Dizziness resident survival guide

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Dizziness Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D.

Synonyms and Keywords: Approach to dizziness, Dizziness workup, Dizziness management, Approach to vertigo, Vertigo workup


Overview

Dizziness is a complex and subjective complaint that encompasses a wide spectrum of symptomatology. It is one of the most common presenting symptoms among patients seen by emergency medical physicians, primary care physicians, neurologists, and otolaryngologists. It can be caused by a disturbance in nearly any system of the body.


Causes

Life Threatening Causes

Common Causes


Diagnosis

Shown below is an algorithm summarizing the diagnosis of dizziness according to the American Academy of Neurology guidelines:[1][2]


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient with dizzinesss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presentation periodical or sustained?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Periodical
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sustained
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Provoked or unprovoked?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History of intoxication or trauma, or unknown?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Provoked
 
 
 
 
 
 
 
 
 
Unprovoked
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History of intoxication
 
 
 
 
 
Unknown
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Apply Dix-Hallpike maneuver
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Deafness
 
 
Headache
 
 
Psychiatric symptoms
 
 
 
 
 
 
 
Barotrauma
 
 
 
Drugs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive
 
 
 
Negative
 
Meniere disease
 
 
Vestibular migraine
 
 
Panic attack, psychiatric condition
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nistagmus dominantly horizontal, direction-fixed, saccade present
 
 
 
 
 
Nistagmus dominantly vertical, no saccade, torsion or gaze evoked bidirectionaly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Benign paroxysmal positional vertigo
 
 
 
Orthostatic hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vestibular neuritis
 
 
 
 
 
Stroke, transient ischemic attack
 
 
 
Diagnosis of benign paroxysmal positional vertigo (BPPV)
Presence of all the following criteria Continuous periods of vertigo triggered by changes in head position.
Vertigo related with twisting, positive nystagmus is triggered by the Dix-Hallpike maneuver.
Presence of a quiescence period between the execution of the Dix-Hallpike maneuver and the beginning of vertigo and nystagmus.
The triggered vertigo and nystagmus rises and then solves within 60 seconds from the onset.

Adapted from The American Academy of Otolaryngology guidelines for benign paroxysmal positional vertigo (DO NOT EDIT).[3]

Treatment

Treat the underlying cause.

Do's

Don'ts


References

  1. Eggers, S. D.Z. (2009). "DIZZINESS: A PRACTICAL APPROACH TO DIAGNOSIS AND MANAGEMENT". Neurology. 72 (24): 2139–2139. doi:10.1212/WNL.0b013e3181aa53ec. ISSN 0028-3878.
  2. Kerber, K. A.; Baloh, R. W. (2011). "The evaluation of a patient with dizziness". Neurology: Clinical Practice. 1 (1): 24–33. doi:10.1212/CPJ.0b013e31823d07b6. ISSN 2163-0402.
  3. 3.0 3.1 Bhattacharyya, Neil; Gubbels, Samuel P.; Schwartz, Seth R.; Edlow, Jonathan A.; El-Kashlan, Hussam; Fife, Terry; Holmberg, Janene M.; Mahoney, Kathryn; Hollingsworth, Deena B.; Roberts, Richard; Seidman, Michael D.; Steiner, Robert W. Prasaad; Do, Betty Tsai; Voelker, Courtney C. J.; Waguespack, Richard W.; Corrigan, Maureen D. (2017). "Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)". Otolaryngology–Head and Neck Surgery. 156 (3_suppl): S1–S47. doi:10.1177/0194599816689667. ISSN 0194-5998.
  4. 4.0 4.1 Edlow JA, Gurley KL, Newman-Toker DE (April 2018). "A New Diagnostic Approach to the Adult Patient with Acute Dizziness". J Emerg Med. 54 (4): 469–483. doi:10.1016/j.jemermed.2017.12.024. PMC 6049818. PMID 29395695.
  5. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE (November 2009). "HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging". Stroke. 40 (11): 3504–10. doi:10.1161/STROKEAHA.109.551234. PMC 4593511. PMID 19762709.
  6. 6.0 6.1 Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE, Wehrle PA, Boggi JO (December 1992). "Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care". Ann. Intern. Med. 117 (11): 898–904. doi:10.7326/0003-4819-117-11-898. PMID 1443950.
  7. Muncie HL, Sirmans SM, James E (February 2017). "Dizziness: Approach to Evaluation and Management". Am Fam Physician. 95 (3): 154–162. PMID 28145669.
  8. Savitz SI, Caplan LR (June 2005). "Vertebrobasilar disease". N. Engl. J. Med. 352 (25): 2618–26. doi:10.1056/NEJMra041544. PMID 15972868.
  9. Hilton M, Pinder D (2004). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". Cochrane Database Syst Rev (2): CD003162. doi:10.1002/14651858.CD003162.pub2. PMID 15106194.