Rosen & Barkin's 5-Minute Emergency Medicine Consult (444 page)

• Vertigo and neurologic symptoms can represent a stroke
  
• Rapid transport to ED
  
• Protect patient from falling
  
• Maintain patient in comfortable position
  
• IV isotonic fluids for patients with vomiting
  
• Monitor for dysrhythmia
  

• IV hydration with isotonic fluids
  
• IV benzodiazepines
  
• IV antiemetics
  

Supportive therapy

• Symptomatic:
  
  • Meclizine: 12.5–25 mg PO q8h
    
  • Diazepam: 5–10 mg PO/PR/IV
    
  • Lorazepam: 0.5–2 mg PO/IV/IM
    
  • Dimenhydrinate: 12.5–50 mg PO
    
  • Ondansetron: 4–8 mg IV/IM/PO
    
  • Metoclopramide: 10 mg IV/IM
    
  • Promethazine: 10–25 mg PO/PR/IV/IM
    
  • Prochlorperazine: 10 mg IV
    
• Therapeutic:
  
  • Hydrochlorothiazide: 25–50 mg PO daily
    
  • Triamterene: 100 mg PO daily
    
  • Acetazolamide: 250 mg PO daily
    
  • Furosemide: 20 mg PO daily
    
  • Prednisone: 1 mg/kg PO daily with taper over 7–14 days
    
  • Dexamethasone: 4 g/L transtympanic injection
    
  • Gentamicin transtympanic perfusion
    
  • Pressure pulse treatment
    
  • Surgery (surgical labyrinthectomy, vestibular neurectomy, sacculotomy)
    

• Diazepam or lorazepam
  
• Ondansetron for nausea, vomiting
  
• IV fluid
  

• Meclizine
  
• Prochlorperazine
  

FOLLOW-UP

Patient refractory to acute control of vertigo and associated effects (e.g., dehydration from protracted vomiting)

• Tolerate oral fluids
  
• Steady gait
  
• Normal neurologic exam
  
• Fall precautions
  
• Recurrent attacks are typical
  
• Dietary restrictions: Sodium, caffeine, chocolate, tobacco, and alcohol intake
  
• Patient needs to avoid driving, operating dangerous equipment, and working at heights until attacks have resolved and sedating medications have been withdrawn
  

• Persistent/intractable symptoms and medical treatment failures
  
• Presence of ear pathology
  

• Proper education in terms of dietary control and avoidance techniques is helpful
  
• Vestibular rehabilitation can be helpful in teaching patients to cope with vertigo and imbalance
  
• Counsel regarding fall risks and avoiding dangerous tasks due to the unpredictable nature of the disease
  
• Refer to neurologist, otologist, and otolaryngologist for outpatient audiometry and electronystagmography testing
  

• Ménière disease typically presents with the classic tetrad of vertigo, hearing loss, tinnitus, and aural fullness
  
• Treatment focus is symptom relief, not cure
  
• Discharged patients should be referred to an outpatient neurologist, otologist, and otolaryngologist
  
• Inpatient care is generally unnecessary and is reserved for patients refractory to acute control of their symptoms or associated effects such as dehydration and vomiting
  
• Surgery is reserved for patients who fail medical therapy with intractable symptoms
  

• Casani AP, Piaggi P, Cerchiai N, et al. Intratympanic treatment of intractable unilateral Meniere disease: Gentamicin or dexamethasone? A randomized controlled trial.
  Otolaryngol Head Neck Surg.
  2012;146:430–437.
  
• James A. Ménière’s disease.
  Clin Evid
  . 2004;11:664–672.
  
• Kerber KA. Vertigo and dizziness in the emergency department.
  Emerg Med Clin North Am
  . 2009;27:39–50.
  
• Kim HH, Wiet RJ, Battista RA. Trends in the diagnosis and management of Ménière’s disease: Results of a survey.
  Otolaryngol Head Neck Surg
  . 2005;132:722–726.
  
• Lempert T. Recurrent spontaneous attacks of dizziness.
  Continuum (Minneap Minn).
  2012;18:1086–1101.
  
• Li JC. Meniere Disease (Idiopathic Endolymphatic Hydrops).
  Emedicine
  . Updated Sept 15, 2011. Available at
  http://emedicine.medscape.com/article/1159069-overview
  .
  
• Pierce NE, Antonelli PJ. Endolymphatic hydrops perspectives 2012.
  Curr Opin Otolaryngol Head Neck Surg
  . 2012;20:416–419.
  
• Sajjadi H, Paparella M. Ménière’s disease.
  Lancet
  . 2008;372:406–414.
  
• Semaan MT, Alagramam KN, Megerian CA. The basic science of Meniere’s disease and endolymphatic hydrops.
  Curr Opin Otolaryngol Head Neck Surg
  . 2005;13:301–307.
  
• Syed I, Aldren C. Meniere’s disease: An evidence based approach to assessment and management.
  Int J Clin Pract
  . 2012;66:166–170.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Dizziness
  
• Labyrinthitis
  

CODES

386.00 Meniere’s disease, unspecified

BASICS

CNS infection with inflammation of leptomeninges defined by an increased number of WBCs in the CSF often associated with fever, nuchal rigidity, headache, and altered mental status.

• Bacterial:
  
  • Neonates: Group B
    Streptococcus
    ,
    Escherichia coli
    and other enteric bacilli,
    Listeria monocytogenes
    
  • Children/adults
    : Streptococcus pneumoniae, Neisseria meningitidis,
    group B
    Streptococcus
    and gram-negative bacilli (<3 yr)
    
  • Elderly/alcoholic:
    S. pneumoniae
    , gram-negative bacilli,
    Listeria
    spp.
    
  • Neurosurgical patients:
    Staphylococcus
    and gram-negative organisms
    
  • Transplant recipients and dialysis patients: Increased incidence of
    Listeria
    spp. infection
    
  • AIDS: Above, plus tuberculosis, fungal, syphilis
    
• Viral
  
• Fungal
  
• Chemical, drug, or toxin induced
  

DIAGNOSIS

• General:
  
  • Fever
    
  • Nuchal rigidity:
    
    • Kernig: Flexed knee resists extension (bilateral).
      
    • Brudzinski: Flexion of neck produces flexion at hips.
      
    • Kernig and Brudzinski signs are neither sensitive nor specific for meningitis.
      
  • Altered mental state, headache
    
  • Photophobia
    
  • Papilledema
    
  • Focal CNS abnormalities
    
  • Seizure, nonsimple
    
  • Petechial and palpable purpuric rash (meningococcal infection)
    
  • Associated infections: Sinusitis, otitis media, pneumonia
    
• Infant/pediatric:
  
  • Fever or hypothermia
    
  • Lethargy
    
  • Weak suck
    
  • Vomiting
    
  • Dehydration
    
  • Respiratory distress
    
  • Apnea
    
  • Cyanosis
    
  • Bulging fontanel
    
  • Hypotonia
    
  • Meningismus often absent in <1 yr old
    
• Elderly and immune compromised:
  
  • Confusion with or without fever
    
  • Less-striking symptoms overall
    

• Neonates: Prematurity, intrapartum complications as fever, prolonged rupture of membrane, antibiotic use, group B
  Streptococcus
  infection
  
• Adults: Recent travels
  
• Elderly: Pneumococcal vaccination status
  
• Immunologic incompetency suggested by frequent infections
  
• Recent trauma or ENT, facial, or neurologic surgery
  
• Shunt