Vertigo

When patients describe feeling dizzy they may mean anything – presyncope, syncope, anxiety, weakness, vertigo or changes in mentation – so always clarify!

Vertigo implies the sensation of the movement when no movement is actually occurring (rotational or otherwise)

Causes

  • Central –
    • Vertebrobasillar insufficiency (will see cross neurological findings)
    • Neoplastic
    • Cerebellar disorders (hemorrhage, degeneration)
    • Basal ganglia disorders
    • MS
    • Neurosyphilis , TB
    • Epilepsy
    • Migraine
    • Cerebrovascular disease
  • Peripheral –
    • Benign paroxysmal position vertigo
    • Larbrynthitis
    • Vestibular neuronitis
    • Ramsay Hunt syndrome (Zoster rash w/i ear canal; hearing loss, CNVII findings)
    • Menière’s disease
    • CN VIII leasions (acoustic neuroma)
    • Otosclerosis
    • Traumatic – post head injury
    • Drug induced – aminoglycosides

Characteristics (points to ask on history) – adapted from Tintinalli’s Emergency Medicine: A Comprehensive Guide ’04

Peripheral Central
Onset Sudden Sudden or gradual
Severity Intense spinning Varied
Pattern Paroxysmal, intermittent Constant
Positional Yes Possible
N/V/diaphoresis Yes Possible
Nystagmus Rotatory-vertical, horizontal Vertical
Fatigue of S&s Yes No
Hearing loss or tinnitus Possible No
AbN TM Possible No
CNS S&s No Yes



 

Medication used in treating vertigo

Antihistamines
Diphenhydramine (Benadryl) 25-50mg PO/IM/IV q4h
Meclizine (Antivert, Bonamine) 25mg PO q6-12h
Hydroxysine (Atarax) 25-50 mg PO q6h
Promethazine (Phenergan) 25mg PO/IM/PR q6-8h

Anticholinergics

Dimenhydrinate (Gravol) 50-100mg PO/IM/IV q4h
Scopolamine (Hyosine) 0.5mg patch behind ear every 3 days

Antiemetics

Metoclopramide (Maxeran) 10-20mg PO/IV q8h

Vasodilators

Betahistine (Serc) 8-16mg PO tid

Benign Paroxysmal Positional Vertigo

  • Due to otoliths in the semicircular canals (most frequently the posterior) which accumulate and shift with head movement thus activating the hair cells causing neuronal activity
  • Age of onset: 50s
  • Females > Males
  • Episodes last up to 1 minute
  • Particular movements tend to set off the vertigo, which fatigues through out the day
  • Associated nystagmus, and nausea/vomiting
  • Diagnosis: Dix Hallpike maneuver
  • Treatment: Epley maneuver, anticholinergics or antihistamines

Menière’s disease

  • Due to increased endolymph within the inner ear
  • Age of onset: 65+
  • Females = Males
  • Episodes last up to hours
  • Associated with nausea/vomiting, tinnitus, decreased hearing, and sensation of fullness
  • Diagnosis: put glycerol in the ear (which acts as an osmotic diuretic)
  • Treatment: symptomatic with betahistine, antihistamines, diuretics (hydrochlorothiazide)

Vestibular neuronitis

  • Viral infection
  • Age of onset: any
  • Can last up to day (no recurrence)
  • May have associated symptoms of viral illness, may have unilateral tinnitus or loss of hearing or positional nystagmus
  • Treatment: symptomatic with antihistamines and antiemetics

Labyrinthitis

  • Infection of the labyrinth (i.e viral, bacterial)
  • Age of onset: any
  • Can last up to day (no recurrence)
  • Associated hearing loss
  • Treatment: symptomatic but if bacterial require antibacterials and may need to be admitted  to ENT for drainage

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