Dizziness

Definition

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

Differential Diagnosis

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

History taking

  • 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

Past Medical history

  • 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

Review of systems

  • 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

Physical exam

  • 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

Laboratory work up

  • 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

Diagnostic tests

  • CT head if indicated
  • Puretone Audiometry (PTA)

Management

  • 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)

References

  • 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 (5th 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.

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