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HKCEM College Tutorial
Dizziness
(Scenario A)
Author
Dr. TW Wong
revised by
Dr. Lam Pui Kin, Rex
Oct., 2013
Scenario A--F/65, DM, HT
▪ Onset
Today, gradual
▪ Provoke
Hx of URI recently
▪ Quality
Spinning sensation +
▪ Relief
Better with eyes closed, worse with neck movement
▪ Severity
Cannot get up
▪ Time
for a few hours already
▪ Associated symptoms: Nausea + vomiting; no tinnitus/hearing loss
▪ Exam: essentially normal
What are the common DDx of vertigo?
▪ CNS problem
▪ Cerebellar stroke
▪ Brain stem stroke
▪ TIA (vertebro-basilar
insufficiency)
▪ CP angle tumor
▪ Demyelination disease
▪ Vestibular migraine
▪ Peripheral
▪
▪
▪
▪
▪
▪
▪
Labyrinthitis
Vestibular neuronitis
BPPV
Meniere’s disease
Ramsay Hunt syndrome
Concussion (labyrinthine)
Acoustic neuroma
Drugs can cause both types of vertigo
Central
Peripheral
▪ Vertigo less intense
▪ More intense
▪ Constant symptom
▪ Paroxysmal acute relapse
▪ Imbalance: severe
▪ Imbalance: milder
▪ Hearing loss and
tinnitus less common
▪ Hearing loss and tinnitus
more common
▪ CNS / Cerebellar sign
+ve
▪ No cerebellar sign
These are NOT INVARIABLE!!!
Otogenic vertigo: DDx matrix
What do you do now?
▪ Symptomatic treatment
▪ investigations...
Vestibular sedatives
▪ Prochlorperazine (Stemetil)
▪
▪
▪
▪
Anti-emetic, phenothiazine group
CNS acting
Not for children
Caution in young adults (dyskinesia)
▪ Dimenhydrinate (Gravol)
▪ First generation antihistamine
▪ Anti-motion sickness (unknown mechanism)
Not
For
Brief
Episodes
▪ Betahistine(Merislon)– antivertigo/selective vasodilator
▪ Diazepam (Valium)—BZD
Beware: not useful if not vestibular ds.
Investigations
▪ Hb
12.4 g/dL
▪ H’stix
7 mmol/L
▪ ECG
ST/T changes
NSR, non-specific
Patient is better but still dizzy after stemetil, what now?
Patient is admitted to EM ward for
further management
▪ BP/P
▪ CBP, L/RFT
▪ Symptomatic treatment
Any special test for vestibular disease?
▪ Dix-Hallpike test (For BPPV only)
▪ Head Thrust Test (to test on the
vestibulo-ocular reflex)
Dix-Hallpike test (Nylen-Barany)
Dix Hallpike test (Nylen-Barany)
Dix-Hallpike: Traditional and Sideway Position
Traditional
position
Sideway
position
Barraclough, Kevin; Bronstein, Adolfo. Vertigo. BMJ. 339:b3493, September 26, 2009
Hallpike test +ve
What manoeuvre can be done?
▪ Canalith-repositioning techniques
▪ The Epley manoeuvre
▪ The Semont manoeuvre
The Epley manoeuvre
Ann Emerg Med. April 2001;37:392-8.
The Semont manoeuvre
Ann Emerg Med. April 2001;37:392-8.
Progress
▪ Patient’s condition gradually improves
▪ Gait is normal
▪ No neurological deficit
▪ Discharge with Stemetil
Who should be referred?
Referral
▪ ENT
▪ unilateral hearing loss
▪ tinnitus
▪ ear discharge etc.
▪ Medical
▪ neck bruit
▪ ? Arrhythmia
▪ ? Cardiac ischemia
▪ headache...
The end
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