Transcription
This is a basic, simplified approach to the dizzy patient by me, Peter Johns, an Emergency Physician at the University of Ottawa. Why did I make this presentation? Well, frankly, many emergency physicians cannot reliably diagnose the most common cause of vertigo, which can then lead to ordering CT scans or MRIs, which are expensive and unwarranted.
The reason why they're having difficulty to diagnose is because the textbooks typically emphasized a "is this a central or peripheral cause?" instead of saying, "Well, how do you make a diagnosis?" And also, there are no videos in the textbooks. So, you need to understand and look for the big three of vertigo. And the big three are as follows: BPPV, which is somewhat distressing but curable, and secondly, vestibular neuritis, which is more distressing at times, but unfortunately, no cure. Now, these two conditions, you will see. You've got to understand and be able to diagnose them: BPPV and vestibular neuritis. That's two of the big three. And the big three, of course, the third big three is, of course, cerebellar or stroke, because you don't want to miss a stroke.
So, just to be clear, BPPV and vestibular neuritis are both very common, but they should be easily distinguishable from each other. Cerebellar stroke is much less common but more dangerous and could be written off as vestibular neuritis if you're not careful. So, there's only really two things you have to do with my basic, simplified approach, and that is: First of all, is the patient not dizzy now and has no nystagmus when you assess their gaze? You have them look left or look right, but they have, um, less than one-minute episodes of vertigo brought on by changes of head position. Then you should evaluate them for BPPV. If they have it, you should cure it with something like the Epley maneuver, a particle repositioning maneuver.
Now, contrary, if the patient has ongoing, acute, severe dizziness, otherwise known as acute vestibular syndrome, so they have vertigo, and it's of course, worsened by changes of head position because all vertigo is worse when you change head position, and they have nystagmus when you assess their gaze. If so, then you look for strokes, um, and you do the HINTS exam. If the exam is reassuring, you can discharge these patients home.
Now, you have to understand that this is not an exhaustive differential diagnosis for vertigo. It's an introduction to allow you to make the diagnosis of the most common causes: BPPV and vestibular neuritis. And if you can confidently diagnose BPPV or vestibular neuritis, then you've ruled out stroke as a cause of their dizziness. There are many other conditions which can cause vertigo, but they're not as common as these, and you definitely need to understand the basic concepts here.
So, now we'll talk about the typical presentation of BPPV, which of course, stands for benign paroxysmal positional vertigo. Whenever someone just says BPPV, they're usually talking about posterior canal BPPV, which is the most common cause. We'll talk about another cause in a minute. So, the most important of the "P"s is the paroxysmal component. The episode of vertigo typically lasts 20 or 30 seconds, and in between these episodes or paroxysms, they feel pretty much normal. But they aren't necessarily completely normal. They feel a wee bit off, but they don't have any ongoing significant spinning, or they're not lying there looking sick. And of course, BPPV is positional, which means that it's initiated or started by moving your head, like getting up from bed, going down to lie down, bending over to pick something up, looking up. Also, rolling over in bed is a very typical trigger of BPPV, and it's not very common to trigger other types of dizziness. Again, remember that all vertigo gets worse when you move your head. If you don't get worse when you move your head, you probably don't have vertigo.
So, the vestibular neuritis and cerebellar stroke, their vertigo will worsen with head movement. But BPPV goes from zero dizziness to intense dizziness with head motion, and then goes away if the patient keeps still in less than a minute. Many patients will feel nauseated and sweaty for longer than a minute. So, they might say, "Oh, I was dizzy for 15 minutes or half an hour." But if you question them carefully, they'll just say, "Oh, no, I was spinning. It only lasted for half a minute." So, good questions to ask are: If it came on with a position change, how long do they feel dizzy for? If they stayed perfectly still, would they still be dizzy or spinning? What's the longest time they are continuously spinning for? They say, "I was spinning for the whole morning for three hours." They don't have BPPV.
When you examine these patients, they're usually seated, and you can't really tell that they're being bothered by anything. And when you examine their gaze, when you ask them to look left or right, you will see no sustained nystagmus. So, if you have a patient with brief episodes, 20 or 30 seconds, brought on by head position, position changes, and you have no ongoing dizziness, it goes away when they're still, and you have them look left and right, and you don't see any nystagmus, then you can go ahead and do a Dix-Hallpike test. The Dix-Hallpike test is only used to diagnose posterior canal BPPV. If they don't have BPPV by history, because they are having hours of dizziness, or you can see nystagmus, then the Dix-Hallpike is of no use to them, and it'll probably mislead you because you'll see some kind of atypical response when you do the Dix-Hallpike test.
