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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. What differentiates peripheral from central vertigo?

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As the World Turns: Vertigo in the Emergency Department


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    1. As the World Turns: Vertigo in the Emergency Department

    2. Andrew K. Chang, MD, FACEP Department of Emergency Medicine Albert Einstein College of Medicine Montefiore Medical Center

    3. Teaching points to be addressed • 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?

    4. Case Presentation • 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

    5. Past Medical History & Social History • Hypertension, on atenolol • No surgeries • Nonsmoker, occasional alcohol

    6. Physical Exam • 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

    7. Your Differential Diagnosis?

    8. Differential Diagnosis • Peripheral Vertigo • Benign paroxysmal positional vertigo (BPPV) • Vestibular neuritis • Labyrinthitis • Meniere’s disease • Central Vertigo • Stroke/Vertebrobasilar insufficiency

    9. ED Course • 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

    10. Hallpike Test

    11. Hallpike Video Clip

    12. Nystagmus video clip

    13. ED course • 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

    14. BPPV • Benign Paroxysmal Positional Vertigo • Age • Head trauma

    15. Characteristic story • 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

    16. Dissecting the acronym “BPPV” • “B” = Benign • Not a brain tumor • Can be severe and disabling

    17. Dissecting the acronym “BPPV” • “P” = Paroxysmal • Episodic, not persistent • Helpful feature in the differential diagnosis

    18. Dissecting the acronym “BPPV” • “P” = Positional • Occurs with position of head • Turning over in bed • Looking up • Bending over

    19. Dissecting the acronym “BPPV” • “V” = Vertigo • An illusion of motion • “The room is spinning” • Other descriptions • Rocking • Tilting • Somersaulting • Descending in an elevator

    20. Peripheral CN VIII Vestibular apparatus Central Brain stem Vestibular nuclei in medulla and pons Cerebellum Vertigo

    21. Vertigo PERIPHERAL CENTRAL

    22. Anatomy: Membranous labyrinth • Semicircular canals • Utricle • Endolymph

    23. Anatomy: Semicircular canals • Semicircular Canals (SCC) • Horizontal • Anterior • Posterior • Cupula • End organ receptors • Endolymph

    24. Anatomy: Utricle • Utricle • Connected to SCC • Contains endolymph • Otoliths (otoconia) • Calcium carbonate • Attached to hair cells • Macule (end organ)

    25. Vestibular system • Tells brain which way the head moves without looking • SCC: angular acceleration • Utricle: linear acceleration

    26. Pathophysiology of BPPV • Otoliths become detached from hair cells in utricle • Inappropriately enter the posterior semicircular canal1 1. Parnes LS, McClure JA. Laryngoscope 1992;102:988-92.

    27. Physiology • Normal situation • As one turns head to the right • Endolymph moves SCC receptors fire  “head turning right” • Stop turning head endolymph stops moving  SCC receptors stop firing  “head has stopped moving”

    28. Pathophysiology of BPPV • BPPV • Stop turning head  otoliths keep moving  drag endolymph  receptors continue to fire inappropriately  “head is still moving” • Eyes  “head is NOT moving” • Brain  room must be spinning in the opposite direction

    29. The Epley Maneuver • First described in 19922 • Bedside • > 80% cure rate 2,3 • Immediate relief • Epley J. Otolaryngol Head Neck Surg 1992;107:399-404 • Lynn S, et al. Otolaryngol Head Neck Surg 1995;113:712-20.

    30. Epley maneuver • Canalith repositioning maneuver • 5 step head hanging maneuver • Moves otoliths out of the posterior semicircular canal and back into utricle where they belong

    31. Epley maneuver • 1. Repeat Hallpike • Previously performed diagnostic Hallpike test tells you the starting position (right or left)

    32. Epley maneuver • Turn head 90 degrees in the other direction

    33. Epley maneuver • 3. Patient rolls onto shoulder, rotates head and looks down towards floor

    34. Epley maneuver • 4. Patient sits back up • 5. Head forward

    35. Epley maneuver

    36. Epley maneuver (video clip)

    37. Epley maneuver • Repeating the Epley maneuver • Post procedure • Remain upright for 8-24 hours

    38. The Epley Maneuver • Contraindications4 • 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

    39. Complications • Vomiting • IV promethazine • Converting to horizontal canal BPPV • Bar-b-que maneuver

    40. Lab studies • In a straightforward case, no lab studies are needed! • Hemoglobin • Fingerstick glucose • Electrolytes if prolonged vomiting

    41. Medications • Sensory Conflict Theory • Class A: benzodiazepines • Prevents process of vestibular rehabilitation • Class B: anticholinergic • Scopolamine: takes 4-6 hrs; not effective in ED • Class C: antihistaminic • IV promethazine (Phenergan) • PO meclizine (Antivert)

    42. Consultations • Will depend upon institution (neurology vs. otolaryngology) • If not better with Epley maneuver • If focal neurologic exam

    43. Summary • 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

    44. 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?

    45. 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

    46. 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?

    47. 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 What differentiates BPPVfrom labyrinthitis and vestibular neuritis (VN)?

    48. 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?

    49. Teaching points • What is the treatment of choice for BPPV? • The Epley maneuver (canalith repositioning maneuver)

    50. Questions??? FERNE www.ferne.org andrewkennethchang@hotmail.com