZZINESS IN THE EMERGENCY DEPARTMENT;A SIMPLIFIED APPROACH

Major Lindsey P. Schmelzer, PA-CEmergency Medicine PA Resident

Mike O’Callaghan Military Medical CenterNellis AFB, Nevada

DISCLAIMERThe views expressed are those of the author(s) and do not reflect the official policy or position of the U.S. Army Medical Department, Department of the Army, Department of Defense, or the U.S. Government.

This study was conducted in accordance with a protocol, reviewed and approved by the Chief of the Department of Clinical Investigation, Madigan Army Medical Center.

The investigators have adhered to the policies for protection of human subjects as prescribed in 45 CFR 46.

OUTLINE• History of Dizziness• A New Approach to Dizziness• Associated Symptoms• Timing and Triggers• Exam Signs and Symptoms• Testing• Acute Vestibular Syndrome• Triggered – Episodic Vestibular Syndrome• Spontaneous – Episodic Vestibular Syndrome• Review• Conclusion

WHAT DO YOU MEAN BY DIZZY?

A. VertigoB. LightheadedC. DisequilibriumD. All of the Above

HISTORY OF DIZZINESS

• Description of dizziness determines differential diagnosis

• Limitations• Few Subjects• Highly selected population• No independent verification of

diagnosis• No long-term follow-up• No brain imaging• Some diagnoses not

recognized • i.e. TIA, vestibular migraine

HISTORY OF DIZZINESS

• Hopkins University (2007)

• 60% of patients selected more than one “dizzy” type

• 50% of patients changed “dizzy” type within 6 minutes

There is NO TIGHT LINK betweendescription of dizziness and

differential diagnosis

A NEW APPROACH TO DIZZINESS

• A new diagnostic paradigm• Published in The Journal of Emergency Medicine (2018)

• Divides patients into three key categories based on associated symptoms, timing and triggers, exam signs and testing

A NEW APPROACH TO DIZZINESS

Dizziness CategoriesAcute Vestibular Syndrome (AVS)

Triggered - Episodic Vestibular Syndrome (t-EVS)Spontaneous - Episodic Vestibular Syndrome (s-EVS)

• Headache (Stroke, Vascular Dissection)• Neck Pain (Vascular Dissection)• Chest Pain (Acute Coronary Syndrome,

Pulmonary Embolism)• SOB (Pulmonary Embolism, Pneumonia,

Anemia)• Palpitations (Arrhythmia)• Bleeding/Fluid Loss (Hypovolemia)• Fever (Systemic Infection)• Positive Pregnancy Test (Ectopic

Pregnancy)

ASSOCIATED SYMPTOMS

• Identify obvious, worrisome associated signs and symptoms

TIMING AND TRIGGERS

• Onset and duration• Episodic or persistent• Triggers

• History of Trauma• Past Medical History• New Medications

EXAM SIGNS AND SYMPTOMS

• Nystagmus• Head Impulse Test• Skew Deviation• Neurological Exam• Gait Testing

NYSTAGMUS

HEAD IMPULSE TEST (HIT)

SKEW DEVIATION

NEUROLOGICAL EXAM

GAIT TESTING

TESTING• Neuroimaging

• Non-contrast head CT• Beneficial to evaluate for hemorrhage• ~20% sensitive for detecting posterior circulation stroke

• MRI with diffusion weighted imaging• Beneficial to evaluate for ischemic stroke• ~80% sensitive for detecting posterior circulation stroke

DIAGNOSTIC PITFALLS

• Grewal (2015)• Primary outcome = stroke within 30 days of ED discharge• Patients who HAD a CT scan were 2.3x more likely to have a stroke

than those who had no CT scan

NEW DIZZINESS CATEGORIES

ACUTE VESTIBULAR SYNDROME

SPONTANEOUS –EPISODIC VESTIBULAR SYNDROME (S-EVS)

TRIGGERED –EPISODIC VESTIBULAR

SYNDROME (T-EVS)

NEW DIZZINESS CATEGORIES

ACUTE VESTIBULAR SYNDROME

• Acute onset of persistent dizziness associated with nausea/vomiting, gait instability, nystagmus, and head motion intolerance lasting days to weeks.