So, how do I feel about doing a Dix-Hallpike test on patients with ongoing vertigo or spontaneous nystagmus on gaze assessment? You're you might as well waterboard them. You're going to torture them. You're going to make them feel bad. You're not going to learn anything valuable. So, as a Soup Nazi would say, "If you have the nystagmus, no Dix-Hallpike for you."
Now, what do you see when you do a Dix-Hallpike test on someone who has BPPV? Here is a very typical response. The first thing you'll notice is when this lady's in the head-hanging position with her left ear down, is that she has no symptoms for the first two or three seconds. Then you'll note that she has vertical nystagmus, upward. You can look at her pupils and see them as they're jerking upwards, and she has a very nice pigmentation at 12 o'clock on her iris, and you can watch that torting towards her downward left ear, um, as it progresses, and it has a crescendo-decrescendo kind of pattern, and it lasts about 15 seconds. Let's have a look at it. So, she's down now in the Dix-Hallpike position. One, two, three, nothing really happening. Then look at that vertical nystagmus. Pupils going up, up, up, up. And see that little pigmentation on her 12 o'clock on her iris? How it's torting towards the downward ear? We're going to see it then. Now it's gone already. That's 15 seconds. Now you'll see it in slow motion, a little closer up, and see how it's vertical, as vertical and torsional towards the downward ear. If you see this response, there is nothing in the world that will give you this except posterior canal BPPV. So, don't be confused when you see the vertical nystagmus in a Dix-Hallpike test and say, "Wow, you must be a central cause." Because central causes cause a vertical nystagmus. No, that's not it. When you do a Dix-Hallpike test and you see this upward vertical nystagmus with a torsional component towards the downward ear, it's a classic BPPV finding. And don't worry. Now, it is true that if you see spontaneously occurring purely vertical, either upward or downward, nystagmus, it's almost always caused by a central cause. But it's rarely seen. Even if you have a cerebellar stroke in the HINTS study, only 12% of the patients who had a central cause of the vertigo had vertical nystagmus.
So, what do you do if you see a typical positive Dix-Hallpike test in someone who sounds like they have BPPV? Well, it's time to cure them with the Epley maneuver. It only takes about six minutes or less to do. It's about 80% effective if you do it to the right patient, the right way. If you repeat it, it becomes more effective than that. Hmmm. There are other maneuvers which exist, but the Epley is the simplest and the best studied. If you want to know how to do the Epley maneuver, just type "Epley" into the search bar of YouTube, or put my name in there. You'll find my channel, my videos, and you'll see how to diagnose Epley, how to do the Epley maneuver, and the Dix-Hallpike test.
Now, what happens if you have someone that really sounds like BPPV, but but it's a negative Dix-Hallpike, or both sides seem to be some eyes jerking around? It could be horizontal canal BPPV, and that's a little more complicated. If you want to learn more about that, you can look up my YouTube video on how to diagnose and treat horizontal canal BPPV.
Now, why should you do the Epley maneuver? Well, frankly, because you can take a patient who is looking like this. So, we're going to have you turn your head the other way now. No, this way. Yep. Are you ready? Yeah. One, two, three, go. I got the. See, I can't. That's good. That's good. That's good. That's. Oh, no, no, no, no, no. Just keep your head like that. We can cure this. Okay. We can cure this. I can't. You're okay. You're doing good. You're doing good. It's going to go away real soon. Leaving soon. Okay. I know it's up to. Don't move your head. And we did cure this lady without starting an IV, taking blood, doing any imaging, referring her to any specialist, and in fact, arranging any follow-up. She just went home, and she was fine. And you change a patient who looked like that, distressed, poor lady, to somebody who looks like this. Okay. So, you're feeling better? I do feel better. Are you glad we did that? I'm very glad we did. Okay. The Epley maneuver seemed to work. Good. Thank you, Doctor. You're welcome. Now, why would you not want to do the Epley maneuver on somebody when you can get an outcome like that? So, that's the end of part one to my basic, simplified approach to the dizzy patient. And, um, we covered the that F that below. The next part will cover if the patient has ongoing symptoms and nystagmus, what do you do then? Thanks for watching.