different descriptions (4)
- vertigo
- presyncope
- disequilibrium
- other
questions to ask (5)
- description of sx
- triggers
- timing
- associations
- rx
Vertigo + neuro deficits =
CENTRAL cause until proven otherwise
examples of neuro sx
diplopia - double vision
dysarthria - slurred or slow speech
dysphagia - difficulty swallowing
dysmetria or ataxia - lack of coordination in movement
vertigo and neuro deficits management
MRI + admission
isolated vertigo ddx (ABC)
A: Acute vestibular neuritis (constant) (benign)
B: BPPV - episodic, triggered, brief (benign)
C: central (constant) isolated
HINTS abbreviation meaning
head impulse
nystagmus
test of skew
nystgamus central vs peripheral cause
central:
- vertical
- horizontal bidirectional (looking to one side you get nystgamus and looking to the other one as well)
peripheral:
horizontal unidirectional (you could have have it looking at both directions but it stays unidirectional as the fast component is towards the same side)
head impulse how to do the exam
take head, mouve neck to relax muscles; suddenly mouve 20 degrees while they fix your nose
test of skew how to do
cover the eye and then uncover and cover the one besides
look for VERTICAL skew
Nystagmus how to look for it
1) observe eyes pt looking in front
2) each lateral side, make sure they are not fixating as this can stop the nystagmus (could put a paper)
Head impulse test in a person who DOES NOT HAVE VERTIGO
it is NORMAL to have a NORMAL test aka no saccade
if pt has VERTIGO and NO SACCADE (normal)
this is NOT GOOD
if pt has VERTIGO and SACCADE (Abnormal test)
THIS IS GOOD = nerve prob = vestibular neuritis
Reassuring HINTS exam for someone with vertigo
- unidirecitonal nystagmus
- NO vertical skew
- ABNormal head impluse test
aka saccade
= vestibular neuritis
Worrisome HINTS exam
pt with vertigo and
- bidirectional nystagmus
- Abn test of skew
- Normal head impulse
Which patients do you perform the HITNS exam on
pt with HOURS or DAYS of CONTINUOUS, ONGOING vertigo AND Spontaneous nystagmus
pt in which you perform the HINTS exam AND the Dix-Hallpike
NONE
in which pt to perform the dix hallpike ?
30sec short vertigo initiated by head movement, NO spontaneous nystagmus
dangerous ddx
- stroke
- TIA
- lethal arrhytmia (Vtach)
indications for dix hallpike (5)
no neuro findings
dizziness or vertigo initiated by head movement
short duration
not dizzy if still
no spontaneous nystagmus
how to do the dix-hallpike
head extended 30degrees
turned 45 degrees
sitting to lying down
observe for nystagmus and reproduction of sx (rotatory in affected ear)
wait for 15 sec
CT as an exam is not sensitive to evaluate dizziness - why?
cause we cant see the posterior fossa well - where the dizziness structures are
aka cerebeluum and brainstem
MRI cannot exclude stroke when
within the first 24-48h
pt with nausea, vomiting and dizziness… we miss which dx
posterior strokes
