As the World Turns: Vertigo in the Emergency Department

Transcription

1 , FACEP 1 As the World Turns: Vertigo in the Emergency Department, FACEP Department of Emergency Medicine Albert Einstein College of Medicine Montefiore Medical Center to be addressed What differentiates peripheral from central vertigo? What differentiates benign paroxysmal positional vertigo (BPPV) from other causes of peripheral vertigo, such as labyrinthitis and vestibular neuritis? Case Presentation 67 year-old man Rolled over in bed After a few seconds delay, he developed nausea and felt as if the room was spinning Symptoms resolved within 30 seconds Room spun in the opposite direction when he rolled back to his original position Past Medical History & Social History Hypertension, on atenolol No surgeries Nonsmoker, occasional alcohol Physical Exam VS: 37.2, 145/85, 90, 18, sat 98% Alert, anxious Head, eyes, ears, neck exam: normal Cardiac exam: normal Rest of exam: normal Neurologic exam (detailed): normal

2 , FACEP 2 Differential Diagnosis Your Differential Diagnosis? Peripheral Vertigo Benign paroxysmal positional vertigo (BPPV) Vestibular neuritis Labyrinthitis Meniere s disease Central Vertigo Stroke/Vertebrobasilar insufficiency ED Course Hallpike Test A diagnostic Hallpike test was performed Torsional nystagmus and reproduction of symptoms in the right head-hanging position Asymptomatic in the left head-hanging position Hallpike Video Clip Nystagmus video clip

3 , FACEP 3 ED course The was performed at the patient s bedside with complete resolution of symptoms No imaging or lab tests done No intravenous line placed Length of stay 20 minutes Patient very grateful BPPV Benign Paroxysmal Positional Vertigo Age Head trauma Characteristic story Turn head After a few seconds delay, vertigo occurs Resolves within 1 minute if you don t move If you turn your head back, vertigo recurs in the opposite direction Dissecting the acronym BPPV B = Benign Not a brain tumor Can be severe and disabling Dissecting the acronym BPPV P = Paroxysmal Episodic, not persistent Helpful feature in the differential diagnosis Dissecting the acronym BPPV P = Positional Occurs with position of head Turning over in bed Looking up Bending over

4 , FACEP 4 Dissecting the acronym BPPV Vertigo V = Vertigo An illusion of motion The room is spinning Other descriptions Rocking Tilting Somersaulting Descending in an elevator Peripheral CN VIII Vestibular apparatus Central Brain stem Vestibular nuclei in medulla and pons Cerebellum Vertigo Anatomy: Membranous labyrinth PERIPHERAL CENTRAL Onset Intensity Duration Nausea/Diaphoresis Sudden Severe Paroxysmal Frequent Slow, gradual Ill defined Constant Infrequent Semicircular canals Utricle Endolymph CNS signs Absent Usually present Tinnitus/hearing loss Can be present Absent Nystagmus Torsional/horizontal Vertical Nystagmus Fatigable Non-fatigable Anatomy: Semicircular canals Semicircular Canals (SCC) Horizontal Anterior Posterior Cupula End organ receptors Endolymph Utricle Connected to SCC Contains endolymph Otoliths (otoconia) Calcium carbonate Attached to hair cells Macule (end organ) Anatomy: Utricle

5 , FACEP 5 Vestibular system Tells brain which way the head moves without looking SCC: angular acceleration Utricle: linear acceleration Pathophysiology of BPPV Otoliths become detached from hair cells in utricle Inappropriately enter the posterior semicircular canal 1 1. Parnes LS, McClure JA. Laryngoscope 1992;102: Physiology Normal situation As one turns head to the right Endolymph moves SCC receptors fire head turning right Stop turning head endolymph stops moving SCC receptors stop firing head has stopped moving Pathophysiology of BPPV BPPV Stop turning head otoliths keep moving drag endolymph receptors continue to fire inappropriately head is still moving Eyes head is NOT moving Brain room must be spinning in the opposite direction The Epley Maneuver First described in Bedside > 80% cure rate 2,3 Immediate relief Canalith repositioning maneuver 5 step head hanging maneuver Moves otoliths out of the posterior semicircular canal and back into utricle where they belong 2. Epley J. Otolaryngol Head Neck Surg 1992;107: Lynn S, et al. Otolaryngol Head Neck Surg 1995;113:

6 , FACEP 6 1. Repeat Hallpike Previously performed diagnostic Hallpike test tells you the starting position (right or left) Turn head 90 degrees in the other direction 3. Patient rolls onto shoulder, rotates head and looks down towards floor 4. Patient sits back up 5. Head forward (video clip)

7 , FACEP 7 Repeating the Post procedure Remain upright for 8-24 hours The Epley Maneuver Contraindications 4 Unstable heart disease High grade carotid stenosis Severe neck disease Ongoing CNS disease (TIA/stroke) Pregnancy beyond 24 th week gestation (relative) 4. Furman JM, Cass SP. N Engl J Med 1999;341: Complications Vomiting IV promethazine Converting to horizontal canal BPPV Bar-b-que maneuver Lab studies In a straightforward case, no lab studies are needed! Hemoglobin Fingerstick glucose Electrolytes if prolonged vomiting Medications Sensory Conflict Theory Class A: benzodiazepines Prevents process of vestibular rehabilitation Class B: anticholinergic Scopolamine: takes 4-6 hrs; not effective in ED Class C: antihistaminic IV promethazine (Phenergan) PO meclizine (Antivert) Consultations Will depend upon institution (neurology vs. otolaryngology) If not better with If focal neurologic exam

8 , FACEP 8 Summary BPPV may be a severe and incapacitating disease Diagnosis via history, nonfocal neurological exam, and a positive Hallpike test Treatment is with the IV promethazine (Phenergan) is probably the best ED medication if one is needed What differentiates peripheral from central vertigo? What differentiates benign paroxysmal position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis? What differentiates peripheral from central vertigo? Peripheral vertigo is more intense, has a sudden onset, is paroxysmal, has fatigable and rotatory nystagmus, and has a nonfocal neurological examination What differentiates peripheral from central vertigo? What differentiates benign paroxysmal position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis? What differentiates BPPV from labyrinthitis and vestibular neuritis (VN)? BPPV Requires head movement Duration of seconds Usually in elderly No relation to viral syndrome Responds to Epley maneuver Labyrinthitis/VN No head movement needed Duration of hours/days Any age Viral syndrome usually precedes is ineffective What differentiates peripheral from central vertigo? What differentiates benign paroxysmal position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis?

9 , FACEP 9 Questions??? The (canalith repositioning maneuver) FERNE andrewkennethchang@hotmail.com