Dizziness

Dizziness is a very challenging presentation in Emergency. Ask any boss or registrar. It could simply be BPPV. Or it could be a stroke. The difference comes down to your history and examination - investigations for dizziness in Emergency will rarely help you. The aim of this blog is to help guide you in understanding what to ask and how to examine your patient correctly.

History

A lot of people can’t tell you what they’re experiencing when they have dizziness. I end up asking several questions to get a sense of my patient’s symptoms.

• Do you feel light-headed like you’re going to faint?

• Is the room spinning as if you are drunk?

• Does it feel like you’re unsteady as if you’re standing on a boat?

These questions can help distinguish symptoms of pre-syncope from vertiginous symptoms. If your patient has pre-syncopal symptoms then you need to go down a different pathway. This blog focuses on patients with symptoms of vertigo.

And vertigo is indeed a symptom, not a diagnosis. We need to ask more questions and complete a careful exam to distinguish what this could be. When I’m sure that my patient has vertiginous symptoms, I am trying to get one crucial piece of information from my patient:

• Are your symptoms constant or do they resolve at rest?

This question is tricky because everyone’s symptoms worsen when they move their head or stand up, regardless of if they’re constant or intermittent. You need to ask many questions in different ways to clarify this.

• If you lie still on the bed with your eyes closed do your symptoms go away completely? Or are they still there?

• Do your symptoms come and go or have they been constant since they started?

And other important questions:

• Have you ever had this before? Beware new vertigo in anyone older than 50, that’s quite unusual.

• Do you have a headache? Frequently occur in posterior circulation strokes.

• What were you doing at the very moment this started?

Examination

It is obviously helpful to do a neurological examination. Do a full exam but we’re particularly looking for subtle cerebellar signs.

• Can your patient sit on the edge of the bed with their arms crossed? (truncal ataxia)

• Any dysmetria, dysarthria, dysdiadochokinesia?

If you find any obvious neurological deficits involve your senior sooner rather than later. Your patient may be suffering a stroke and will need a workup accordingly.

There are of course two specific exams we need to talk about – the Dix-Hallpike and the HINTS+ examination. These exams are looking for completely different things and should be done under different situations. They should not be done on the same patient for fear of false positives.

• The Dix-Hallpike should be done for patients who have intermittent vertigo. These patients should not have nystagmus while at rest.

• The HINTS+ examination should be done for patients with hours or days of constant vertiginous symptoms that never resolve. These patients should have nystagmus at rest.

Dix-Hallpike

Indications – intermittent vertigo brought on by head movement. The patient should not have nystagmus while at rest.

Before you start, hand your patient a vomit bag. Yes, really.

There are some great resources online with pictures already that you can look at showing exactly how to complete this examination. Importantly, you are trying to elicit rotational or rotatory or torsional nystagmus (all words describing the same thing). Dr Peter John’s lecture below explains this in more depth and has some terrific videos demonstrating this finding.

If you have found torsional nystagmus, congratulations! You’ve diagnosed BPPV. Do your patient a favour and treat them with the Epley’s manoeuvre:

This is the classical form of BPPV affecting the posterior canal. Less commonly you can find a horizontal canal BPPV. A patient’s symptoms will sound similar, but they will have a negative Dix-Hallpike test. The test for horizontal canal BPPV is quite simple – the supine roll test. Dr John again holds court:

You should see horizontal nystagmus that always beats towards the floor or always beats towards the ceiling (geotropic or apogeotropic). The Gufoni manoeuvre demonstrated in the video above can help treat these patients.

Even when you do everything right, your patient may just be too nauseous to tolerate your examination or keep their eyes open. They may need more help for formal diagnosis like a vertigo clinic appointment. 

HINTS+

Indications – constant vertigo for hours or days. To complete the full exam, you need to demonstrate that the patient has nystagmus at rest.

The HINTS+ exam has some impressive stats behind it. The derivation paper that first described this examination in 2009 showed that in the right patient it has a 100% sensitivity and 96% specificity for diagnosing strokes [1]. The problem is people do this examination wrong all the time – they interpret the results poorly or they apply it to the wrong patient. This test is trying to pick up subtle strokes that can mimic other causes of constant vertigo like vestibular neuritis.

HINTS+ stands for:

• Head impulse test

• Nystagmus (at rest)

• Test of skew

• +/- Hearing loss

Nystagmus should be observed with the patient looking straight forward, then to the left and the right. You must find nystagmus at rest to complete the rest of the exam. If the patient has NO nystagmus, then stop here.

The head impulse test is about showing if a patient continues to track a stationary object when their head is moved suddenly. The test of skew is about seeing if there is any vertical correction to a person’s gaze when blocking one eye at a time (everyone will have a small degree of horizontal correction).

These examination findings are subtle and specific. Watching videos is much more helpful than reading me harp on about it. I’ll let Dr Johns teach you again. Some excellent findings are shown from minute 8:00:

How do we interpret our results? Have a look at this table. Counterintuitively, the head impulse test should be abnormal in someone who has a peripheral cause (i.e. a benign cause).

A peripheral cause might be something like vestibular neuritis or labyrinthitis. A central cause implies a small posterior stroke, and these patients will need a full stroke work-up and usually an admission.

If you complete this exam in the wrong patient, you will get false positives. If you do a HINTS+ exam on a patient with BPPV:
1. You should stop at the first step because they should not have nystagmus at rest and
2. You will get a “normal” head impulse test which suggests a central cause of vertigo (like a stroke). 

Someone who has BPPV obviously is not having a stroke. In this situation, HINTS+ is not helpful.

Unfortunately, about only half of posterior circulation strokes will present with nystagmus at rest. That’s why we do a full neurological exam, to pick up other more obvious signs of a stroke.

Treatment

A lot of emergency departments will use stemetil (prochlorperazine) in the treatment of vertigo. This antiemetic and antipsychotic medication will help improve short term symptoms and may help you complete the examinations you need to. That being said, it’s not recommended in any vertigo guideline. The treatment for BPPV are canalith repositioning manoeuvres. Many patients are discharged with stemetil and their symptoms never improve because the importance of these manoeuvres was never explained. Be cautious in long term stemetil – this is a band-aid solution.

Many patients find these manoeuvres uncomfortable and need more help. There are many physiotherapists specialising in vertigo and can complete vestibular rehabilitation therapy. If you’re lucky you may also be close to a vertigo clinic which can use a rotundum positioning chair to diagnose the precise kind of BPPV your patient has and treat it accordingly.

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