VERTIGO NOT JUST DIZZINESS Lafe Bush Definitions Vertigo

VERTIGO NOT JUST DIZZINESS Lafe Bush

Definition's • Vertigo – An abnormal sensation of movement or rotation of the patient or their environment • Dizziness – Is a range of sensations such as feeling faint, woozy, weak or unsteady, Lightheaded, or pre syncope

Vertigo • Affects 20 -30% of the population • 2. 5% of all ED visits • 2 -3 times more common in women then men

PREVELENCE of DIZZYNESS • Common DX – 32. 9% otologic/vestibular – 21. 1% cardiovascular – 11. 5% respiratory – 11. 2% neurologic (4% CVA) – 11% metabolic – 10. 6% injury/poisoning – 7. 2% digestive

Anatomy

VASCULATURE OF THE BRAIN • Right/Left common carotid arteries – External = face and scalp – Internal = anterior 3/5 of cerebrum • Right/left vertebral arteries – 2/5 cerebrum, cerebellum, and brainstem • Circle of Willis – Anterior cerebral artery – Middle cerebral artery – Posterior cerebral artery

Cranial Nerves

Vestibular Apparatus • Vestibular nerve – Sends messages to the brain • 3 Semi Circular Canals – Filled with fluid which moves and gives information about speed and direction • Macula – Located in the Vestibule Contains hair cells (Crista) with give information about the position of the head – Otoliths cristals located in Macula

CLASSIFICATIONS OF VERTIGO • Central Vertigo – Due to a disease process of the central nervous system • Peripheral Vertigo – Disorders of the inner ear and/or 8 th cranial nerve

CENTRAL VERTIGO • • • Stroke Tumors Vertebrobasilar Disease Intoxications Multiple Sclerosis Migraines

Differentiation Central Vertigo • • • Vertigo lasting hours to days Less severe then with peripheral vertigo Relatively unaffected by head movement Nausea/Vomiting Unsteady Gait – Unable to sit upright with arms crossed – Finger to nose test/heel to knee test • Past Medical History

PMH ASSOCIATED WITH CENTRAL VERTIGO • Hypertension • Atrial Fibrillation • Cardiac embolism – Valvular problems • • • History of CVA Obesity Atherosclerosis Diabetes Sickle cell anemia

STROKE’s • Cerebellar infarction • Posterior inferior cerebellar artery syndrome • Cerebellar and brainstem hemorrhage

CEREBELLUM • Supplied by – Superior Cerebellar Artery (SCA) – Anterior Inferior Cerebellar Artery (AICA) – Posterior Inferior Cerebellar Artery (PICA)

Cerebellar strokes • 1. 5% of all strokes • 10% of all cerebellum strokes will be a cerebellar hemorrhage • Commonly missed diagnoses in the ED and pre -hospital setting

S &S Cerebellar Strokes • • Vertigo Dyscoordination Gait Ataxia Nose finger test Running the heal of foot down shin Ability to walk Ability to sit up straight with arms crossed

VERTEBROBASILAR INSUFFICIENCY • • • Vertigo Loss of vision Diplobia Nausea/vomiting Loss of coordination

Posterior inferior cerebellar artery syndrome (Wallenberg’s Syndrome) • Stroke vertebral or posterior inferior cerebellar artery • Supplies blood to the Medulla and Cerebellum • Ipsilateral limb ataxia • Loss of pain and temperature sensation • Vertigo • Feeling of being pulled to one side

Brain stem Strokes • Troublesome due to small size • Symptoms can be one sided or bilateral • Look for crossed signs as nerves cross at the brainstem – Weakness of the arm on left and weakness of the face on right

S & S of Brain Stem Strokes • • • Vertigo Tenitus Diplopia Decrease level of consciousness Dysarthria Dysphagia

MULTIPLE SCLEROSIS • • Vertigo lasting hours to weeks Mild sense of Vertigo History Nystagmus will be present

Migraine • 40% of Migraines will be associated with vertigo • Vertigo • Dizziness • Unsteadiness • Extreme sensitivity to motion • Aura

PERIPHERAL VERTIGO • • Vestibular Neuronitis (neuropathy) Benign paroxysmal positional vertigo Meniere’s disease Medications

Differentiation Peripheral • Vertigo comes in bursts lasting approximately 30 seconds • Relieved with holding still • One directional nystagmus • Nausea/vomiting

Vestibular Neuronitis (neuropathy) • • • Sudden onset Debilitating vertigo Associated unsteadiness Nausea/vomiting One directional horizontal nystagmus toward the healthy ear

Benign paroxysmal positional vertigo • • Most common cause of vertigo 20% More common in women Occurs most often at age 50 or > Often occurs in the morning when getting out of bed

BBPV

Vestibular Neuritis • Viral • Gradual onset • Symptoms are worse the first day and then become progressively better • Persistent Vertigo • Labrinthitis is similar but with hearing loss or tinnitus

Meniere’s disease • Possibly due to a abnormal amount of fluid in the inner ear. • Recurring episodes of vertigo => 20 min <24 Hours • Nausea Vomiting (severe cases) • Tinnitus (hearing loss over time) • Feeling of fullness in affected side

Dizziness • Studies have shown that Vertigo was the primary symptom in 37% of cardiovascular events • 55 -71% of syncope patients complain of dizziness prior to passing out

