Download As the World Turns: Vertigo in the Emergency Department

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As the World Turns
Andrew K. Chang, MD, FACEP
As the World Turns: Vertigo in
the Emergency Department
Andrew K. Chang, MD, FACEP
Department of Emergency Medicine
Albert Einstein College of Medicine
Montefiore Medical Center
Teaching points to be addressed
Case Presentation
• What differentiates peripheral from
central vertigo?
• What differentiates benign paroxysmal
positional vertigo (BPPV) from other
causes of peripheral vertigo, such as
labyrinthitis and vestibular neuritis?
• What is the treatment of choice for BPPV?
• 67 year-old man
• Rolled over in bed
• After a few seconds delay, he developed
nausea and felt as if the room was spinning
• Symptoms resolved within 30 seconds
• Room spun in the opposite direction when
he rolled back to his original position
Andrew K. Chang, MD
Andrew K. Chang, MD
Past Medical History & Social History
• Hypertension, on atenolol
• No surgeries
• Nonsmoker, occasional alcohol
Physical Exam
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VS: 37.2, 145/85, 90, 18, sat 98%
Alert, anxious
Head, eyes, ears, neck exam: normal
Cardiac exam: normal
Rest of exam: normal
• Neurologic exam (detailed): normal
Andrew K. Chang, MD
Andrew K. Chang, MD
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As the World Turns
Andrew K. Chang, MD, FACEP
Differential Diagnosis
• Peripheral Vertigo
Your Differential Diagnosis?
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Benign paroxysmal positional vertigo (BPPV)
Vestibular neuritis
Labyrinthitis
Meniere’s disease
• Central Vertigo
• Stroke/Vertebrobasilar insufficiency
Andrew K. Chang, MD
ED Course
Hallpike Test
• A diagnostic Hallpike test was performed
• Torsional nystagmus and reproduction of
symptoms in the right head-hanging
position
• Asymptomatic in the left head-hanging
position
Andrew K. Chang, MD
Hallpike Video Clip
Andrew K. Chang, MD
Nystagmus video clip
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As the World Turns
Andrew K. Chang, MD, FACEP
ED course
BPPV
• The Epley maneuver was performed at
the patient’s bedside with complete
resolution of symptoms
• No imaging or lab tests done
• No intravenous line placed
• Length of stay 20 minutes
• Patient very grateful
• Benign Paroxysmal Positional Vertigo
• Age
• Head trauma
Andrew K. Chang, MD
Characteristic story
Andrew K. Chang, MD
Dissecting the acronym “BPPV”
• “B” = Benign
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Turn head
After a few seconds delay, vertigo occurs
Resolves within 1 minute if you don’t move
If you turn your head back, vertigo recurs in
the opposite direction
• Not a brain tumor
• Can be severe and
disabling
Andrew K. Chang, MD
Dissecting the acronym “BPPV”
• “P” = Paroxysmal
Andrew K. Chang, MD
Dissecting the acronym “BPPV”
• “P” = Positional
• Episodic, not persistent
• Helpful feature in the differential diagnosis
Andrew K. Chang, MD
• Occurs with position of head
• Turning over in bed
• Looking up
• Bending over
Andrew K. Chang, MD
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As the World Turns
Andrew K. Chang, MD, FACEP
Dissecting the acronym “BPPV”
• Peripheral
• “V” = Vertigo
• CN VIII
• Vestibular apparatus
• An illusion of motion
• “The room is spinning”
• Other descriptions
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Vertigo
• Central
• Brain stem
• Vestibular nuclei in
medulla and pons
• Cerebellum
Rocking
Tilting
Somersaulting
Descending in an elevator
Andrew K. Chang, MD
Vertigo
PERIPHERAL
Onset
Tinnitus/hearing loss
Sudden
Severe
Paroxysmal
Frequent
Absent
Can be present
Nystagmus
Torsional/horizontal
Nystagmus
Fatigable
Intensity
Duration
Nausea/Diaphoresis
CNS signs
Andrew K. Chang, MD
Anatomy: Membranous labyrinth
CENTRAL
Slow, gradual
Ill defined
Constant
Infrequent
Usually present
Absent
Vertical
Non-fatigable
• Semicircular canals
• Utricle
• Endolymph
Andrew K. Chang, MD
Andrew K. Chang, MD
Anatomy: Semicircular canals
• Semicircular Canals (SCC)
Anatomy: Utricle
• Utricle
• Horizontal
• Anterior
• Posterior
• Connected to SCC
• Contains endolymph
• Otoliths (otoconia)
• Calcium carbonate
• Attached to hair cells
• Macule (end organ)
• Cupula
• End organ receptors
• Endolymph
Andrew K. Chang, MD
Andrew K. Chang, MD
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As the World Turns
Andrew K. Chang, MD, FACEP
Vestibular system
• Tells brain which way the head moves
without looking
• SCC: angular acceleration
• Utricle: linear acceleration
Andrew K. Chang, MD
Physiology
• Otoliths become
detached from hair
cells in utricle
• Inappropriately enter
the posterior
semicircular canal1
1. Parnes LS, McClure JA. Laryngoscope 1992;102:988-92.
Andrew K. Chang, MD
Pathophysiology of BPPV
• Normal situation
• BPPV
• As one turns head to the right
• Endolymph moves ÆSCC receptors fire Æ
“head turning right”
• Stop turning headÆ endolymph stops
moving Æ SCC receptors stop firing Æ
“head has stopped moving”
Andrew K. Chang, MD
The Epley Maneuver
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Pathophysiology of BPPV
• Stop turning head Æ otoliths keep moving Æ
drag endolymph Æ receptors continue to
fire inappropriately Æ “head is still moving”
• Eyes Æ “head is NOT moving”
• Brain Æ room must be spinning in the
opposite direction
Andrew K. Chang, MD
Epley maneuver
• Canalith repositioning maneuver
• 5 step head hanging maneuver
First described in 19922
Bedside
> 80% cure rate 2,3
Immediate relief
• Moves otoliths out of the posterior
semicircular canal and back into utricle
where they belong
2.
