Dizziness resident survival guide: Difference between revisions
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==Overview== | ==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]]. | [[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== | ==Causes== | ||
===Life Threatening Causes=== | ===Life Threatening Causes=== | ||
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==Diagnosis== | ==Diagnosis== | ||
* Shown below is an [[algorithm]] summarizing the [[diagnosis]] of [[dizziness]] according to the American Academy of Neurology guidelines. | * Shown below is an [[algorithm]] summarizing the [[diagnosis]] of [[dizziness]] according to the American Academy of Neurology guidelines:<ref name="urlDIZZINESS: A PRACTICAL APPROACH TO DIAGNOSIS AND MANAGEMENT | Neurology">{{cite web |url=https://n.neurology.org/content/72/24/2139 |title=DIZZINESS: A PRACTICAL APPROACH TO DIAGNOSIS AND MANAGEMENT | Neurology |format= |work= |accessdate=}}</ref><ref name="pmid28145669">{{cite journal |vauthors=Muncie HL, Sirmans SM, James E |title=Dizziness: Approach to Evaluation and Management |journal=Am Fam Physician |volume=95 |issue=3 |pages=154–162 |date=February 2017 |pmid=28145669 |doi= |url=}}</ref><ref name="urlThe evaluation of a patient with dizziness | Neurology Clinical Practice">{{cite web |url=https://cp.neurology.org/content/1/1/24 |title=The evaluation of a patient with dizziness | Neurology Clinical Practice |format= |work= |accessdate=}}</ref> | ||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
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*Always ask the patient what do they mean by [[dizziness]]. [[Dizziness]] may have a different meaning among patients; while [[vertigo]] may represent a [[Vestibular function|vestibular]] condition, [[presyncope]] directs to a [[cardiovascular]] problem, or [[disequilibrium]] a [[neurological]] or [[Psychiatric Disorders|psychiatric]] one. | *Always ask the patient what do they mean by [[dizziness]]. [[Dizziness]] may have a different meaning among patients; while [[vertigo]] may represent a [[Vestibular function|vestibular]] condition, [[presyncope]] directs to a [[cardiovascular]] problem, or [[disequilibrium]] a [[neurological]] or [[Psychiatric Disorders|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]]. | *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]].<ref name="pmid29395695">{{cite journal |vauthors=Edlow JA, Gurley KL, Newman-Toker DE |title=A New Diagnostic Approach to the Adult Patient with Acute Dizziness |journal=J Emerg Med |volume=54 |issue=4 |pages=469–483 |date=April 2018 |pmid=29395695 |pmc=6049818 |doi=10.1016/j.jemermed.2017.12.024 |url=}}</ref> | ||
*Ask for any eliciting or exacerbating features. [[Dix-Hallpike test|Dix-Hallpike]] maneuver may easily detect a [[benign paroxysmal positional vertigo]] (BPPV) and differentiate it from | *Ask for any eliciting or exacerbating features. [[Dix-Hallpike test|Dix-Hallpike]] maneuver may easily detect a [[benign paroxysmal positional vertigo]] (BPPV) and differentiate it from an [[orthostatic hypotension]].<ref name="pmid15791890">{{cite journal |vauthors=Swartz R, Longwell P |title=Treatment of vertigo |journal=Am Fam Physician |volume=71 |issue=6 |pages=1115–22 |date=March 2005 |pmid=15791890 |doi= |url=}}</ref> | ||
*Perform a full [[neurological examination]]. A head-impulse, [[nystagmus]], test of skew (HINTS) can differentiate between a central from a peripheral cause. | *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]]. | *When taking [[vital signs]], remember to measure [[blood pressure]] in standing and [[supine position]].<ref name="pmid19762709">{{cite journal |vauthors=Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE |title=HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging |journal=Stroke |volume=40 |issue=11 |pages=3504–10 |date=November 2009 |pmid=19762709 |pmc=4593511 |doi=10.1161/STROKEAHA.109.551234 |url=}}</ref> | ||
*Perform a [[Romberg's test|Romberg test]]. A positive [[Romberg's test|Romberg test]] may disclose a peripheral etiology. | *Perform a [[Romberg's test|Romberg test]]. A positive [[Romberg's test|Romberg test]] may disclose a peripheral etiology.<ref name="pmid1443950">{{cite journal |vauthors=Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE, Wehrle PA, Boggi JO |title=Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care |journal=Ann. Intern. Med. |volume=117 |issue=11 |pages=898–904 |date=December 1992 |pmid=1443950 |doi=10.7326/0003-4819-117-11-898 |url=}}</ref> | ||
==Don'ts== | ==Don'ts== | ||
