Vertigo resident survival guide: Difference between revisions
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Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. | Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. | ||
* [[Brainstem stroke]] | *[[Brainstem stroke]] | ||
* [[Cyanide poisoning]] | *[[Cyanide poisoning]] | ||
* [[Drug overdose]] | *[[Drug overdose]] | ||
* [[Malignant hypertension]] | *[[Malignant hypertension]] | ||
===Common Causes=== | ===Common Causes=== | ||
* [[Benign paroxysmal positional vertigo]] | *[[Benign paroxysmal positional vertigo]] | ||
* [[Cerebellar stroke syndrome|Cerebellar stroke]] | *[[Cerebellar stroke syndrome|Cerebellar stroke]] | ||
* [[Meniere's disease]] | *[[Meniere's disease]] | ||
* [[Transient ischemic attack|Vertebrobasilar transient ischemic attack]] | *[[Transient ischemic attack|Vertebrobasilar transient ischemic attack]] | ||
* [[Migraine|Vestibular migraine]] | *[[Migraine|Vestibular migraine]] | ||
* [[Vestibular neuritis]] | *[[Vestibular neuritis]] | ||
==Diagnosis== | ==Diagnosis== | ||
Shown below is an algorithm summarizing the diagnosis of vertigo according to the American Academy of Neurology guidelines. | Shown below is an [[algorithm]] summarizing the [[diagnosis]] of [[vertigo]] according to the American Academy of Neurology guidelines. | ||
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== Treatment == | |||
[[Treatment]] of [[vertigo]] will vary depending on the underlying [[Causes|cause]]: | |||
*To view the treatment of [[benign paroxysmal positional vertigo]] [[Benign paroxysmal positional vertigo medical therapy|click here]]. | |||
*To view the treatment of [[Ménière's disease|Meniere disease]] [[Meniere Disease#Treatment|click here]]. | |||
*To view the treatment of [[orthostatic hypotension]] [[Orthostatic hypotension#Treatment|click here]]. | |||
*To view the treatment of [[panic attack]] [[Panic attack#Treatment|click here]]. | |||
*To view the treatment of [[transient ischemic attack]] [[transient ischemic attack medical therapy|click here]]. | |||
*To view the treatment of [[stroke]] [[Stroke medical therapy|click here]]. | |||
*To view the treatment of [[Migraine|vestibular migraine]] [[Migraine medical therapy|click here]]. | |||
==Do's== | ==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 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]].<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 an [[orthostatic hypotension]]. | |||
*Perform a full [[neurological examination]]. A head-impulse, [[nystagmus]], test of skew (HINTS) can differentiate between a central from a peripheral [[Causes|cause]]. | |||
*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 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]] [[laboratory]] tests as routine.<ref name="pmid14439502">{{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]].<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]]).<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]]. | |||
*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]].<ref name="pmid293956952">{{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== | ||
Revision as of 06:05, 5 October 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D.
Synonyms and Keywords: BPPV, stroke, dizziness, Meniere-s syndrome
Overview
Vertigo (from the Latin vertigin-, vertigo, "dizziness," originally "a whirling or spinning movement," from vertere "to turn") is a specific type of dizziness, a major symptom of a balance disorder. It is the sensation of spinning or swaying while the body is actually stationary with respect to the surroundings. The effects of vertigo may be slight. It can cause nausea and vomiting and, in severe cases, it may give rise to difficulties with standing and walking.
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
- Benign paroxysmal positional vertigo
- Cerebellar stroke
- Meniere's disease
- Vertebrobasilar transient ischemic attack
- Vestibular migraine
- Vestibular neuritis
Diagnosis
Shown below is an algorithm summarizing the diagnosis of vertigo according to the American Academy of Neurology guidelines.
| Subjective sensation of movement of objects around us or of our own body, usually a spinning sensation. | |||||||||||||||||||||||||||||||||||||||||
| '''Vertigo''' | |||||||||||||||||||||||||||||||||||||||||
| Symptoms of nausea, vomiting, hearing loss, tinnitus, ear fullness, and otalgia + History of upper respiratory infection and/or drug ingestion | Symptoms of polyuria, polydipsia, weight gain, and hair loss + History of chronic disorders | Symptoms of neurologic deficit (slurred speech and diplopia) + History of head trauma and/or demyelinating disease | |||||||||||||||||||||||||||||||||||||||
| Peripheral vertigo | Systemic vertigo | Central vertigo | |||||||||||||||||||||||||||||||||||||||
| Common •BPPV •Vestibular neuronitis •Meniere syndrome •Acute otitis media Uncommon •Ototoxic drugs •Perilymphatic fistula •Acoustic neuroma | •Diabetes •Hypothyroidism | Common •Cerebellar stroke •Vertebrobasilar insufficiency •Brainstem stroke •Migraine Uncommon •CNS infection •Multiple sclerosis | |||||||||||||||||||||||||||||||||||||||
Treatment
Treatment of vertigo will vary depending on 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.[1]
- 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.[2]
- Perform a Romberg test. A positive Romberg test may disclose a peripheral etiology.[3]
Don'ts
- Do not perform imaging laboratory tests as routine.[4]
- Do not forget about psychiatric causes. Many times psychiatric conditions, such as panic attacks, may mimic dizziness.[5]
- 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).[6]
- 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.[7]
- Do not give any kind of pharmacologic treatment for BPPV.[8]
References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.