• Key distinction from t-EVS• Patient is dizzy at baseline when head is in neutral position• Dizziness exacerbated by head motion

• Benign• Vestibular Neuritis • Acute Labyrinthitis

• Dangerous• Posterior Circulation Infarct

CASE #1

• Associated symptoms: nausea, vomiting and gait instability. States she had the “flu” last week. No tinnitus or hearing loss.

• Timing and Triggers: Abrupt onset. Persistent dizziness. Worse with head motion.

• Exam Signs: Horizontal nystagmus with fast component to the right. HIT positive –corrective saccade on left. No skew deviation. No CN deficits. No cerebellar signs. No ataxia.

• Testing: Rapid Influenza A/B negative

44yo F presents to the ED dizziness over the past 48hrs.

CASE #1

• Vestibular Neuronitis• Benign, self-limited disorder• Often viral or post-viral inflammatory disorder affecting

vestibular portion of CN VIII• May differentiate from labyrinthitis which technically

should have hearing loss and/or tinnitus

• Treatment• Antiemetic• +/- oral corticosteroid

• Disposition• Discharge home

CASE #2

• Exam Signs: Vertical (down-beating) nystagmus in primary gaze. HIT normal. Skew deviation present. Difficulty with finger to nose and heel to shin. Truncal ataxia – unable to sit-up in bed.

• Testing: Non-contrast head CT normal.

65-year-old male presents with dizziness and generalized weakness.

• Associated Symptoms: Nausea. Difficulty speaking. Double vision. History of type 2 diabetes mellitus, hypertension and hyperlipidemia.

• Timing and Triggers: Gradual onset of dizziness over the past 24hrs. Suddenly unable to walk 1hr ago. Endorsed dizziness when head is neutral, but worse with head movement.

CASE #2• Posterior Circulation Ischemic Stroke

• Sudden inability to walk is common finding

• May have additional signs of Posterior Circulation Stroke

• Dizziness • Dysarthria• Dystaxia• Diplopia• Dysphagia

• Neuro deficits = danger!• Treatment

• Thrombolysis vs thrombectomy• Early neurosurgical consultation due

to high risk for cerebellar edema and/or herniation

• Disposition• Admit

SPONTANEOUS –EPISODIC VESTIBULAR SYNDROME

• Recurrent, spontaneous episodes of dizziness that range in duration from minutes to hours.

• Key distinction from AVS and t-EVS• Dizziness is not reproducible on exam

• Benign• Vestibular Migraine

• Dangerous• Transient Ischemic Attack

CASE #3

• Associated Symptoms: Nausea, vomiting and difficulty walking during episodes. Sensitivity to light and blurred vision during spells. History of occasional headaches.

• Timing and Triggers: Spells occur spontaneously and typically last hours. No identifiable triggers.

• Exam Signs: No nystagmus. Negative HIT. No skew deviation. No neurological deficits. No gait or truncal ataxia.

• Testing: N/A

38-year-old female with complaint of recurrent, severe episodes of dizziness over the past 3 months.

CASE #3

• Vestibular Migraine• Patients often have a personal or family history of migraine

headaches• Photophobia, phonophobia and/or visual aura often

accompany episodes• Headache may be present during or following episode

• Treatment• Vestibular suppressants for acute episodes

• Benzos, antiemetics, antihistamines• Triptans when vertigo acts as a migraine aura• Migraine prophylaxis

• Beta blockers, tricyclic antidepressants or topiramate

• Disposition• Discharge home

CASE #4

• Associated Symptoms: Abrupt onset. Difficulty speaking and walking during episode. No history of dizziness. No recent trauma. History of diabetes mellitus, hypertension and hyperlipidemia.

