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. 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.

• • 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

Child with fever and symptoms of UTI

Unstable/Septic

Stable

Admit + IV antibiotics + Consider specialist consult

Urine culture and urianalysis

First UTI

Recurrent UTI

<2years old

>2years old

Ultrasound

Ultrasound

Normal

Abnormal

Normal

Abnormal

DMSA scan if appropriate

Further management

Antibiotic for 7-14 days according to sensitivity

Further management according to findings

• MAG3 renography • urography

{{{MR urography • Delayed DMSA scan }}}

Obstruction

Vesicoureteral reflux

MAC3 renography

MCV

Treatment of febrile children with UTI

Stable

Toxic

Oral antibiotic 7-14 days

Parenteral antibiotic, once improved shift to oral antibiotic

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 (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.
• Perform a Romberg test. A positive Romberg test may disclose a peripheral etiology.

Don'ts

• Do not perform imaging laboratory tests 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 blood vessels rigidity (arteriosclerosis).
• 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.
• Do not give any kind of pharmacologic treatment for BPPV.