*Do not perform [[imaging]] | *Do not perform [[imaging]] [[laboratory]] tests as routine.<ref name="pmid1443950">{{cite journal |vauthors=Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE, Wehrle PA, Boggi JO |title=Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care |journal=Ann. Intern. Med. |volume=117 |issue=11 |pages=898–904 |date=December 1992 |pmid=1443950 |doi=10.7326/0003-4819-117-11-898 |url=}}</ref> | ||
*Do not forget about [[Psychiatric Disorders|psychiatric]] causes. Many times [[Psychiatric Disorders|psychiatric conditions]], such as [[panic attacks]], may mimic [[dizziness]]. | *Do not forget about [[Psychiatric Disorders|psychiatric]] causes. Many times [[Psychiatric Disorders|psychiatric conditions]], such as [[panic attacks]], may mimic [[dizziness]].<ref name="pmid28145669">{{cite journal |vauthors=Muncie HL, Sirmans SM, James E |title=Dizziness: Approach to Evaluation and Management |journal=Am Fam Physician |volume=95 |issue=3 |pages=154–162 |date=February 2017 |pmid=28145669 |doi= |url=}}</ref> | ||
*Do not forget abut [[orthostatic hypotension]]. [[Orthostatic hypotension]] is a very common cause of [[dizziness]], especially in [[Elderly|elderly people]] due to [[blood vessels]] rigidity ([[arteriosclerosis]]). | *Do not forget abut [[orthostatic hypotension]]. [[Orthostatic hypotension]] is a very common cause of [[dizziness]], especially in [[Elderly|elderly people]] due to [[blood vessels]] rigidity ([[arteriosclerosis]]).<ref name="pmid15972868">{{cite journal |vauthors=Savitz SI, Caplan LR |title=Vertebrobasilar disease |journal=N. Engl. J. Med. |volume=352 |issue=25 |pages=2618–26 |date=June 2005 |pmid=15972868 |doi=10.1056/NEJMra041544 |url=}}</ref> | ||
*Do not miss [[Transient ischemic attack|transiten ischemic attack]] (TIA). [[TIA]] is one of the most missed [[diagnosis]] when a patient presents with [[dizziness]]. | *Do not miss [[Transient ischemic attack|transiten ischemic attack]] (TIA). [[TIA]] is one of the most missed [[diagnosis]] when a patient presents with [[dizziness]]. | ||
*When looking after [[Benign paroxysmal positional vertigo|benign paroxysmal vertigo]] (BPV), do not perform [[Dix-Hallpike test|Dix-Hallpike]] only once. [[Benign paroxysmal positional vertigo|BPPV]] only comes positive in around 70% of the times with first attempt, several attempts may be necessary. | *When looking after [[Benign paroxysmal positional vertigo|benign paroxysmal vertigo]] (BPV), do not perform [[Dix-Hallpike test|Dix-Hallpike]] only once. [[Benign paroxysmal positional vertigo|BPPV]] only comes positive in around 70% of the times with first attempt, several attempts may be necessary.<ref name="pmid15106194">{{cite journal |vauthors=Hilton M, Pinder D |title=The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD003162 |date=2004 |pmid=15106194 |doi=10.1002/14651858.CD003162.pub2 |url=}}</ref> | ||
*Do not give any kind of [[pharmacologic]] treatment for [[Benign paroxysmal positional vertigo|BPPV]]. | *Do not give any kind of [[pharmacologic]] treatment for [[Benign paroxysmal positional vertigo|BPPV]].<ref name="pmid29395695">{{cite journal |vauthors=Edlow JA, Gurley KL, Newman-Toker DE |title=A New Diagnostic Approach to the Adult Patient with Acute Dizziness |journal=J Emerg Med |volume=54 |issue=4 |pages=469–483 |date=April 2018 |pmid=29395695 |pmc=6049818 |doi=10.1016/j.jemermed.2017.12.024 |url=}}</ref> | ||
==References== | ==References== | ||
{{Reflist|2}} {{WikiDoc Help Menu}} {{WikiDoc Sources}} | {{Reflist|2}} {{WikiDoc Help Menu}} {{WikiDoc Sources}} | ||
<references /> | <references /> | ||
Revision as of 05:03, 20 August 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D.
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][3]
| 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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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.[5]
- 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.[6]
- Perform a Romberg test. A positive Romberg test may disclose a peripheral etiology.[7]
Don'ts
- Do not perform imaging laboratory tests as routine.[7]
- Do not forget about psychiatric causes. Many times psychiatric conditions, such as panic attacks, may mimic dizziness.[2]
- 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
- ↑ "DIZZINESS: A PRACTICAL APPROACH TO DIAGNOSIS AND MANAGEMENT | Neurology".
- ↑ 2.0 2.1 Muncie HL, Sirmans SM, James E (February 2017). "Dizziness: Approach to Evaluation and Management". Am Fam Physician. 95 (3): 154–162. PMID 28145669.
- ↑ "The evaluation of a patient with dizziness | Neurology Clinical Practice".
- ↑ 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.
- ↑ Swartz R, Longwell P (March 2005). "Treatment of vertigo". Am Fam Physician. 71 (6): 1115–22. PMID 15791890.
- ↑ 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.
- ↑ 7.0 7.1 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.
- ↑ 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.