STROKE SCALES • NIH Stroke Scale • Cincinnati Prehospital Stroke Scale (CPSS) – Facial Droop – Arm Drift – Speech • Los Angeles Prehospital Stroke Screen (LAPSS) – Blood Glucose – Facial Droop – Grip strength – Arm drift

STROKE SCALE CONTINUED • MEND exam – CPSS + NIH

NYSTAGMUS • • • Involuntary movement of the eyeballs Increased blood alcohol levels Drugs Strokes BPVV And many other reasons

Dix-Hallpike maneuver • Rapidly move patient from sitting to supine position with head turned 45 degrees • Wait 30 seconds • Return patient to sitting position • And check for nystagmus (if negative check other side)

HEAD IMPULSE, NYSTAGMUS, AND TEST OF SKEW (HINTS) • Horizontal head impulse test – Have patient focus on examiner nose – Rapid low amplitude rotation of the head toward the midline – Eyes should stay focused – In peripheral vertigo rapid movement toward effected side will cause a saccade as they look back at the target (positive)

HEAD IMPULSE, NYSTAGMUS, AND TEST OF SKEW (HINTS) • Nystagmus – Fast phase that is unidirectional beating away from the affected side (peripheral) – Vertical or rotational (central) – Changes in direction (central)

HEAD IMPULSE, NYSTAGMUS, AND TEST OF SKEW (HINTS) • Test of Skew – Alternate eye cover testing skew deviation – Focus on an object – Alternately cover each eye – As cover is moved eye will look up or down correcting for misalignment either up or down (Brainstem Stroke or central vertigo)

HEAD IMPULSE, NYSTAGMUS, AND TEST OF SKEW (HINTS) • Must have continuous vertigo • Must be perfected (not an easy skill) • Not widely practiced in ED

Case study • 76 YO male • Sudden onset of dizziness at 2300 (feeling off balance) unable to ambulate • HX of Bell’s Palsy with right facial droop, TIA, CABG, cardiac stents • No SOB, Nausea, vomiting, trouble with vision, trouble with hearing, no weakness, no numbness

Case study cont • • • Neuro consult called Patient deemed to be having a CVA CT negative TPA administered Only physical sign was lower extremity ataxia

Patient 2 • September • 41 Year old male • Complains – Spinning sensation (made worse with opening eyes and head turning) – Nausea – Vomiting • Denies – Headache , neck or back pain – CP, SOB, Palpitations

Patient 2 continued • April 21 • EMS called for vertigo (spinning feeling) with vomiting • Now has HX of Bells Palsey, migraines, vertigo, HTN • PERL + horizontal right sided nystagmus • Extremities intact with no motor deficits

Patient 2 continued • ED differential DX – Benign positional vertigo, dehydration, doubt CVA, doubt posterior circulation ischemia • Neurologist Dx – 41 YO male – Rotatory and horizontal nystagmus on lateral and upgaze – Gait ataxia • CT shows left inferior medial cerebellum stroke – Positive Romberg sign and widened stance – Negative deficits – Finger – to – nose intact

CASE STUDY • ALS and BLS dispatched for 41 y/o male dizzy and vomiting. Upon BLS arrival PD on scene. PD stated they cancelled ALS prior to BLS arrival. Pt presents on knees vomiting into tub. Pt is alert and oriented to person, place and time. Pt is very diaphoretic and pale. Pt stated he began to not feel well two days ago. Pt stated it feels like vertigo. Pt had similar episode a year ago and took left over meclizine. Last night symptoms worsened and he was went to urgent care. This morning pt. began vomiting, nausea and feeling weak. Holding eyes closed is the only thing that helps dizziness. Pt stated he has been having a headache for past month. Vitals and PT moved to stair chair. Pt moved to stretcher and moved to ambulance. Pt vitals and monitored en route to hospital. Pt moved to room 3 and report and care given over to RN. • P 62 , rr 18, B/P 164 -110 • HX HTN takes Diovan

CASE STUDY • Patient 41 year old male comes to the emergency room with chief complaint of dizziness and vertigo symptoms since the past 2 days. Patient took meclizine from prior prescription. This morning with persistent dry heaving, dizziness, and diaphoresis. Patient called EMS because he was having severe vertigo symptoms of spinning. Patient acutely retching in the emergency room. Patient however believes that the dizziness is related to his BP which is now 129/90 • Diff dx = Benign positional vertigo, dehydration, doubt CVA, doubt posterior ischemia

• 1330 patient re-assessed not feeling any better headache has increased patient to be discharged with Compazine and valium and neuro consult • Patient CT was done which interestingly enough showed that patient has a indeterminate posterior cerebellar infarct. This appears to be acute based on clinical findings. • Patient admitted to hospital for neuro consult

NEUROLOGIST EXAM • A&O to norm; no acute distress: head normocephalic; no signs of trauma; no nuchal rigidity; full range of motion of the cervical spine; no edema of lower extremities • Cranial nerves: II. Visual fields full to confrontation; III, IV, VI extraocular movements intact with normal pupils, rotary and horizontal nystagmus on lateral and upgaze, worst on the left lateral gaze, no ptosis; V sensation on face intact in all three divisions; VII no facial asymmetry or weakness VIII hearing intact: xii tongue protrudes in the midline without atrophy or fasciculation's • Motor is normal. • Patient ultimately discharged with PT

QUESTIONS