David Johnson Staff Specialist, Emergency Medicine Dizziness David Johnson Staff Specialist, Emergency Medicine

Dizziness Need to decide is this Vertigo Lightheadedness/presyncope Central Peripheral Lightheadedness/presyncope Sepsis Drugs Cardiac Anxiety

Vertigo History Sensation of motion 1/3 of cases unable to determine Room spinning Patient spinning “swimming” or “floating” 1/3 of cases unable to determine

Peripheral vs central Peripheral Central Sudden onset Nystagmus – horizontal or rotatory, fixed direction Fast towards affected ear Hearing loss Nausea, diaphoresis Positive head impulse Negative skew Slower onset – mostly Less nystagmus. May be vertical Does not fatigue Persists with fixation Usually other neuro signs or headache Often impaired balance Negative head impulse Positive skew

BPPV Most common cause of vertigo Very sudden onset, often after being supine Vertigo on head turning, not when head is still Duration of vertigo <1 min for each episode If this is not the story, do not make the diagnosis

Other peripheral causes Viral labyrinthitis Constant +/- viral infection +/- hearing loss Meniere’s Tinnitus/aural fullness Acoustic neuroma Suppurative labyrinthitis

Central causes Cerebellar stroke Brainstem stroke Drug toxicity Lateral Medullary Syndrome

Physical exam Full neurological exam Cerebellar signs Ears, Weber/Rinne HINTS exam Head impulse Nystagmus Test of skew

HINTS Exam

Investigations MRI CT has sensitivity approx 16% for posterior fossa disease If you are worried get an MRI. If you are not worried do no imaging.