EMCrit 358 - Dizziness Makes Me Dizzy Still! - GRACE-3 and more with Peter Johns
Sep 24, 2023
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Explore the challenging task of diagnosing posterist stroke and managing dizzy and vertiginous patients in the emergency department. Discuss the 15 recommendations from Grace-3 for patients with dizziness and vestibular disorders. Learn about episodic vestibular syndromes and the importance of performing a comprehensive neuro exam for all dizzy patients. Understand the correct technique for performing the head impulse test and the significance of skew deviation in stroke. Discover the need for a regimented training program and the importance of assessing gait in dizzy patients.
A comprehensive neuro exam is crucial when evaluating patients with dizziness to differentiate between peripheral and central causes and identify stroke risk.
Evaluating a patient's gate and hearing can provide insights into the cause of dizziness and help differentiate between peripheral and central causes.
Central paroxysmal positional vertigo (CPBV) is rare and most cases of positional vertigo are benign and peripheral in origin; thorough assessment and understanding can avoid unnecessary imaging or excessive concern for central causes.
Deep dives
The importance of a comprehensive neuro exam and the hints exam
When evaluating patients with dizziness, it is crucial to conduct a comprehensive neuro exam, including a thorough assessment of the posterior circulation. The hints exam, which involves assessing for nystagmus (with direction and change), test of skew, and abnormal head impulse test, can further aid in determining the cause of dizziness. These exams can help differentiate between peripheral and central causes and identify patients who may be at risk for strokes. It is essential to prioritize these exams before considering imaging or other interventions.
The role of gate and hearing exams in evaluating dizziness
In addition to the neuro and hints exams, evaluating a patient's gate and hearing can provide further insights into the cause of dizziness. Patients with difficulty walking or unsteadiness may warrant additional investigation. The bedside test for hearing, such as rubbing fingers near the ear to check if the patient can hear, can also be valuable. While peripheral causes like vestibular neuritis are often associated with specific gate patterns and hearing loss, it is important to rule out central causes through a comprehensive evaluation.
Addressing misconceptions about central paroxysmal positional vertigo
While central paroxysmal positional vertigo (CPBV) may exist, it is considered rare. Most cases of positional vertigo are typically benign and peripheral in origin, such as benign positional paroxysmal vertigo (BPPV). It is crucial to differentiate between the two by carefully assessing patient symptoms, conducting exams like the Dix Hallpike test, and ruling out central features. By understanding the distinct characteristics and presentation of CPBV, healthcare professionals can confidently manage patients with positional vertigo without unnecessary imaging or excessive concern for central causes.
Overcoming challenges in assessing and diagnosing dizziness
Some healthcare professionals may feel challenged by the intricacies of evaluating and diagnosing dizziness. However, through experience and practice, these skills can be developed. Learning to interpret symptoms, perform key exams, and differentiate between central and peripheral causes can enhance diagnostic accuracy. It is important to prioritize the assessment of dizziness and educate oneself on the various conditions that can present with similar symptoms, such as vestibular migraines and specific types of BPPV. By improving competencies in these areas, healthcare professionals can optimize patient care and avoid unnecessary testing or misdiagnoses.
Takeaways for assessing and managing dizziness
In summary, assessing and managing dizziness involves a comprehensive approach. This includes conducting a thorough neuro exam, performing the hints exam (assessing for nystagmus, skew, and abnormal head impulse), evaluating gate and hearing, and ruling out central causes. While challenges may arise, with experience and learning, healthcare professionals can develop the skills needed to accurately diagnose and manage patients with dizziness. By following a systematic approach and being aware of misconceptions, unnecessary imaging and interventions can be avoided, improving patient outcomes.
