Vertigo: Difference between revisions
Ostermayer (talk | contribs) |
Ostermayer (talk | contribs) |
||
Line 134: | Line 134: | ||
##Meclizine (antivert) 25mg PO QID | ##Meclizine (antivert) 25mg PO QID | ||
##Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr | ##Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr | ||
#Anticholinergics | #Anticholinergics | ||
##Scopolamine transdermal patch 0.5mg (behind ear) QID | ##Scopolamine transdermal patch 0.5mg (behind ear) QID |
Revision as of 16:16, 6 August 2013
Background
- Perception of movement (rotational or otherwise) where no movement exists
- Pathophysiology
- Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems
- Must distinguish peripheral from central cause
- Peripheral: 8th CN, vestibular apparatus
- Central: Brainstem, cerebellum
Clinical Features
Peripheral | Central | |
Onset | Sudden | Sudden or slow |
Severity | Intense spinning | Ill defined, less intense |
Pattern | Paroxysmal, intermittent | Constant |
Aggravated by position/movement | Yes | Variable |
Nausea/diaphoresis | Frequent | Variable |
Nystagmus | Rotatory-vertical, horizontal | Vertical |
Fatigue of symptoms/signs | Yes | No |
Hearing loss/tinnitus | May occur | Does not occur |
Abnormal tympanic membrane | May occur | Does not occur |
CNS symptoms/signs | Absent | Usually present |
Diagnosis
Algorithm
HINTS Exam
Can reliably^ distinguish peripheral cause from cerebellar/brain stem CVA
- Head Impulse Testing
- Tests vestibulo-ocular reflex
- Have pt fix their eyes on your nose
- Move their head in the horizontal plane to the left and right
- If reflex is intact their eyes will stay fixed on your nose
- If reflex is abnormal eyes will move w/ their head and won't stay fixed on your nose
- It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
- Nystagmus
- Benign nystagmus only beats in one direction no matter which direction their eyes look
- Bad nystagums beats in every direction their eyes look
- If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
- Test of Skew
- Vertical dysconjugate gaze is bad
- Alternating cover test
- Have pt look at your nose w/ their eyes and then cover one eye
- When rapidly uncover the eye look to see if the eye quickly moves to re-align
- If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)
^Sensitivity (for posterior ischemic CVA):
- HINTS = 100%?
- MRI <48hrs after symptom onset = 83%
- MRI >48hrs = 100%?
- CT = 16%
DDX
- Vestibular/otologic
- Benign Paroxysmal Positional Vertigo (BPPV)
- Traumatic (following head injury)
- Infection
- Labyrinthitis
- Vestibular Neuritis (Neuronitis)
- Ramsay Hunt syndrome
- Syndrome
- Meniere Disease
- Neoplastic
- Vascular
- Otosclerosis
- Paget disease
- Toxic or drug-induced: aminoglycosides
- Neurologic
- Vertebrobasilar insufficiency
- Head turning causes vertigo, diplopia, dysarthria, b/l loss of vision, syncope
- Lateral Wallenberg syndrome
- Anterior inferior cerebellar artery syndrome
- Neoplastic: cerebellopontine angle tumors
- Cerebellar disorders: hemorrhage, degeneration
- Basal ganglion diseases
- Multiple sclerosis
- Infections: neurosyphilis, tuberculosis
- Epilepsy
- Migraine (basilar)
- Cerebrovascular disease
- Vertebrobasilar insufficiency
- General
- Hematologic: anemia, polycythemia, hyperviscosity syndrome
- Toxic: alcohol
- Chronic renal failure
- Metabolic
Work-up
- Glucose check
- Full neuro exam
- TM exam
- ?CT/MRI - if symptoms consistent with central cause
Peripheral Vertigo Treatment
Symptomatic control
- Antihistamines
- Meclizine (antivert) 25mg PO QID
- Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr
- Anticholinergics
- Scopolamine transdermal patch 0.5mg (behind ear) QID
- Antidopaminergics
- Metoclopramide 10-20 IV or PO TID
Cause Reversal
- Epley maneuver (see BPPV)
Central Vertical Treatment
- R/O CVA
- MRI
- R/O Vascular inssufficency
Disposition
- Most pts w/ peripheral vertigo can be discharged home
- Most pts w/ central vertigo require urgent imaging and consultation while in the ED
See Also
Source
- Tintinalli