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Vertigo Update

1/24/2018

2 Comments

 
Dizziness can be difficult to assess in the ED given the vast range of etiologies and varying ways patients interpret their symptoms. Additionally, not all patients with emergency conditions will present with obvious focal deficits. A clinical decision making rule (HINTS) can help to more rapidly identify stroke patients to initiate acute therapies faster. The HINTS rule outperforms ABCD2  for stroke diagnosis in the ED when performed by qualified practitioners in patients with Acute Vestibular Syndrome. 

Typically, patients with peripheral vertigo appear to have an acute change and may be very ill appearing, with nausea and vomiting and severe vertigo symptoms. Those with central vertigo typically have a more insidious onset, constant symptoms, and typically less severe symptoms. 

Common Causes

  • Basilary/Posterior Stroke
  • BPPV
  • Vestribular Neuritis
  • Meniere's Disease

Signs of a Central Cause

Symptoms of a central vertigo may be difficult to identify. Typically, there are some of the "5 D's"
  • Dizziness
  • Dysarthria
  • Diplopia
  • Dysphagia
  • Dysmetria
  • Ataxia

HINTS Exam

LINK TO 8 MINUTE HOW TO VIDEO

Indications of a Central Cause: 
  • Head-Impulse Test without a defect/loss of fixation
  • ​Nystagmus: Any vertical , torsional, or direction-changing nystagmus
  • Positive vertical test of skew ​

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From: HINTS Outperforms ABCD2 Score to screen for stroke

Pharmacologic Management

  • BPPV: Treated with benzodiazapines or meclizine
  • Vestibular Neuritis: Consider starting steroids, methylprednisolone 100mg daily and tapered slowly.
diagnosing_dizziness.pdf
File Size: 1924 kb
File Type: pdf
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2 Comments

NIH Stroke Scale & Training

12/8/2016

4 Comments

 
The NIH stroke scale it used to identify the severity of stroke like symptoms, and should be scored on the patient's initial presentation, without coaching or duplication. It is important to be consistent when scoring all patients, and identify all deficits. 

NIH stroke scale scores patients 0-42, with higher scores indicating increased severity.

Training for appropriate use of the NIH stroke scale is free, at http://nihss-english.trainingcampus.net/

iPhone applications, such as StatCoder, are available and free.
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4 Comments

Altered Consciousness & Coma

12/27/2015

3 Comments

 
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Adapted from Rosens, chp 16. 

Little Old Lady Workup (LOL)

Testing to consider in an elderly patient with altered mental status
ABG: hypoxia, CO2 retention, SOB
BMP/CMP: electrolyte abnormalities, hepatic encephalopathy
UA: infection, DKA, ingestion
PT/INT: hemorrhage, anemia, hypercoagulable
Lactate: ketotic state, ingestion, ischemia
TSH: thyroid storm, hypothyroid
Cardiac Enzymes: MI, ischemia, cardiogenic shock
CXR: infection, pneumothorax, CHF
CT head: hemorrhage, mass
MRI: edema, mass, ischemia
CTA: pulmonary emboli, aortic dissection
LP/CSF: infection, ICP

Confusion

Organic Confusion

Acute onset confusion with fluctuating consciousness and poor recent memory, possibly associated with focal deficits, hallucinations or abnormal vital signs. 

Functional Confusion

Chronic or slow-onset, normally alert and oriented, with some agitation or anxiety, possibly auditory hallucinations and normal vitals, no focal deficits, and illusions or delusions. 
3 Comments

HINTS  Screen for Stroke in Acute, Continuous Vertigo and Dizziness

12/3/2015

2 Comments

 
Adapted from a presentation by Ty Nichols, 12/2/2015
Dizziness can be difficult to assess in the ED given the vast range of etiologies and varying ways patients interpret their symptoms. Additionally, not all patients with emergency conditions will present with obvious focal deficits. A clinical decision making rule (HINTS) can help to more rapidly identify stroke patients to initiate acute therapies faster. The HINTS rule outperforms ABCD2  for stroke diagnosis in the ED when performed by qualified practitioners in patients with Acute Vestibular Syndrome. 
Link to 8 minute how-to video
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Full Article
2 Comments
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This site is independently owned and operated and not affiliated with the George Washington University, George Washington University Hospital, or Medical Faculty Associates. All information on this site is the opinion of the author alone and in no way should be seen to represent the views of the George Washington University, George Washington University Hospital, or Medical Faculty Associates. The information on this page is for personal use only and should not be see as medical advice or used directly for patient care. The author provides no guarantee of the accuracy of the information provided on this page. ​

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  • Clinical
    • Discharge Macros
    • Suboxone
    • Procedure Macros
    • Exam Macros
    • Pediatric Macros
    • Antibiogram
    • Follow Up
    • 2023 MDM
    • Heart Pathway
    • Jeromy's Macros
  • Education
    • EM Education
    • Critical Care
    • FOAM
  • Orientation
    • Dept Orientation
    • Cerner
    • Dragon
  • Links
    • Clinical Links
    • StatMacros
    • ICU Bootcamp
  • Private
    • MCS
    • GWU Contacts & Map