%% #note/sharing | #on/emergencymedicine | #on/diagnosis ```toc ``` %% # Dizziness and Vertigo - Summary: You MUST take a Baysean approach (Kerber et al., 2015) - ABCD2 - General Neuro History and Physical - [[HINTS+ Exam]]: ONLY USE WITH CONSTANT DIZZINESS AND NYSTAGMUS AT REST - Head Impulse Test: [Peter Johns - HINTS Exam Youtube](https://www.youtube.com/watch?v=lkjWjFSVFGM) - Should be abnormal on the opposite side, meaning the saccade crosses then snaps back - Abnormal when turned _towards the affected ear_ - Test faster, not farther - Nystagmus - Must be present at rest, looking straight ahead or eyes moving to side. - Note direction and character - Must not be verticle - Abnormal when looking _away from the affected ear_ - Test of Skew - Must be negative - Low risk = negative on all, moderate and higher risk probably need imaging - Also cannot have any - peripheral neurologic symptoms - headache or neck pain - Diplopia, dysphagia, dysmetria, dystaxia - New gait disorder ## Acute Vestibular Syndrome ### Labrynthitis - Summary: Generally fairly acute in onset symptoms - dizziness, unsteadiness, or vertigo worse with head movement - sometimes follows URI - Low risk patient who can walk but feels unsteady ### Posterior Circulation Stroke - Summary: Acute onset of symptoms - severe vertigo, ataxia, unsteadiness worse with head movement - Risk for vascular cause - maybe associated brainstem symptoms - Diplopia, dysphagia, dysmetria, dystaxia, "dizziness" - Concern increased if headache, neck pain, inability to walk ## Intermittent Vertigo syndromes ### Benign Positional Paroxysmal Vertigo - Summary: recurrent (often for years) sudden and brief - severe vertigo with vomiting - may feel exhausted between - No associated brainstem symptoms ### Vestibular Migraine - Summary: - Recurrent episodes of moderate length - associated headaches, photophobia, acoustaphobia - previous headaches have migranous features - scintilating scotomata ### Posterior Circulation TIA - Summary: ## Sources: Weigart, Scott. (2022, January 28). _EMCrit 316 – Vertigo and Posterior Stroke with Peter Johns_. [https://emcrit.org/emcrit/vertigo-redux/](https://emcrit.org/emcrit/vertigo-redux/) Johns, P., & Rosenberg, H. (2020). Just the Facts: How to assess a patient with constant significant vertigo and nystagmus in the emergency department. _CJEM_, _22_(4), 463–467. [https://doi.org/10.1017/cem.2020.34](https://doi.org/10.1017/cem.2020.34) Kerber, K. A., Meurer, W. J., Brown, D. L., Burke, J. F., Hofer, T. P., Tsodikov, A., Hoeffner, E. G., Fendrick, A. M., Adelman, E. E., & Morgenstern, L. B. (2015). Stroke risk stratification in acute dizziness presentations: A prospective imaging-based study. _Neurology_, _85_(21), 1869–1878. [https://doi.org/10.1212/WNL.0000000000002141](https://doi.org/10.1212/WNL.0000000000002141)