as the world turns vertigo in the emergency department n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
As the World Turns: Vertigo in the Emergency Department PowerPoint Presentation
Download Presentation
As the World Turns: Vertigo in the Emergency Department

Loading in 2 Seconds...

play fullscreen
1 / 50

As the World Turns: Vertigo in the Emergency Department - PowerPoint PPT Presentation


  • 252 Views
  • Uploaded on

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?

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'As the World Turns: Vertigo in the Emergency Department' - salena


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide2

Andrew K. Chang, MD, FACEP

Department of Emergency Medicine

Albert Einstein College of Medicine

Montefiore Medical Center

teaching points to be addressed
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?
case presentation
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
past medical history social history
Past Medical History & Social History
  • Hypertension, on atenolol
  • No surgeries
  • Nonsmoker, occasional alcohol
physical exam
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
differential diagnosis
Differential Diagnosis
  • Peripheral Vertigo
    • Benign paroxysmal positional vertigo (BPPV)
    • Vestibular neuritis
    • Labyrinthitis
    • Meniere’s disease
  • Central Vertigo
    • Stroke/Vertebrobasilar insufficiency
ed course
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
ed course1
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
slide14
BPPV
  • Benign Paroxysmal Positional Vertigo
  • Age
  • Head trauma
characteristic story
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
dissecting the acronym b ppv
Dissecting the acronym “BPPV”
  • “B” = Benign
    • Not a brain tumor
    • Can be severe and disabling
dissecting the acronym b p pv
Dissecting the acronym “BPPV”
  • “P” = Paroxysmal
    • Episodic, not persistent
    • Helpful feature in the differential diagnosis
dissecting the acronym bp p v
Dissecting the acronym “BPPV”
  • “P” = Positional
    • Occurs with position of head
      • Turning over in bed
      • Looking up
      • Bending over
dissecting the acronym bpp v
Dissecting the acronym “BPPV”
  • “V” = Vertigo
    • An illusion of motion
    • “The room is spinning”
    • Other descriptions
      • Rocking
      • Tilting
      • Somersaulting
      • Descending in an elevator
vertigo
Peripheral

CN VIII

Vestibular apparatus

Central

Brain stem

Vestibular nuclei in medulla and pons

Cerebellum

Vertigo
vertigo1
Vertigo

PERIPHERAL

CENTRAL

anatomy membranous labyrinth
Anatomy: Membranous labyrinth
  • Semicircular canals
  • Utricle
  • Endolymph
anatomy semicircular canals
Anatomy: Semicircular canals
  • Semicircular Canals (SCC)
    • Horizontal
    • Anterior
    • Posterior
  • Cupula
    • End organ receptors
  • Endolymph
anatomy utricle
Anatomy: Utricle
  • Utricle
    • Connected to SCC
    • Contains endolymph
    • Otoliths (otoconia)
      • Calcium carbonate
      • Attached to hair cells
      • Macule (end organ)
vestibular system
Vestibular system
  • Tells brain which way the head moves without looking
    • SCC: angular acceleration
    • Utricle: linear acceleration
pathophysiology of bppv
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.

physiology
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”
pathophysiology of bppv1
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
the epley maneuver
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.
epley maneuver
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
epley maneuver1
Epley maneuver
  • 1. Repeat Hallpike
    • Previously performed diagnostic Hallpike test tells you the starting position (right or left)
epley maneuver2
Epley maneuver
  • Turn head 90 degrees in the other direction
epley maneuver3
Epley maneuver
  • 3. Patient rolls onto shoulder, rotates head and looks down towards floor
epley maneuver4
Epley maneuver
  • 4. Patient sits back up
  • 5. Head forward
epley maneuver6
Epley maneuver
  • Repeating the Epley maneuver
  • Post procedure
    • Remain upright for 8-24 hours
the epley maneuver1
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

complications
Complications
  • Vomiting
    • IV promethazine
  • Converting to horizontal canal BPPV
    • Bar-b-que maneuver
lab studies
Lab studies
  • In a straightforward case, no lab studies are needed!
  • Hemoglobin
  • Fingerstick glucose
  • Electrolytes if prolonged vomiting
medications
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)
consultations
Consultations
  • Will depend upon institution (neurology vs. otolaryngology)
  • If not better with Epley maneuver
  • If focal neurologic exam
summary
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
teaching points
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?
teaching points1
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
teaching points2
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?
what differentiates bppv from labyrinthitis and vestibular neuritis vn
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)?
teaching points3
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?
teaching points4
Teaching points
  • What is the treatment of choice for BPPV?
  • The Epley maneuver (canalith repositioning maneuver)
questions
Questions???

FERNE www.ferne.org

andrewkennethchang@hotmail.com