Vertigo is a topic covered in the 5-Minute Emergency Consult.

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Emergency Central

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Basics

Description

  • Dizziness, 3–4% of ED visits, difficult symptom to diagnose, describes a variety of experiences, including:
    • Vertigo
    • Weakness, fainting
    • Lightheadedness
    • Unsteadiness
  • Vertigo, a hallucination of movement:
    • Spinning or turning
    • Sensation of movement between the patient and the environment
    • Oscillopsia (illusion of an unstable visual world)
    • Most patients have an organic etiology.
  • Maintenance of equilibrium depends on interaction of 3 systems:
    • Visual
    • Proprioceptive
    • Vestibular
  • Any disease that interrupts the integrity of above systems may give rise to vertigo.
  • Peripheral vertigo:
    • Often, severe symptoms
    • Intermittent episodes lasting seconds to minutes, occasionally hours
    • Horizontal or horizontal–torsional nystagmus (also positional, fatigues, and suppressed by fixation)
    • Normal neurologic exam
    • Sometimes associated hearing loss or tinnitus
  • Central vertigo:
    • Usually mild continuous symptoms
    • All varieties of nystagmus (horizontal, vertical, rotatory)
    • No positional association
    • Presence of neurologic findings most of the time

Etiology

Peripheral
  • Acute peripheral vestibulopathy (APV):
    • Vestibular neuritis (most common):
      • Single acute attack continuous rotational vertigo
      • Constant for several days
      • Present even when still
      • No hearing deficits
      • Highest incidence in 3rd–5th decade
    • Acute labyrinthitis:
      • Similar to vestibular neuritis but:
        • Associated with hearing deficit
        • May be viral (common), serous, acute suppurative, toxic, or chronic
  • Benign paroxysmal positional vertigo (BPPV):
    • Most common cause recurrent vertigo
    • Posterior canal, 85–95% of BPPV cases
    • Lateral semicircular less common
    • Probable cause is loose particles (otoliths) in semicircular canals
    • Can be secondary to other entities including trauma and APV
  • Ototoxic drugs:
    • Aminoglycosides
    • Antimalarials
    • Erythromycin
    • Furosemide
  • Ménière disease:
    • Episodic vertigo, hearing loss, and tinnitus
  • Acoustic neuroma:
    • Tumor of Schwann cells enveloping the 8th cranial nerve (CN VIII)
    • Develops into central cause
    • Progressive unilateral hearing deficits and tinnitus
    • May also involve CN V, VII, or X
  • Trauma:
    • Rupture of tympanic membrane, round window, labyrinthine concussion, or development of perilymphatic fistula can all have severe symptoms.
  • Otitis media and serous otitis with effusion
  • Foreign body in ear canal

Central
  • Vertebrobasilar artery insufficiency:
    • Disturbances may be transient or exacerbated by movement of the neck.
  • Cerebellar infarction
  • Cerebellar hemorrhage:
    • Neurosurgical emergency
    • Sudden onset of headache, vertigo, vomiting, and ataxia
    • Visual paralysis to affected side
    • Ipsilateral CN VI paralysis
  • Multiple sclerosis:
    • Onset between 20–40 yr
    • All forms of nystagmus
    • May have abrupt onset of severe vertigo and vomiting
    • History of other vague and varying neurologic signs or symptoms
  • Brainstem hypertensive encephalopathy
  • Trauma:
    • Vertiginous symptoms common after whiplash injury
    • Postconcussive syndrome or damage to labyrinth or CN VIII secondary to basilar skull fracture
    • Vertebral artery injury has been seen after chiropractic manipulation.
  • Temporal lobe epilepsy:
    • Associated with hallucinations, aphasia, trancelike states, or convulsions
    • More common in younger patients
  • Vertebrobasilar migraines:
    • Prodrome of vertigo, dysarthria, ataxia, visual disturbances, or paresthesias followed by headache
    • Often a family history of migraines or similar attacks
  • Tumor
  • Subclavian steal syndrome:
    • Exercise of an arm causing shunting of blood from vertebral and basilar arteries into the subclavian artery, resulting in vertigo or syncope
    • Secondary to a stenotic subclavian artery
    • Diminished unilateral radial pulse or differential systolic BP between arms
  • Hypoglycemia

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Citation

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TY - ELEC T1 - Vertigo ID - 307049 Y1 - 2016 PB - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307049/all/Vertigo ER -