14. Assessing and treating dizziness in the emergency department

Question 1

What are the most common emergency room vertigo diagnoses?

Answer 1

• BPPV (35%)
• Mixed - syncope, anxiety (30%)
• Vestibular neuritis (15%)
• Migrainous vertigo (15%)
• Stroke - cerebellar (5%)
• Meniere’s (<1%)

Question 2

Which 3 big causes should you rule out first for acute vertigo?

Answer 2

• Presyncope - postural BP
• Pulmonary embolism - arterial saturation
• Cardiac dysrhythmia - ECG

Question 3

What is Ramsey Hunt Syndrome?

Answer 3

• aka herpes zoster oticus
• Condition that can cause dizziness
• Varicella zoster - shingles outbreak that affects the facial nerve near one of your ears

Question 4

What is low and high current illsory self-motion?

Answer 4

• Low current - feeling of gentle rocking of self

* High current - feeling of violent spinning of self + room

Question 5

How can you rule out pulmonary embolism?

Answer 5

Check arterial saturation

Question 6

What non/minimally-invasive examinations can be carried out on a patient with vertigo?

Answer 6

Eyes
• Gaze
• VOR
• Hallpike
• Fundoscopy

Ears
• Otoscopy (rarely informative)

Legs
• Gait (+ tandem)

Question 7

How can you treat vestibular neuritis?

Answer 7

• Vestibular sedatives for 24-36 hours
• Mobilise at day 3
• Treat any BPPV or migraine

Question 8

What are any red flags for a patient coming in with dizziness (/main signs of cerebellar stroke)?

Answer 8

• Headache - 40% posterior circulation stroke
• Gait ataxia - may be non-vertiginous manifestation of cerebellar stroke
• Hyperacute onset - suggests vascular origin
• Vertigo + hearing loss - anterior inferior cerebellar artery or urgent ENT problem
• Prolonged symptoms (>4 days) - problem with floor of 4th ventricle