Dizziness resident survival guide

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.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Electrolyte imbalance
• Traumatic brain injury
• Heatstroke

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.

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.
• Ask for any eliciting or exacerbating features. Dix-Hallpike maneuver may easily detect a benign paroxysmal positional vertigo and differentiate it from a 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.
• Perform a Romberg test. A positive Romberg test may disclose a peripheral etiology.

Don'ts

• Do not perform imaging as as routine.
• Do not forget about psychiatric causes. Many times psychiatric conditions, such as panic attacks, may mimic dizziness.
• Do not forget abut orthostatic hypotension. Orthostatic hypotension is a very common cause of dizziness, especially in elderly people due to vessels rigidity (arteriosclerosis).
• Do not miss transit ischemic attack. 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. BPV only comes positive in around 70% of the times with first attempt, several attempts may be necessary.
• Do not give any kind of pharmacologic treatment for BPV.