1. As the World Turns: Vertigo in the Emergency Department

2. Andrew K. Chang, MD, FACEP Department of Emergency Medicine Albert Einstein College of Medicine Montefiore Medical Center

3. Andrew K. Chang, MD Teaching points to be addressed What differentiates peripheral from central vertigo? What differentiates benign paroxysmal positional vertigo (BPPV) from other causes of peripheral vertigo, such as labyrinthitis and vestibular neuritis? What is the treatment of choice for BPPV?

4. Andrew K. Chang, MD Case Presentation 67 year-old man Rolled over in bed After a few seconds delay, he developed nausea and felt as if the room was spinning Symptoms resolved within 30 seconds Room spun in the opposite direction when he rolled back to his original position

5. Andrew K. Chang, MD Past Medical History & Social History Hypertension, on atenolol No surgeries Nonsmoker, occasional alcohol

6. Andrew K. Chang, MD Physical Exam VS: 37.2, 145/85, 90, 18, sat 98% Alert, anxious Head, eyes, ears, neck exam: normal Cardiac exam: normal Rest of exam: normal Neurologic exam (detailed): normal

7. Your Differential Diagnosis?

8. Andrew K. Chang, MD Differential Diagnosis Peripheral Vertigo Benign paroxysmal positional vertigo (BPPV) Vestibular neuritis Labyrinthitis Meniere’s disease Central Vertigo Stroke/Vertebrobasilar insufficiency

9. Andrew K. Chang, MD ED Course A diagnostic Hallpike test was performed Torsional nystagmus and reproduction of symptoms in the right head-hanging position Asymptomatic in the left head-hanging position

10. Andrew K. Chang, MD Hallpike Test

11. Hallpike Video Clip

12. Nystagmus video clip

13. Andrew K. Chang, MD ED course The Epley maneuver was performed at the patient’s bedside with complete resolution of symptoms No imaging or lab tests done No intravenous line placed Length of stay 20 minutes Patient very grateful

14. Andrew K. Chang, MD BPPV Benign Paroxysmal Positional Vertigo Age Head trauma

15. Andrew K. Chang, MD Characteristic story Turn head After a few seconds delay, vertigo occurs Resolves within 1 minute if you don’t move If you turn your head back, vertigo recurs in the opposite direction

16. Andrew K. Chang, MD Dissecting the acronym “ B PPV” “B” = Benign Not a brain tumor Can be severe and disabling

17. Andrew K. Chang, MD Dissecting the acronym “B P PV” “P” = Paroxysmal Episodic, not persistent Helpful feature in the differential diagnosis

18. Andrew K. Chang, MD Dissecting the acronym “BP P V” “P” = Positional Occurs with position of head Turning over in bed Looking up Bending over

19. Andrew K. Chang, MD Dissecting the acronym “BPP V ” “V” = Vertigo An illusion of motion “The room is spinning” Other descriptions Rocking Tilting Somersaulting Descending in an elevator

20. Andrew K. Chang, MD Vertigo Peripheral CN VIII Vestibular apparatus Central Brain stem Vestibular nuclei in medulla and pons Cerebellum

21. Andrew K. Chang, MD Vertigo Onset SuddenSlow, gradual Intensity SevereIll defined Duration ParoxysmalConstant Nausea/Diaphoresis FrequentInfrequent CNS signs AbsentUsually present Tinnitus/hearing loss Can be presentAbsent Nystagmus Torsional/horizontal Vertical Nystagmus FatigableNon-fatigable PERIPHERALCENTRAL

22. Andrew K. Chang, MD Anatomy: Membranous labyrinth Semicircular canals Utricle Endolymph

23. Andrew K. Chang, MD Anatomy: Semicircular canals Semicircular Canals (SCC) Horizontal Anterior Posterior Cupula End organ receptors Endolymph

24. Andrew K. Chang, MD Anatomy: Utricle Utricle Connected to SCC Contains endolymph Otoliths (otoconia) Calcium carbonate Attached to hair cells Macule (end organ)

25. Andrew K. Chang, MD Vestibular system Tells brain which way the head moves without looking SCC: angular acceleration Utricle: linear acceleration

26. Andrew K. Chang, MD Pathophysiology of BPPV Otoliths become detached from hair cells in utricle Inappropriately enter the posterior semicircular canal 1 1. Parnes LS, McClure JA. Laryngoscope 1992;102:988-92.

