Introduction : Dizziness and vertigo are common reasons for patients to present to the emergency room. This article will highlight key steps in the evaluation and management of patients with emergency vertigo and focus on the symptoms of vertigo and the differences between peripheral and central vertigo.
In the emergency setting, there is a great deal of uncertainty when clinicians are faced with the evaluation and management of dizziness. Much of this uncertainty about the presentation of dizziness arises when trying to distinguish between “peripheral” (usually benign) and “central” (potentially life-threatening) dizziness. The key to distinguishing between them is to be clear about the three most common peripheral vestibular disorders.
The three most common specific peripheral vestibular disorders.
Often, the most effective way to “exclude” a life-threatening central disorder is to “classify” it as a peripheral vestibular disorder. Peripheral vestibular system disorders are important because they are the primary cause of dizziness, have a highly consistent clinical presentation, and can be effectively treated. Central disorders should be considered when the clinical presentation differs from the consistent clinical features of peripheral vestibular system disorders. We will focus on key steps in the management of patients with emergency dizziness, concentrating on vertigo symptoms and the distinction between peripheral vestibular and central vestibular disorders.
Effective clinical evaluation of patients with emergency dizziness requires a well-organized approach that allows the physician to gather all of the most meaningful information and then elucidate the most likely cause of the patient’s dizziness and identify any “red flags” that may indicate a central disorder.
Step 1: Determine if dizziness is a major symptom rather than a minor concomitant symptom
There is no doubt that dizziness is a common concomitant symptom. More than 60% of patients in the emergency department will complain of dizziness when asked specifically if they are dizzy, and in most of these patients, dizziness is a minor concomitant symptom rather than a major symptom. One of the major problems with dizziness is that the patient’s description of it can be very vague, variable, and unreliable, so it is important to first consider whether there are other more obvious symptoms before focusing all attention on dizziness. For example, if chest pain is the primary symptom, it would be more effective to focus on cardiovascular disease rather than vestibular system disease at the outset.
Step 2: Define the characteristics of the dizziness symptoms
Determine whether the symptom is paroxysmal or persistent before characterizing it. If the symptoms are paroxysmal, then the triggers, frequency, and duration of the episodes should be explored. If the symptoms are persistent, it is important to identify the form of onset and the exacerbating and remitting factors. It is also important to identify the concomitant symptoms, especially to gather information on auditory or local neurological symptoms.
If dizziness is the main symptom, the next step is to further characterize it. Detailed information on the medical history helps to roughly classify patients with dizziness, which is relevant to determine the underlying etiology. Valuable categories of symptom presentation are as follows: acute severe prolonged dizziness, recurrent spontaneous dizziness, and recurrent posture-related dizziness. The type of symptom presentation is determined by the details of the disease history. Acute severe prolonged dizziness is a sudden onset of persistent symptoms (usually debilitating). Patients with recurrent spontaneous dizziness have at least multiple episodes without any apparent precipitating event. Recurrent posture-related dizziness characteristically is induced by specific head movements.
Step 3: Perform a comprehensive neurologic examination
A thorough neurologic examination is important because any associated motor, sensory, or speech disturbances are likely to suggest a central disorder regardless of the other features of dizziness. This is because peripheral vestibular disease and general medical disorders do not cause focal neurological deficits. On the other hand, hearing loss on one side is strongly suggestive of a peripheral etiology. For the same reason, a thorough internal systemic examination is also important when trying to rule out, for example, cardiac arrhythmias or upright hypotension.
Step 4: Perform a neuro-otologic evaluation
If the source of the symptoms is not clear after completing steps 1 to 3, then a neuro-otologic evaluation is particularly important. Subtle abnormalities in eye movements or vestibulo-ocular muscle reflexes are of high localization value. Critical neuro-otologic investigations include nystagmus examination, position testing (when the patient is able), and head-turning tests.
Types of nystagmus associated with the type of dizzy presentation.
Step 5: Systematic elaboration of the differential diagnosis
In the systematic elaboration of the case, it is important to first identify the type of dizziness to which the patient belongs, and then determine the possible etiology through the characteristic clinical manifestations and the results obtained from the ancillary examinations.
Acute severe prolonged vertigo: vestibular neuronitis; the diagnosis of stroke should be considered for any patient presenting with acute severe vertigo.
Recurrent spontaneous vertigo episodes: Meniere’s disease, migraine; transient ischemic attack should be considered in patients with cerebrovascular risk factors when transient vertigo occurs (measured in minutes).
Recurrent posture-induced vertigo attacks: BPPV; central nervous system disorders can cause positional vertigo attacks, but their attacks usually have many features to distinguish them from vertigo attacks of BPPV.