Dizziness/vertigo

Basics

Dizziness, 3–4% of ED visits, costing US >$4 billion/yr, difficult symptom to diagnose, often misdiagnosed
Patients use various words to describe their experience including:
- Vertigo (the illusory sense of movement)
- Weakness, fainting
- Lightheadedness
- Unsteadiness
Key point: The word that patients use (e.g., vertigo vs. dizziness vs. lightheadedness) is not diagnostically important. It is the timing and triggers that drive the evaluation (see below)
To best find the cause, rather than focusing on the descriptor the patient uses, take a standard history focusing on trying to see if the patient has some toxic-metabolic-infectious cause (e.g., a GI bleed or a systemic infection or a dysrhythmia), which is the case in 50% of ED patients with dizziness
If not obvious cause, use timing and triggers to place the patient into one of 3 categories:
- Acute vestibular syndrome (AVS) – acute onset of continuous dizziness
- Triggered episodic vestibular syndrome (t-EVS) – brief episodes of dizziness triggered, usually by movements of the head or body
- Spontaneous episodic vestibular syndrome (s-EVS) – longer episodes of dizziness not triggered by anything

Toxic-metabolic-infectious causes:
- Toxins and many medications
- Electrolyte disturbances and dehydration
- Systemic infections
- Dysrhythmias
AVS:
- Most common cause – vestibular neuritis and labyrinthitis
- Posterior circulation stroke
- Multiple sclerosis
- Wernicke
Triggered-EVS:
- BPPV
- Orthostatic hypotension
- Rarely central positional paroxysmal vertigo (CPPV)
Spontaneous-EVS:
- Vestibular migraine
- TIA (posterior circulation)
- Ménière disease
- Panic attacks
- Rarely, intermittent low flow states (e.g., dysrhythmias or PE)

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