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Y2 LCRS2 Neuroscience and Mental Health > Assessing and treating dizziness in the emergency department > Flashcards

Assessing and treating dizziness in the emergency department Flashcards

1
Q

What is a vestibular symptom?

A

A feeling that you are moving when you are not - this is of SELF or the ENVIRONMENT

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2
Q

What is the name of the condition where you see the environment move?

A

Oscillopsia

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3
Q

What does oscillopsia indicate?

A

Indicates a nystagmus - an involuntary eye movement (nystagmus) –> patient sees the world move (oscillopsia).

NB: Normally, when you look in a different direction you do not see the world move because your brain updates the visual map.

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4
Q

What is the best way of recording what type of dizziness a person has?

A

They should describe their symptoms in sentences such as “rocking like a boat”, “spinning like a merry-go-round”, “floating”.
“seeing the world move” = nystagmus

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5
Q

What is a nystagmus?

A

When the patient sees the world move

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6
Q

How does intesity of vestibular stimulation of the brain dictate symptoms that the person perceives?

A

Low stimulation —> feeling of gentle rocking of self
High stimulation —> a feeling of violent spinning of self and the room

(HOWEVER the patient still does not SEE movement because these stimulations were done clinically in patients with no nystagmus.)

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7
Q

What is the single most common cause of dizziness?

A

BPPV (35%)

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8
Q

List the most common A&E vertigo diagonses.

A 
Benign paroxysmal positional vertigo - 35%
Vestibular neuritis - 15%
Migrainous vertigo - 15%
Stroke - 5%
Mixed (syncope, anxiety..) - 30%
Meniere's <1% - NOT COMMON !
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9
Q

Can migraines occur without headaches?

A

Yes and migraines can cause vertigo

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10
Q

What must you first check when you see a person with acute vertigo? What must you exclude?

A

Check: postural BP, arterial saturation and ECG.

Then exclude:
Presyncope
Pulmonary embolism
Cardiac dysrhythmia

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11
Q

What diagnoses should you base your history and examination around in a patient with acute vertigo?

A 
BPPV
Vestibular neuritis 
Migrainous vertigo 
Stroke (cerebellar)
(Meniere's - rare)
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12
Q

What are the three areas which you should examine in acute vertigo?

A

Eyes - gaze, VOR, hallpike, fundoscopy
Ears - otoscopy
Legs - gait

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13
Q

What are the 4 core examinations of the eyes in acute vertigo?

A

Gaze
VOR
Hallpike
Fundoscopy/opthalmoscope

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14
Q

What is used to examine the ears?

A

Otoscope

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15
Q

What is tandem gait?

A

Tandem gait is where the toes of the back foot touch the heel of the front foot at each step.

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16
Q

What is used to examine the eyes?

A

Opthalmoscope

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17
Q

What do you look for when you examine gaze in acute vertigo?

A

Nystagmus - causes can be central or peripheral (inner ear, nerve or brainstem)

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18
Q

What is the difference between a peripheral and central nystagmus in terms of diagnosis?

A

Peripheral - horizontal or vertical eye movements which can be evoked, positional (by turning the head), or spontaneous.
Central - usually vertical and is worsened by fixation of the gaze

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19
Q

Why does visual fixation cause a central nystagmus to get worse?

A

Visual fixation is removed by blocking the information being sent to the brain by blinding the eye; the brain no longer has information to suppress the nystagmus so it gets worse.

20
Q

How do you test the vestibulo-ocular reflex?

A

Head impulse test

21
Q

What is fundoscopy used to test?

A

Look at the retina
Check for a spontaneous nystagmus
Check the effect of visual fixation on nystagmus

22
Q

When can otoscopy be useful when diagnosing acute vertigo?

A
  1. For looking for varicella zoster virus (VZV) vesicles in ACUTE UNILATERAL PERIPHERAL vestibular loss
  2. Suppurative infection in meningitis

Otherwise, otoscopy is rarely informative in acute vertigo.

23
Q

What is the difference between BPPV and postural hypotension?

A

Patient with BPPV will feel dizzy when LYING BACK when turning in bed.

24
Q

What are the characteristics of BPPV?

A

LATENCY, ADAPTABILITY, FATIGUABILITY.
Positional - when lying back and turning over in bed (vertigo brough on by head turning?)
Brief - seconds (but may come with prolonged malaise)

Red flags = headache, atypical nystagmus (tortional or downbeat)

25
Q

What is the treatment of BPPV?

A

Epley movement

Semont movement

26
Q

Describe the characteristics of vestibular neuritis.

A

Continuous vertigo
Obvious “vestibular” nystagmus
Positive head impulse test
Normal gait

(NB: this is like Bell’s Palsy but of the 8th nerve)

27
Q

What is the onset of vestibular neuritis?

