Dizziness

Dizziness is impairment of spatial perception and stability and can be classified as vertigo, presyncope, or disequilibrium.

Differential Diagnosis: (MIDS)

Medical/Metabolic/Mental:

• Benign Paroxysmanl Positional Vertigo (BPPV)
• Vestibular neuritis
• Meniere disease
• Otosclerosis
• Vestibular migraine Cerebrovascular disease
• Cerebellopontine angle and posterior fossa meningiomas
• Arrhythmia-Brady/Tachy
• Sick Sinus
• AV Block
• Acute coronary syndrome
• Hyper/Hypoglycemia
• Hyper/Hypothyroidism
• Hyper/Hypothermia
• Hypoxia
• CHF
• Anxiety
• Orthostatic hypotension/hypovolemia
• Dehydration
• Diabetic neuropathy

Infectious/Inflammatory:

• Sepsis
• Encephalitis
• Meningitis
• Vestibular neuronitis

 Drugs:

• Antiarrhythmics
• Anti-Parkinson’s
• Anti-hypdertensives
• Benzodiazepines
• B-Blockers
• Ca-Channel Blockers
• Caffeine
• Alcohol intoxication or withdrawal
• Narcotics
• Vasodilators
• Hyper/Hypokalemia
• Diuretics
• Antidementia agents
• Antiepileptics
• Dipyridamole
• Skeletal muscle relaxants
• Urinary anticholinergics
• Lithium
• Digitalis glycosides
• Antithyroid agents
• Anticoagulants

Structural:

• Cardiac Tamponade
• Impacted Cerumen
• Pneumo/Hemothorax
• Primary autonomic failure (MS, Parkinsons)
• Stroke/TIA

• Follow the OPQRST questions
• Ask about duration of the condition
• Sequence of events- triggers, loss of consciousness
• Asks about relations to posture
• Ask about recent falls
• Ask about losing consciousness
• Associated symptoms:
  • Pallor, diaphoresis, SOB, Chest pain, palpitation, fever/chills,
• Rule out vertigo: Feel like you are spinning or that the room is?
• Rule out syncope or pre-syncope: do you feel like you might black out or you black out?
• Ask about feeling unsteady on their feet or have difficulty maintaining their balance (disequilibrium)
• Is there any history of previous similar events?
• Are you using any medications, herbal products or substance?
• Ask if there was any recent change in medication or dosage
• Do you drink alcohol?
• Ask if client noticed any weakness in limbs
• Ask if there is any change in bowel or bladder habits
• Ask about smoking
• Ask about dietary habits
• Ask if client do any exercise
• Ask about home or workplace stress

• Ask about similar episodes in the past
• Ask about past medical problems (DM, A-fib/arrhythmia, Migraine, Mennier’s Disease, or stroke or cardiac problems)
• Ask about previous hospitalizations

• General: recent weight loss, fever/chills, built, energy level, skin turgor
• ENT: Meniere’s, ear wax, hearing, eye problem
• CNS: headache, weakness, balance/mobility, tremors, head injury
• CVS: palpitation, chest pain, SOB,
• GI: nausea/vomiting, diarrhea,  blood in stool

• Explain to patient what you are going to do
• Obtain their consent
• Wash your hands
• Check vital signs: postural vital signs
• Observe general status: skin color/warmth, level of distress, pallor, diaphoresis, cap refill,
• HEENT exam: examine vision, hearing, ear canals
• CVS- S1 S2, murmurs, respiratory crackles, pedal edema, peripheral pulses
• Neurological  exam- Cranial nerves, Cincinnati scale to r/o stroke,  Dix-Hallpike maneuver
• The Dix-Hallpike maneuver is the gold standard test for the diagnosis of posterior canal BPPV
• Caloric test

• CBC for anemia
• Electrolytes
• eGFR
• ECG for arrhythmia, SVT, conduction delays, …
• Urinalysis: for infections, sepsis, …
• Urinary pregnancy: for hemodynamic instability
• Urinary drug screen if needed

• CT head if indicated
• Puretone Audiometry (PTA)

• Dizziness is a symptom therefore treatment should be directed toward resolving the underlying causes and removing identified triggers.
• Emergent care if acute stroke
• Adequate hydration
• Metoclopramide 5-10 mg po or IM QID
• Prochlorperazine 5-10 mg po or IM, QID
• Meclizine, 12.5 to 50 mg orally every 4 to 8 hours
• Meniere’s disease:
  • Salt restriction
  • Droperidol
  • Diazepam
  • Dimenhydrinate
  • Diphenhydramine
  • Meclizine
  • Anti-vertiginous medications, anti-emetics, sedatives, antidepressants, and psychiatric management have been reported to be beneficial in reducing the severity of vertigo and vegetative symptoms and in improving tolerance of Meniere’s symptoms.
  • Betahistine dihydrochloride 16 mg TID for 2-3 months
• Vestibular neuritis:
  • Prednisone 60-80 mg PO x4 days taper dose over next 10 days
  • Dimenhydrinate 50 to 100 mg every 6 hours
  • Carbamazepine or Cxcarbazepine
  • Promethazine 25 to 50 mg are often required every 4 to 6 hours
• Vertigo (BPPV)
• Antihistamines- Benadryl 50 mg PO Q4-6 hr
• Betahistine (H1 agonist and H3 antagonist) 8-16mg TID
• Dix-Hallpike maneuver(diagnosis and treatment)
• Refer to ENT or neurologist for otoconia repositioning procedure(Epley maneuver)

• Keller, K.B., Sabatino, D., Winland-Brown, J., Porter, B. O. (2015). Cardiovascular problems. In L. Dunphy, J. Winland-Brown, B. Porter, & D. Thomas.Primary care the art and science of advanced nursing practice (4th ed.) (pp.430-432). Philadelphia: F.A. Davis Co.
• Graham M.R. (2013). Neurological problems. In C.R. Uphold & M.R. Graham. Clinical guidelines in family practice (5^th ed). (pp.906-910).Florida: Barmarrae Books Inc.
• Cummings CW, Flit PW, Haughey BH, Robbins KT, Thomas JR, Harker LA, et al., editors: Cummings Otolaryngology: Head and Neck Surgery, 4th ed. Mosby, Inc.; 2005.
• Karlberg M, Annertz M, Magnusson M. Acute vestibular neuritis visualized by 3-T magnetic resonance imaging with high dose gadolinium. Arch Otolaryngol Head Neck Surg. 2004 Feb; 130 (2):229-32.