vertigo in the emergency department
TRANSCRIPT
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Vertigo
Lucy Webber
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Vertigo = ‘Hallucination of movement’
Disturbance of vestibular system
CENTRAL PERIPHERAL
CENTRAL NERVOUS SYSTEM
OTOLOGICAL CAUSES
Cerebellar haemorrhage/ischaemia Vertebrobasilar insufficiency
Head & neck trauma Multiple Sclerosis
Vertebrobasilar Migraine Hypoglycaemia
Tumours Migraine
Meningitis/encephalitis Degenerative
BPPV Ménières Disease Acute labyrithitis
Otitis Media (Acute/Chronic suppurative)
Acoustic Neuroma Cholesteatoma
Foreign body/wax
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Background
• Common presentation • Typically rotational • Illusion of tilting to one side/swaying• Feeling of imbalance when standing/walking• Diagnosis relies on accurate hx and examination • Often described by pts as ‘dizziness’, ‘spinning’,
‘lightheadedness’, ‘unsteadiness’
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History• Onset and duration of first attack • Associated symptoms:
• Exacerbating/relieving factors – effects of change in posture, head/neck movements, darkness
• PMHx: Diabetes, CV disease, ear problems, trauma• DHx • SHx: ETOH intake, recreational drugs
OTOLOGICAL: Otalgia, otorrhoea, change in hearing, tinnitus
NON-OTOLOGICAL: Nausea & vomiting, fever, systemic upset, preceding viral illness
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Examination
• Full neurological exam incl. cerebellar exam (DANISH)• Otoscopy, Rinnes/Weber’s Tests• HINTS exam (YouTube video) – Head Impulse, Nystagmus, Test of Skew – Presence of 1 of 3 signs sensitivity of 100%, specificity of
96% for dx of stroke!
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HINTS Exam• Head Impulse
– Pt fixes eyes on examiner’s nose. Head quickly rotated. Normal side eyes remain fixated. Affected side eyes make corrective saccade to fix on target
– Abnormal VOR reflex suggests peripheral pathology
• Nystagmus – Vertical/bidirectional nystagmus = central pathology
• Test of Skew – Cover/uncover test pt focuses on examiner’s nose. Refixation of eyes/vertical
misalignment suggests central pathology
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Approach to Vertigo
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Benign Paroxysmal Positional Vertigo (BPPV) • Commonest cause • Debris in semicircular canals
Sx: - Dizziness induced by sudden head movement- Nausea- Lasts 30-60 secs Signs: - Nystagmus towards affected side Ix: - Dix-Hallpike manoeuvreTx: - Epley’s manoeuvre - Vestibular exercises - Reassurance
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Ménière’s Disease• Severe endolymphatic hydrops – abnormal fluctuation in endolymph fluid = inner ear pressure • Idiopathic
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Acute Labyrinthitis• Inner ear inflammation • Vestibular neuronitis/neuritis – affects balance only, no hearing loss • Typical age of onset: 30-60yrs • Causes: Viral, bacterial, head injury, • drugs • 95% of pts - single episode
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Otitis Media• Causes: Viral/bacterial infection, allergies Inflamed mucous membranes Eustachian tube
dysfunction • Common bacterial infections: Strep. pneumoniae, H. influenzae, M. catarrhalis, Staph.
Aureus
Refer to ENT if: Failure of resolution Persistent discharge Recurrent episodes (≥3 in 6mths, ≥ 4 in 1
yr) - grommets Complications: VIIth nerve palsy,
mastoiditis
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CVA • Most common cause of central
vertigo • Posterior Circulation Stroke
– Cranial nerve palsy & contralateral motor/sensory deficit
– Bilateral motor/sensory deficit– Conjugate eye movement disorder– Cerebellar dysfunction – Isolated homonymous hemianopia
• Admit• MRI with DWI (CT has 16% sensitivity for
posterior fossa pathology) • Bleed Refer to Neurosurgeons • Ischaemia Aspirin 300mg for 2/52