A

SUBACUTE (minutes to hours)

28
Q

How is vestibular neuritis treated?

A
  • Vestibular sedatives for 24-36 hours
  • Mobilise at day 3
  • Treat any BPPV or migraine
29
Q

What are the red flags symptoms in patients who present with vertigo?

A 
Headache 
Gait ataxia 
Hyperacute onset 
Vertigo AND hearing loss
Prolonges symptoms (>4 days)
30
Q

Describe what each of the red flag symptoms in vertigo could indicate.

A

= Headache – 40% posterior circulation (vertebral arteries which fuse to form basilar) –>stroke.
= Gait ataxia – may be only non-vertiginous manifestation of cerebellar stroke.
= Hyperacute onset – suggests vascular origin.
= Vertigo + hearing loss – could be 2 things: AICA(anterior inferior cerebellar artery - causes a peripheral ischaemia) or urgent ENT problem.
= Prolonged symptoms (> 4 days) - floor of 4th ventricle problem.

31
Q

What are the features of acute vestibular migraine?

A

History of migraine
Acute vertigo may come without headache
Recurrent episodes
Diagnosis of exclusion from cerebellar stroke

32
Q

What are the main symptoms of cerebellar stroke? (!)

A

Headache
Gait problems
Hearing loss

33
Q

Describe the onset and duration of symptoms in cerebellar stroke.

A 
HYPERACUTE onset (thunderclap onset vertigo)
PROLONGED symptoms (>4days)
34
Q

What does the head impulse test do?

A

Tests the VOR (tests for the function of the 8th nerve)

35
Q

What does abnormal gait indicate in vertigo?

A

That the problem is central (e.g. affecting th ecerebellum) rather than peripheral (like the inner ear)

36
Q

What is skew deviation (of the head) + acute vertigo usually a sign of?

A

Stroke

37
Q

What would the head impulse test be like in stroke?

A

Normal (as the problem is not peripheral)

38
Q

What is the cause of Ramsey Hunt Syndrome? What are the symptoms?

A

Peripheral varicella zoster infection affecting the facial nerve
May cause: loss of auditory, vestibular and facial nerve function e.g. hearing loss, drooping of the face,vertigo. Can also cause a rash inside the ear.

39
Q

What percentage of TBI (traumatic brain injury) patients are affected by BPPV?

A

47%

40
Q

What is vestibular agnosia?

A

lack of sensation of dizziness despite a peripheral activation (an evoked nystagmus) indicating a loss of vestibular sensation

41
Q

What patients is vestibular agnosia most common in ? Why?

A

TBI patients with BPPV - there is a dysfunction in the brain network affecting the sensation of vertigo

42
Q

A 65 year old with hypertension has a 4 year history of recurrent attacks of violent spinning dizziness with sweating, a sensation of impending doom and nausea. He feels unwell for about an hour afterwards. The attacks occur on looking up and alco occur in bed. What one test would you perform to confirm the diagnosis?

A

Hallpike manoeuvre

43
Q

A previously well 44 year old has a 1 year history of episodic rocking-type dizziness lasting 30-60 minutes. During these episodes she notices that she prefers to lie down in a quiet dark room until the dizziness abates. She has mild asthma, suffered from severe headaches in her 20s but now only gets the occasional headache (x1/month). The examination is normal although there was a 10mm postural drop in systolic BP. What is the likely diagnosis?

  1. Vertebro-basilar insufficiency
  2. Postural hypotension
  3. BPPV
  4. Vestibular migraine
  5. Cardiac dysrrythmia
A
  1. Vertebro-basilar insufficiency isn’t really a diagnosis
    BPPV could also be a cause as migraines can trigger it
44
Q

Not in lecture: What are the causes of BPPV?

A

Often unknown but related to a blow to the head or migraines. Crystals in the otolith organs become dislodged.

45
Q

How do you diagnose BPPV?

A

HALLPIKE maneouvre
Bend the patient backwards while holding their head
This should induce nystagmus within 20-30 seconds.

46
Q

What is BPPV?

A

Getting dizzy on moving your head

47
Q

A previously well 34 year old develops severe and sudden onset spinning dizziness whilst working out at the gym. Dizziness was associated with nausea, vomiting and headache even though he had no previous headache history. The next day it was the same and he vomited when he got up. He went to the GP and the nurse prescribed stemetil. Along with migraine, what is the most likely differential diagnosis?

  1. BPPV
  2. Cerebellar stroke
  3. Meniere’s disease
  4. Meningitis
  5. Vestibular neuritis
A

2.

Y2 LCRS2 Neuroscience and Mental Health (17 decks)

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