Episode 3: Vertigo

by Bob Stuntz in


Vertigo is a common chief complaint.  Usually, the patient won’t tell you “Hey, I have vertigo.”  It is usually dizziness, weakness, lightheadedness, or, in my local language, “I feel all wonky.”  It can be something as serious as a cerebellar bleed, or as benign as some vestibular irritation.  It’s your job to figure it out.  Remember, ask the patient what they mean when they say “dizzy.”  Ask about motion.  Are they off balance, do they feel like the room is spinning, are they feeling like they’re on a boat?  Differentiate orthostasis from vertigo.  Patients will have a hard time telling unless you force them to specify. 

Do a full neurologic exam:

  • Cranial nerves
  • Ocular: extraocular movements, pupil reactivity, nystagmus
  • Sensation
  • Motor
  • Romberg
  • Pronator drift
  • Head impulse testing
  • Sit them up - do they lose balance, or do they feel like they’re going to pass out?
  • HAVE THEM WALK!!!
  • Head impulse testing: 

General Approach

  • Make sure Vertigo is isolated
  • Do a GOOD neuro exam and document it 
  • Look for long tract findings (Upper motor neuron signs, or signs that there is something going on in the upper spinal cord/brainstem.  Remember your upper motor neuron findings from med school?  Think clonus, hyperreflexia, upgoing babinski).   
  • If not isolated need to do an MRI/further workup
  • Look for neighborhood signs – the midbrain/cerebellum is a tight space and it is rare that central vertigo presents without any other neuro findings.  Look for the five D’s of Vertigo.  If they have any of the five besides dizziness, it is not isolated vertigo:
  • Dizzy
  • Diploplia
  • Dysphagia
  • Dysarthria 
  • Dysmetria

If the patient has isolated vertigo, there are three main causes, the ABC’s of isolated vertigo:

  • A    Acute Vestibular Neuronitis
  • B     BPPPV
  • C    Cerebellar stroke

Proposed Algorithm for Vertigo

Figure 1: Algorithm for evaluation of patients with vertigo.  

Figure 1: Algorithm for evaluation of patients with vertigo.  

If still unclear and high risk get MRI

  • Vascular risk factors
  • Older Age
  • Prior Stroke
  • Maximal in onset

If still unclear and low risk OK to d/c

  • Strictly positional
  • Hearing changes 
  • HTN
  • Sudden in onset

References: 

HINTS Exam: Kattah, JC 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 et al.  Disconnect Between Charted Vestibular Diagnoses and Emergency Department Management Decisions: A Cross-Sectional Analysis From a Nationally Representative Sample.  Acad Emerg Med.  October 2009.  16 (10): 970-977.  

Nelson J, Virre E.    The Clinical Differentiation of Cerebellar Infarction from Common Vertigo Syndromes.   Western Journal of Emergency Medicine.   Volume X, No. 4  November 2009

Kim AS, Fullerton HJ, Johnston SC.  Risk of vascular events in emergency department patients discharged home with diagnosis of dizziness or vertigo.  Ann Emerg Med. 2011 Jan;57(1):34-41.

 

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