3.
Epley J. Otolaryngol Head Neck Surg 1992;107:399-404
Lynn S, et al. Otolaryngol Head Neck Surg 1995;113:712-20.
Andrew K. Chang, MD
Andrew K. Chang, MD
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As the World Turns
Andrew K. Chang, MD, FACEP
Epley maneuver
Epley maneuver
• 1. Repeat Hallpike
• Previously performed
diagnostic Hallpike test
tells you the starting
position (right or left)
• Turn head 90
degrees in the other
direction
Andrew K. Chang, MD
Epley maneuver
• 3. Patient rolls onto
shoulder, rotates
head and looks down
towards floor
Andrew K. Chang, MD
Epley maneuver
• 4. Patient sits back
up
• 5. Head forward
Andrew K. Chang, MD
Epley maneuver
Andrew K. Chang, MD
Andrew K. Chang, MD
Epley maneuver (video clip)
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As the World Turns
Andrew K. Chang, MD, FACEP
Epley maneuver
The Epley Maneuver
• Contraindications4
• Repeating the Epley maneuver
• Post procedure
• Remain upright for 8-24 hours
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Unstable heart disease
High grade carotid stenosis
Severe neck disease
Ongoing CNS disease (TIA/stroke)
Pregnancy beyond 24th week gestation
(relative)
4. Furman JM, Cass SP. N Engl J Med 1999;341:1590-96
Andrew K. Chang, MD
Complications
• Vomiting
Andrew K. Chang, MD
Lab studies
• In a straightforward case, no lab studies
are needed!
• IV promethazine
• Converting to horizontal canal BPPV
• Bar-b-que maneuver
• Hemoglobin
• Fingerstick glucose
• Electrolytes if prolonged vomiting
Andrew K. Chang, MD
Medications
Andrew K. Chang, MD
Consultations
• Sensory Conflict Theory
• Will depend upon institution (neurology
vs. otolaryngology)
• Class A: benzodiazepines
• Prevents process of vestibular rehabilitation
• Class B: anticholinergic
• Scopolamine: takes 4-6 hrs; not effective in ED
• If not better with Epley maneuver
• If focal neurologic exam
• Class C: antihistaminic
• IV promethazine (Phenergan)
• PO meclizine (Antivert)
Andrew K. Chang, MD
Andrew K. Chang, MD
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As the World Turns
Andrew K. Chang, MD, FACEP
Summary
Teaching points
• BPPV may be a severe and incapacitating
disease
• Diagnosis via history, nonfocal neurological
exam, and a positive Hallpike test
• Treatment is with the Epley maneuver
• IV promethazine (Phenergan) is probably
the best ED medication if one is needed
• What differentiates peripheral from central
vertigo?
• What differentiates benign paroxysmal
position vertigo (BPPV) from other cause
of peripheral vertigo, such as labyrinthitis
and vestibular neuritis?
• What is the treatment of choice for BPPV?
Andrew K. Chang, MD
Teaching points
• What differentiates peripheral from
central vertigo?
• Peripheral vertigo is more intense, has a
sudden onset, is paroxysmal, has
fatigable and rotatory nystagmus, and
has a nonfocal neurological examination
Andrew K. Chang, MD
What differentiates BPPV from labyrinthitis and
vestibular neuritis (VN)?
• BPPV
• Requires head
movement
• Duration of seconds
• Usually in elderly
• No relation to viral
syndrome
• Responds to Epley
maneuver
• Labyrinthitis/VN
• No head movement
needed
• Duration of hours/days
• Any age
• Viral syndrome usually
precedes
• Epley maneuver is
ineffective
Andrew K. Chang, MD
Andrew K. Chang, MD
Teaching points
• What differentiates peripheral from central
vertigo?
• What differentiates benign paroxysmal
position vertigo (BPPV) from other cause
of peripheral vertigo, such as labyrinthitis
and vestibular neuritis?
• What is the treatment of choice for BPPV?
Andrew K. Chang, MD
Teaching points
• What differentiates peripheral from central
vertigo?
• What differentiates benign paroxysmal
position vertigo (BPPV) from other cause
of peripheral vertigo, such as labyrinthitis
and vestibular neuritis?
• What is the treatment of choice for BPPV?
Andrew K. Chang, MD
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As the World Turns
Andrew K. Chang, MD, FACEP
Teaching points
• What is the treatment of choice for BPPV?
• The Epley maneuver (canalith
repositioning maneuver)
Questions???
FERNE
www.ferne.org
[email protected]
Andrew K. Chang, MD