Dizziness is impairment of spatial perception and stability and can be classified as vertigo, presyncope, or disequilibrium.
Differential Diagnosis: (MIDS)
- Benign Paroxysmanl Positional Vertigo (BPPV)
- Vestibular neuritis
- Meniere disease
- Vestibular migraine Cerebrovascular disease
- Cerebellopontine angle and posterior fossa meningiomas
- Sick Sinus
- AV Block
- Acute coronary syndrome
- Orthostatic hypotension/hypovolemia
- Diabetic neuropathy
- Vestibular neuronitis
- Ca-Channel Blockers
- Alcohol intoxication or withdrawal
- Antidementia agents
- Skeletal muscle relaxants
- Urinary anticholinergics
- Digitalis glycosides
- Antithyroid agents
- Cardiac Tamponade
- Impacted Cerumen
- Primary autonomic failure (MS, Parkinsons)
- 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
- 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
- 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
- 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 (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.