Dizziness resident survival guide: Difference between revisions
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{{familytree | | | | | |!| | | | | | F01 | | | F02 | | | F03 | | | | | | | | F04 | | | | F05 | | | |!| |F01= [[Deafness]] |F02= Headache |F03= [[Psychiatric]] symptoms |F04= Barotrauma |F05= Drugs }} | {{familytree | | | | | |!| | | | | | F01 | | | F02 | | | F03 | | | | | | | | F04 | | | | F05 | | | |!| |F01= [[Deafness]] |F02= Headache |F03= [[Psychiatric]] symptoms |F04= Barotrauma |F05= Drugs }} | ||
{{familytree | | |,|-|-|^|-|-|.| | | |!| | | | |!| | | | |!| | | | | | | | | | | | | | | | |,|-|-|-|^|-|-|-|.| }} | {{familytree | | |,|-|-|^|-|-|.| | | |!| | | | |!| | | | |!| | | | | | | | | | | | | | | | |,|-|-|-|^|-|-|-|.| }} | ||
{{familytree | | F01 | | | | F02 | | F03 | | | F04 | | | F05 | | | | | | | | | | | | | | | F06 | | | | | | F07 | | | |F01= Positive |F02= Negative |F03= [[Meniere disease]] |F04= Vestibular migraine|F05= [[Panic attack]], [[psychiatric]] condition |F06= [[ | {{familytree | | F01 | | | | F02 | | F03 | | | F04 | | | F05 | | | | | | | | | | | | | | | F06 | | | | | | F07 | | | |F01= Positive |F02= Negative |F03= [[Meniere disease]] |F04= Vestibular migraine|F05= [[Panic attack]], [[psychiatric]] condition |F06= [[Nistagmus]] dominantly horizontal, direction-fixed, [[saccade]] present |F07= [[Nistagmus]] dominantly vertical, no [[saccade]], torsion or [[gaze]] evoked bidirectionaly }} | ||
{{familytree | | |!| | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | |!| }} | {{familytree | | |!| | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | |!| }} | ||
{{familytree | | F01 | | | | F02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | F03 | | | | | | F04 | | | |F01= [[Benign paroxysmal positional vertigo]] |F02= [[Orthostatic hypotension]] |F03= [[Vestibular neuritis]] |F04= [[Stroke]], [[transient ischemic attack]] }} | {{familytree | | F01 | | | | F02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | F03 | | | | | | F04 | | | |F01= [[Benign paroxysmal positional vertigo]] |F02= [[Orthostatic hypotension]] |F03= [[Vestibular neuritis]] |F04= [[Stroke]], [[transient ischemic attack]] }} | ||
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*When taking vital signs, remember to measure blood pressure in standing and supine position. | *When taking vital signs, remember to measure blood pressure in standing and supine position. | ||
*Perform a Romberg test. A positive Romberg test may disclose a peripheral etiology. | *Perform a Romberg test. A positive Romberg test may disclose a peripheral etiology. | ||
==Don'ts== | ==Don'ts== | ||
| Line 63: | Line 59: | ||
*Do not forget about psychiatric causes. Many times psychiatric conditions, such as panic attacks, may mimic dizziness. | *Do not forget about psychiatric causes. Many times psychiatric conditions, such as panic attacks, may mimic dizziness. | ||
*Do not forget abut orthostatic hypotension. Orthostatic hypotension is a very common cause of dizziness, especially in elderly people due to vessels rigidity (arteriosclerosis). | *Do not forget abut orthostatic hypotension. Orthostatic hypotension is a very common cause of dizziness, especially in elderly people due to vessels rigidity (arteriosclerosis). | ||
*Do not miss transit ischemic attack. TIA is one of the most missed diagnosis when a patient presents with dizziness. | |||
*When looking after benign paroxysmal vertigo (BPV), do not perform Dix-Hallpike only once. BPV only comes positive in around 70% of the times with first attempt, several attempts may be necessary. | *When looking after benign paroxysmal vertigo (BPV), do not perform Dix-Hallpike only once. BPV only comes positive in around 70% of the times with first attempt, several attempts may be necessary. | ||
*Do not give any kind of pharmacologic treatment for BPV. | *Do not give any kind of pharmacologic treatment for BPV. | ||
Revision as of 04:23, 20 August 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D.
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.[1]
Causes
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
Common Causes
- Hypotension
- Dehydration
- Hypoglycemia
- Arrhythmias
- Stroke
- Labyrinthitis
- Meniere's disease
- BPV
- Medication effects
Diagnosis
Shown below is an algorithm summarizing the diagnosis of dizziness according to the American Academy of Neurology guidelines.
| 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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- Always ask the patient what do they mean by dizziness. Dizziness may have a different meaning among patients; while vertigo may represent a vestibular condition, presyncope directs to a cardiovascular problem, or disequilibrium a neurological or psychiatric one.
- Intentionally ask for any history of possible intoxication, medications used, and exposures. A full history review may disclose dizziness due to trauma or an intoxication.
- Ask for any eliciting or exacerbating features. Dix-Hallpike maneuver may easily detect a benign paroxysmal positional vertigo and differentiate it from a orthostatic hypotension.
- Perform a full neurological examination. A head-impulse, nystagmus, test of skew (HINTS) can differentiate between a central from a peripheral cause.
- When taking vital signs, remember to measure blood pressure in standing and supine position.
- Perform a Romberg test. A positive Romberg test may disclose a peripheral etiology.
Don'ts
- Do not perform imaging as as routine.
- Do not forget about psychiatric causes. Many times psychiatric conditions, such as panic attacks, may mimic dizziness.
- Do not forget abut orthostatic hypotension. Orthostatic hypotension is a very common cause of dizziness, especially in elderly people due to vessels rigidity (arteriosclerosis).
- Do not miss transit ischemic attack. TIA is one of the most missed diagnosis when a patient presents with dizziness.
- When looking after benign paroxysmal vertigo (BPV), do not perform Dix-Hallpike only once. BPV only comes positive in around 70% of the times with first attempt, several attempts may be necessary.
- Do not give any kind of pharmacologic treatment for BPV.
References
- ↑ Chan Y (2009). "Differential diagnosis of dizziness". Curr Opin Otolaryngol Head Neck Surg. 17 (3): 200–3. doi:10.1097/MOO.0b013e32832b2594. PMID 19365263.