27. Andrew K. Chang, MD Physiology Normal situation As one turns head to the right Endolymph moves  SCC receptors fire  “head turning right” Stop turning head  endolymph stops moving  SCC receptors stop firing  “head has stopped moving”

28. Andrew K. Chang, MD Pathophysiology of BPPV BPPV Stop turning head  otoliths keep moving  drag endolymph  receptors continue to fire inappropriately  “head is still moving” Eyes  “head is NOT moving” Brain  room must be spinning in the opposite direction

29. Andrew K. Chang, MD The Epley Maneuver First described in 1992 2 Bedside > 80% cure rate 2,3 Immediate relief 2.Epley J. Otolaryngol Head Neck Surg 1992;107:399-404 3.Lynn S, et al. Otolaryngol Head Neck Surg 1995;113:712-20.

30. Andrew K. Chang, MD Epley maneuver Canalith repositioning maneuver 5 step head hanging maneuver Moves otoliths out of the posterior semicircular canal and back into utricle where they belong

31. Andrew K. Chang, MD Epley maneuver 1. Repeat Hallpike Previously performed diagnostic Hallpike test tells you the starting position (right or left)

32. Andrew K. Chang, MD Epley maneuver Turn head 90 degrees in the other direction

33. Andrew K. Chang, MD Epley maneuver 3. Patient rolls onto shoulder, rotates head and looks down towards floor

34. Andrew K. Chang, MD Epley maneuver 4. Patient sits back up 5. Head forward

35. Andrew K. Chang, MD Epley maneuver

36. Epley maneuver (video clip)

37. Andrew K. Chang, MD Epley maneuver Repeating the Epley maneuver Post procedure Remain upright for 8-24 hours

38. Andrew K. Chang, MD The Epley Maneuver Contraindications 4 Unstable heart disease High grade carotid stenosis Severe neck disease Ongoing CNS disease (TIA/stroke) Pregnancy beyond 24 th week gestation (relative) 4. Furman JM, Cass SP. N Engl J Med 1999;341:1590-96

39. Andrew K. Chang, MD Complications Vomiting IV promethazine Converting to horizontal canal BPPV Bar-b-que maneuver

40. Andrew K. Chang, MD Lab studies In a straightforward case, no lab studies are needed! Hemoglobin Fingerstick glucose Electrolytes if prolonged vomiting

41. Andrew K. Chang, MD Medications Sensory Conflict Theory Class A: benzodiazepines Prevents process of vestibular rehabilitation Class B: anticholinergic Scopolamine: takes 4-6 hrs; not effective in ED Class C: antihistaminic IV promethazine (Phenergan) PO meclizine (Antivert)

42. Andrew K. Chang, MD Consultations Will depend upon institution (neurology vs. otolaryngology) If not better with Epley maneuver If focal neurologic exam

43. Andrew K. Chang, MD Summary BPPV may be a severe and incapacitating disease Diagnosis via history, nonfocal neurological exam, and a positive Hallpike test Treatment is with the Epley maneuver IV promethazine (Phenergan) is probably the best ED medication if one is needed

44. Andrew K. Chang, MD Teaching points What differentiates peripheral from central vertigo? What differentiates benign paroxysmal position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis? What is the treatment of choice for BPPV?

45. Andrew K. Chang, MD Teaching points What differentiates peripheral from central vertigo? Peripheral vertigo is more intense, has a sudden onset, is paroxysmal, has fatigable and rotatory nystagmus, and has a nonfocal neurological examination

46. Andrew K. Chang, MD Teaching points What differentiates peripheral from central vertigo? What differentiates benign paroxysmal position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis? What is the treatment of choice for BPPV?

47. Andrew K. Chang, MD What differentiates BPPV from labyrinthitis and vestibular neuritis (VN)? BPPV Requires head movement Duration of seconds Usually in elderly No relation to viral syndrome Responds to Epley maneuver Labyrinthitis/VN No head movement needed Duration of hours/days Any age Viral syndrome usually precedes Epley maneuver is ineffective

48. Andrew K. Chang, MD Teaching points What differentiates peripheral from central vertigo? What differentiates benign paroxysmal position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis? What is the treatment of choice for BPPV?

49. Andrew K. Chang, MD Teaching points What is the treatment of choice for BPPV? The Epley maneuver (canalith repositioning maneuver)

50. Questions??? FERNE www.ferne.orgwww.ferne.org andrewkennethchang@hotmail.com