Approach to Giddiness

Question 1

General management of giddiness in ED

Answer 1

1. ABCs, vital sign monitoring, continuous cardiac monitoring
2. Postural parameters taken
3. Evaluate for:
   - CVS: arrhythmia, cardiac murmur
   - Hypovolemia: blood loss (DRE), dehydration
   - Anemia
4. POCTs:
   - CBG
   - ECG
   - UPT (if suspect ectopic pregnancy)

Question 2

Physical examination for giddiness

Answer 2

Cranial nerve PE TRO central cause
Gait TRO central cause
CVS
Eye
Ear TRO hearing loss
- otoscope to look for cholesteatoma

*Head Impulse-Nystagmus-Test of Skew (HINTS)
- useful ONLY in acute vestibular syndrome
- differentiate between peripheral vs central cause

Question 3

How to perform HINTS examination?

Answer 3

Head impulse:
- Hold patient’s head and suddenly turn it right or left by 30 degrees
- NO catch up saccade: normal OR central
- Catch up saccade: peripheral

Nystagmus:
- No nystagmus: normal
- Unidirectional: peripheral
- Bidirectional: central

Test of skew:
- Alternately cover one eye, then the other
- No vertical skew: normal or peripheral
- Vertical skew: central

ANY 1/3 suggestive of central cause is worrying

Question 4

Specific management of vestibular syndromes

Answer 4

Symptomatic
- Anti-emetics: Stemetil (IM prochlorperazine)
- Anti-histamine (PO cinnarizine or betahistine)
- BZD (PO diazepam)

IV hydration if vomiting is severe

For BPPV
- Diagnosis: Dix-hallpike test
- Tx: Epley manoever

Disposition
- Discharge if it is peripheral cause
- No neurological deficits

Question 5

Central causes of giddiness

Answer 5

Posterior circulation stroke
Vertebrobasilar insufficiency
TIA
Haemorrhagic stroke (cerebellar)
Multiple sclerosis

Question 6

General discharge advice

Answer 6

Avoid the following while symptomatic:
- Driving
- Riding bike
- Climbing heights
- Operating heavy machinery
- Alcohol
- Swimming

Question 7

Non-specific causes of giddiness &/or Red flags

Answer 7

1. Pre-syncope
2. Neurological (points to central cause)
   - stroke*
   - haemorrhage
   - vertebrobasilar insufficiency
   - TIA
   - Multiple sclerosis
3. CVS
   - cardiac failure, IHD, arrythmia
4. Anemia
5. Hypovolemia
   - blood loss, dehydration
6. Hypoglycaemia