Vertigo the Big 3

Every ‘heart sink list‘ includes the ‘feeling a bit dizzy, doc‘ presentation. Even with the semantic AI diagnostology probe ramped up to 11…’dizzy‘ remains a word reticent to reveal it’s true identity, until it is too late…

Fear not, for Dr Peter Johns, Canadian emergency physician and dizziness demystifier, has made a video on how to diagnose ‘The Big 3 of Vertigo” in the Emergency Department

The big 3 of vertigo: BPPV; Vestibular neurits; an Cerebellar stroke


Summary:  The Big 3 of Vertigo

Dr Johns advocates an organized approach. If there are concerning neurological features; severe head or neck pain; or the patient is unable to stand, they warrant a CT scan and an inpatient stay.

Patients whose vertigo is initiated by movement and only lasts less than 2 minutes at a time are most likely suffering from benign paroxysmal positional vertigo (BPPV) and would benefit from a Dix-Hallpike test followed by treatment with an Epley maneuver.

It is important to note that patients with BPPV do not have nystagmus at rest, also  HINTS+ testing is not indicated in this population (reserved for patients with hours or days of vertigo at rest).



In the presence of horizontal canal BPPV on the Dix-Hallpike test, the Gufoni maneuver is advised. HINTS+ testing is not indicated in this population (reserved for patients with hours or days of continuous vertigo.)


Patients with protracted vertiginous symptoms (hours to days) warrant a HINTS+ examination and in the presence of positive features they require imaging and admission to look for a CVA.

There are four components of the HINTS+ exam and each component has either a ‘central’ or ‘peripheral’ result. If any of the components tested have a positive central result, the result is described as HINTS+ central.

HINTS+
Peripheral
HINTS+
Central
NystagmusNone/
Unidirectional
Bidirectional
Test of skewNO vertical skewVertical
Head Impulse TestAbnormalNormal
+ Bedside test of hearingNO new lossNew loss

If none of the HINTS+ exam point to a central cause then the patient has vestibular neuritis and may be safely discharged.


Further Reading


Neurological Mind Boggler 700

CLINICAL CASES

Neurological Mind-boggler

Dr Tom Cassidy MBBS FACEM. Emergency physician, Perth Australia. Father of two humans and whimsical lyricist. Special skills: relocating ECGs, reading toxidromes and interpreting dislocations | @tgpcassidyLinkedIn |

2 Comments

  1. Hi Tom, thanks for featuring my approach.

    It’s very important for clinicians to realize that patients with BPPV don’t have nystagmus at rest, and that you can’t use HINTS + exam unless the patient has nystagmus at rest. If you could edit it to include these points, it will prevent a lot of confusion.

    Thanks again,

    Peter Johns

    Ottawa, Canada

  2. 🌸AICA strokes or TIA can mimik like Meniere’s

    And

    🌸PICA strokes can mimik like
    BPPV

    or

    acute unilateral vestibulopathy.

    🌸The most important clue, I think is

    Vascular risk factors
    *Inability to stand*
    Swaying to side with eyes open
    Especially I find that

    *Inability to stand*, tandem gait are really helpful to diagnose a central lesion vs peripheral!

    We can make it HINTSS plus

    The second S for standing!

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