Dizziness resident survival guide
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| Dizziness Resident Survival Guide Microchapters |
|---|
| Overview |
| Causes |
| Diagnosis |
| Treatment |
| Do's |
| Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D.
Synonyms and Keywords: approach to dizziness, dizziness workup, dizziness management, approach to vertigo, vertigo workup
Overview
Dizziness is a complex and subjective complaint that encompasses a wide spectrum of symptomatology. It is one of the most common presenting symptoms among patients seen by emergency medical physicians, primary care physicians, neurologists, and otolaryngologists. It can be caused by a disturbance in nearly any system of the body.
Causes
Life Threatening Causes
- Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
Common Causes
- Hypotension
- Dehydration
- Hypoglycemia
- Arrhythmias
- Stroke
- Labyrinthitis
- Meniere's disease
- BPV
- Medication effects
Diagnosis
Shown below is an algorithm summarizing the diagnosis of dizziness according to the American Academy of Neurology guidelines:[1][2]
| Patient with dizzinesss | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Presentation periodical or sustained? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Periodical | Sustained | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Provoked or unprovoked? | History of intoxication or trauma, or unknown? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Provoked | Unprovoked | History of intoxication | Unknown | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Apply Dix-Hallpike maneuver | Physical examination | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Deafness | Headache | Psychiatric symptoms | Barotrauma | Drugs | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Positive | Negative | Meniere disease | Vestibular migraine | Panic attack, psychiatric condition | Nistagmus dominantly horizontal, direction-fixed, saccade present | Nistagmus dominantly vertical, no saccade, torsion or gaze evoked bidirectionaly | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Benign paroxysmal positional vertigo | Orthostatic hypotension | Vestibular neuritis | Stroke, transient ischemic attack | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The clinical diagnosis of benign paroxysmal positional vertigo according to The American Academy of Otolaryngology is as follows:[3]
| Presence of all the following criteria | Continuous periods of vertigo triggered by changes in head position. |
|---|---|
| Vertigo related with twisting, positive nystagmus is triggered by the Dix-Hallpike maneuver. | |
| Presence of a quiescence period between the execution of the Dix-Hallpike maneuver and the beginning of vertigo and nystagmus. | |
| The triggered vertigo and nystagmus rises and then solves within 60 seconds from the onset. |
Adapted from The American Academy of Otolaryngology guidelines for benign paroxysmal positional vertigo (DO NOT EDIT).[3]
Treatment
Treat the underlying cause.
- To view the treatment of benign paroxysmal positional vertigo click here.
- To view the treatment of Meniere disease click here.
- To view the treatment of orthostatic hypotension click here.
- To view the treatment of panic attack click here.
- To view the treatment of transient ischemic attack click here.
- To view the treatment of stroke click here.
- To view the treatment of vestibular migraine click here.
Do's
- Always ask the patient what do they mean by dizziness. Dizziness may have a different meaning among patients; while vertigo may represent a vestibular condition, presyncope directs to a cardiovascular problem, or disequilibrium a neurological or psychiatric one.
- Intentionally ask for any history of possible intoxication, medications used, and exposures. A full history review may disclose dizziness due to trauma or an intoxication.[4]
- Ask for any eliciting or exacerbating features. Dix-Hallpike maneuver may easily detect a benign paroxysmal positional vertigo (BPPV) and differentiate it from an orthostatic hypotension.
- Perform a full neurological examination. A head-impulse, nystagmus, test of skew (HINTS) can differentiate between a central from a peripheral cause.
- When taking vital signs, remember to measure blood pressure in standing and supine position.[5]
- Perform a Romberg test. A positive Romberg test may disclose a peripheral etiology.[6]
Don'ts
- Do not perform imaging laboratory tests as routine.[6]
- Do not forget about psychiatric causes. Many times psychiatric conditions, such as panic attacks, may mimic dizziness.[7]
- Do not forget abut orthostatic hypotension. Orthostatic hypotension is a very common cause of dizziness, especially in elderly people due to blood vessels rigidity (arteriosclerosis).[8]
- Do not miss transiten ischemic attack (TIA). TIA is one of the most missed diagnosis when a patient presents with dizziness.
- When looking after benign paroxysmal vertigo (BPV), do not perform Dix-Hallpike only once. BPPV only comes positive in around 70% of the times with first attempt, several attempts may be necessary.[9]
- Do not give any kind of pharmacologic treatment for BPPV.[4]
References
- ↑ Eggers, S. D.Z. (2009). "DIZZINESS: A PRACTICAL APPROACH TO DIAGNOSIS AND MANAGEMENT". Neurology. 72 (24): 2139–2139. doi:10.1212/WNL.0b013e3181aa53ec. ISSN 0028-3878.
- ↑ Kerber, K. A.; Baloh, R. W. (2011). "The evaluation of a patient with dizziness". Neurology: Clinical Practice. 1 (1): 24–33. doi:10.1212/CPJ.0b013e31823d07b6. ISSN 2163-0402.
- ↑ 3.0 3.1 Bhattacharyya, Neil; Gubbels, Samuel P.; Schwartz, Seth R.; Edlow, Jonathan A.; El-Kashlan, Hussam; Fife, Terry; Holmberg, Janene M.; Mahoney, Kathryn; Hollingsworth, Deena B.; Roberts, Richard; Seidman, Michael D.; Steiner, Robert W. Prasaad; Do, Betty Tsai; Voelker, Courtney C. J.; Waguespack, Richard W.; Corrigan, Maureen D. (2017). "Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)". Otolaryngology–Head and Neck Surgery. 156 (3_suppl): S1–S47. doi:10.1177/0194599816689667. ISSN 0194-5998.
- ↑ 4.0 4.1 Edlow JA, Gurley KL, Newman-Toker DE (April 2018). "A New Diagnostic Approach to the Adult Patient with Acute Dizziness". J Emerg Med. 54 (4): 469–483. doi:10.1016/j.jemermed.2017.12.024. PMC 6049818. PMID 29395695.
- ↑ Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE (November 2009). "HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging". Stroke. 40 (11): 3504–10. doi:10.1161/STROKEAHA.109.551234. PMC 4593511. PMID 19762709.
- ↑ 6.0 6.1 Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE, Wehrle PA, Boggi JO (December 1992). "Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care". Ann. Intern. Med. 117 (11): 898–904. doi:10.7326/0003-4819-117-11-898. PMID 1443950.
- ↑ Muncie HL, Sirmans SM, James E (February 2017). "Dizziness: Approach to Evaluation and Management". Am Fam Physician. 95 (3): 154–162. PMID 28145669.
- ↑ Savitz SI, Caplan LR (June 2005). "Vertebrobasilar disease". N. Engl. J. Med. 352 (25): 2618–26. doi:10.1056/NEJMra041544. PMID 15972868.
- ↑ Hilton M, Pinder D (2004). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". Cochrane Database Syst Rev (2): CD003162. doi:10.1002/14651858.CD003162.pub2. PMID 15106194.