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Dizziness in the ed

Dizziness in the ed. Jordan Smedresman SUNY Downstate College of Medicine Class of 2013. 30 year old woman with “dizziness”. Suddenly started ~6 hours prior to evaluation when she stood up after dinner Felt the room spinning, had to be supported to keep from falling

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Dizziness in the ed

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  1. Dizziness in the ed Jordan Smedresman SUNY Downstate College of Medicine Class of 2013

  2. 30 year old woman with “dizziness” • Suddenly started ~6 hours prior to evaluation when she stood up after dinner • Felt the room spinning, had to be supported to keep from falling • Nausea , one episode of vomiting • Similar episode one week prior, spontaneously resolved after “a few hours” • No history of trauma, no recent illness, no tinnitus • Still unsteady on her feet, but gradually improving, nausea has resolved

  3. PMH—anemia • PSH—c-section 7 years ago • Allergies—shellfish (rash), no drugs • Meds—iron, Centrum

  4. Temp 98.2, HR 86, RR 16, 178/107 (repeat 150/100) • Physical exam unremarkable

  5. Neuro Exam • Alert and oriented x3 • CN II-XII intact, slight horizontal nystagmus upon turning the head, worse when turning left • Muscle strength 5/5 in all extremities, normal sensation • Reflexes 2+ throughout • FTN intact • Gait unsteady, not ataxic • Upon lying flat, symptoms returned • Patient refused Dix-Hallpike test

  6. Labs • WBC: 9.3 • Hb: 12.4 • Hct: 40.6 • Plt: 344 • MCV: 65 • β-HCG: 0 • T4: 1.18 • TSH: 1.792 • Na: 141 • K: 4.2 • Cl: 104 • CO2: 26.6 • BUN: 14 • Cr: 0.6 • Glucose: 104 • Ca: 10.2

  7. Benign Paroxysmal Positional Vertigo • Usually multiple short (seconds) episodes reproduced by tilting the head • Often caused by canaliths • Can last weeks to months • Vomiting is rare • Diagnosed through history. Dix-Hallpike can helpful (50-80% sensitive)

  8. Canalith Repositioning

  9. Vestibular Neuronitis • Believed to be viral or postviral inflammatory disorder • Rapid onset of severe, persistent vertigo with nausea/vomiting and gait instability (fall toward affected side) • Spontaneous nystagmus • Clinical diagnosis • Usually lasts 1-2 days

  10. This patient • Time course—vestibular neuronitis • Suggestive setting—BPPV (more predictable head movements, no recent illness) • Nystagmus—more typical of vestibular neuronitis • Treatment—meclizine with ENT followup • Second line—benzos

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