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

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

3. 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

4. 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

5. 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

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

7. Central causes Cerebellar stroke Brainstem stroke Drug toxicity
Lateral Medullary Syndrome

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

9. HINTS Exam

10. 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.