Rosen & Barkin's 5-Minute Emergency Medicine Consult (222 page)

• Serum glucose
  
• Hematocrit, if suspected anemia/blood loss
  
• Electrolytes and renal function
  
  • VBG if considering CO poisoning or CO
    ₂
    narcosis
    
• UA to evaluate for infection
  
• Toxicologic screen, if suspected exposure
  

• CT head if acute bleed suspected
  
  • CT only ∼40% sensitive for ischemic posterior circulation stroke
    
• MRI if no other etiology found and HINTS exam concerning in a patient with the AVS
  

• Dix-Hallpike maneuver, head thrust maneuver, and test for skew deviation.
  
• EKG to detect arrhythmia, MI
  
• Lumbar puncture in setting of unexplained infectious signs or headache
  

Each of the timing and triggers categories has its own differential diagnosis. Here are the common and the dangerous causes:

• AVS – acute vestibular syndrome
  
  • Benign
    
    • Viral labyrinthitis (hearing involved)
      
    • Vestibular neuritis (hearing not involved
      
  • Dangerous
    
    • Stroke, particularly brainstem or cerebellar
      
    • Occasionally low cardiac output state (e.g., PE, ACS)
      
• EVS – episodic (spontaneous) vestibular syndrome
  
  • Benign
    
    • Vestibular migraine
      
  • Dangerous
    
    • TIA
      
    • Rarely, brief low cardiac output state (e.g., arrhythmia, PE that breaks up and migrates)
      
• PVS – positional (triggered) vestibular syndrome
  
  • Benign
    
    • BPPV
      
    • Orthostatic hypotension (if benign cause)
      
  • Dangerous
    
    • Orthostatic hypotension (if serious cause)
      
    • Rarely, CPPV (central paroxysmal positional vertigo) caused by a posterior fossa mass
      
• CVS – chronic vestibular syndrome
  
  • Benign
    
    • Psychiatric causes (anxiety and depression)
      
    • Benign medication side effects
      
  • Dangerous
    
    • Rarely a posterior fossa mass
      

TREATMENT

• Abnormal vital signs clinically managed
  
• Stabilization should be determined by more specific classification of dizziness based on the history, physical exam, and ancillary studies.
  

Symptomatic control until diagnosis established

If BPPV suspected perform Epley maneuver

• Ondansetron: 4 mg IV or ODT
  
• Diazepam: 2.5–5 mg IV or 2–10 mg PO
  
• Diphenhydramine: 25–50 mg IV, IM, or PO
  
• Meclizine: 25 mg PO (no more than 2–3 days)
  
• Promethazine: 12.5 mg IV q6h or 25–50 mg PO, IM, or PR q6h
  

Note: These medications are for symptom relief; response has no etiologic implications.

FOLLOW-UP

Admission or discharge of patients with dizziness should be based on the underlying etiology or associated symptoms.

• Admission or discharge of patients with dizziness should be based on the underlying and the patient’s ability to function safely at home.
  
• If patient has isolated complaint of dizziness with normal neurologic and oculomotor testing as described above, consider discharge with follow-up instructions
  

Refer for completion of workup as an outpatient to a primary care physician, ENT, or neurologist depending upon likely cause.

• The patient should be instructed:
  
  • Not to drive or operate machinery if he is feeling dizzy
    
  • To get up slowly after sitting or lying down
    
• Patient should return to the ED or see his doctor right away if:
  
  • Symptoms of neurologic problem (worsening headache, confusion, memory loss, new motor or sensory loss)
    
  • Symptoms of an infection (stiff neck, fevers, or chills)
    
  • Symptoms of acute cardiovascular or pulmonary problem (new acute abdominal chest or back pain, new dyspnea, or hemoptysis)
    
  • Symptoms of fluid losses (intractable emesis or stools, GI or vaginal bleeding)
    

• Use the “timing and triggers” technique to diagnose dizzy patients.
  
• Advanced age and traditional stroke risk factors increase the likelihood of acute stroke as cause of dizziness.
  
• Noncontrast CT is NOT sensitive for acute cerebellar stroke.
  
• Patients with cerebellar stroke can present with isolated dizziness.
  
• It is a “negative” head impulse test (lack of corrective saccade) that is worrisome; a “positive” test suggests a peripheral vestibular etiology.
  
• The treatment for BPPV is an Epley maneuver, NOT meclizine.
  

• Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction.
  Lancet Neurol
  . 2008;7:951–964.
  
• Hwang DY, Silva GS, Furie KL, et al. Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting acute posterior fossa infarct.
  J Emerg Med
  . 2012;42:559–565.
  
• Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: Three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.
  Stroke
  . 2009;40:3504–3510.
  
• Newman-Toker DE, Cannon LM, Stofferahn ME, et al. Imprecision in patient reports of dizziness symptom quality: A cross-sectional study conducted in an acute care setting.
  Mayo Clin Proc
  . 2007;82:1329–1402.
  
• Newman-Toker DE, Hsieh YH, Camargo CA Jr, et al. Spectrum of dizziness visits to US emergency departments: Cross-sectional analysis from a nationally representative sample.
  Mayo Clin Proc
  . 2008;83(7):765–775.
  

See Also (Topic, Algorithm, Electronic Media Element)

Vertigo

CODES

• 386.11 Benign paroxysmal positional vertigo
  
• 386.30 Labyrinthitis, unspecified
  
• 780.4 Dizziness and giddiness
  

BASICS

• Intimate partner violence (IPV) is the physical, sexual, or psychological abuse by a current or former partner.
  
• Occurs in adult and adolescent intimate relationships across the socioeconomic spectrum.
  

• Most victims are women injured by male perpetrators
  
• Men and individuals in same-sex relationships may also be victims.
  
• Risk factors for IPV include female sex, young age (20–24) and being separated from partner/spouse.
  

DIAGNOSIS

Asking specifically about IPV increases likelihood of identifying victims.

• Traumatic injuries:
  
  • Wide variety of presentations
    
  • Unwitnessed head, neck, facial injuries are common
    
  • Forearm bruises or fractures suggesting a defensive posture
    
  • Injuries in various stages of healing
    
• Psychiatric:
  
  • Chronic pain syndromes
    
  • Depression
    
  • Somatization
    
  • Anxiety
    
  • Suicidality
    
  • Substance abuse