• Timing and Triggers: Episode lasted 30 minutes before it resolved completely.

• Exam Signs: No nystagmus. Negative HIT. No skew deviation. No neurological deficits. No gait or truncal ataxia.

• Testing: Non-contrast head CT normal

72-year-old male presents for his annual wellness visit. As patient is leaving, he casually mentions an episode of severe dizziness 3 days ago. States, “I’m sure it was nothing, but I figured I’d mention it since I have you here.”

CASE #4• Transient Ischemic Attack (posterior circulation)

• Transient episode lasting <24hrs (frequently <1hr)• Complete resolution without residual neurological deficits

• Signs of Posterior Circulation Ischemia during episode, including dizziness, dysarthria, dystaxia, diplopia or dysphagia

• ABCD2 score estimates the risk of stroke after a TIA

CASE #4

• Treatment: • Little acute management (given resolution of symptoms)• Consider aspirin (once hemorrhage is ruled-out)• Consider dual antiplatelet therapy for high risk TIAs

(ABCD2 score >6)• Aspirin and clopidogrel

• Disposition: It depends. • Based on provider preference and local policies. • Strongly consider admitting high-risk patients for

expedited neuroimaging• MRI Brain with DWI AND MRA Brain AND MRA Neck

TRIGGERED-EPISODIC VESTIBULAR SYNDROME

• Brief episodes of dizziness lasting seconds to minutes, with an identifiable trigger that consistently causes dizziness.

• Most common triggers • Change in head position• Standing up

• Benign• Benign Paroxysmal Positional Vertigo

• Dangerous• Orthostatic Hypotension due to serious medical illness

CASE #5

• Associated symptoms – Nausea w/ several episodes of vomiting. No tinnitus or hearing loss. No significant past medical history

• Timing and Triggers – Episodic dizziness. Triggered by head movement. When head is kept still, the symptoms resolve completely.

• Exam Signs - Dix-Hallpike maneuver elicits rotary nystagmus when head tilted to the right. HIT negative. No skew deviation. No neurological deficits. No gait or truncal ataxia.

• Testing – N/A

35-year-old woman complains of dizziness that started suddenly few hours ago while getting out of bed.

CASE #5• Benign Paroxysmal Positional Vertigo

• Sudden-onset vertigo triggered by head movements

• Nausea/vomiting common• Vertigo ranges from 5–40 seconds

• Symptoms worse in the morning (fatigue as the day goes on)

• No associated hearing loss or tinnitus• Dix-Hallpike elicits rotary nystagmus when

head is tilted to the affected side• Nystagmus onset after 3 -15 seconds• Resolves after 30 seconds

• Treatment• Epley Maneuver• Vestibular Suppression w/ Meclizine,

Benadryl, Scopolamine or Benzos• Disposition

• Discharge Home

CASE #5

REVIEW

OUTLINE• History of Dizziness• A New Approach to Dizziness• Associated Symptoms• Timing and Triggers• Exam Signs and Symptoms• Testing• Acute Vestibular Syndrome• Triggered – Episodic Vestibular Syndrome• Spontaneous – Episodic Vestibular Syndrome• Review• Conclusion

QUESTIONS?

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2. Drachman DA, Hart CW. An approach to the dizzy patient. Neurology. 1972;22(4):323-334. doi:10.1212/wnl.22.4.323

3. Newman-Toker DE. DIAGNOSING DIZZINESS IN THE EMERGENCY DEPARTMENT: Why “What do you mean by ‘dizzy’?” Should Not Be the First Question You Ask. February 2008. http://dspace-prod.mse.jhu.edu:8080/handle/1774.2/32522. Accessed February 10, 2020.

4. Atzema CL, Grewal K, Lu H, Kapral MK, Kulkarni G, Austin PC. Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo. Annals of Neurology. 2016;79(1):32-41. doi:10.1002/ana.24521