Medical Excellence- Issue 1

transient or persistent), and tinnitus or aural fullness in the af- fected ear, with other causes excluded [91]. Reflex syncope (also called neurocardiogenic or neurally mediated syncope) includes vasovagal syncope, carotid sinus hypersensitivity, and situational syncope (e.g., micturition, def- ecation, cough) [105]. Those who faint usually experience pro- dromal symptoms; presyncopal spells without loss of conscious- ness substantially outnumber spells with syncope [94]. Dizziness is the most common presyncopal symptom, and it may be of any type, including vertigo [106]. Presyncopal symptoms usually last 3–30 min [107]. Diagnosis is based on clinical history, exclud- ing dangerous mimics (especially arrhythmia), and can be con- firmed by formal head-up tilt table testing [82]. The principal dangerous diagnosis for s-EVS is TIA [93]. Although for years isolated vertigo was considered to not be due to TIA, recent evidence strongly suggests that TIA can present Diagnostic Approach to the Acutely Dizzy Patient Episodic vestibular syndromes^ Examiner can trigger the dizziness at time of exam (triggered-EVS) Examiner cannot trigger the dizziness at time of exam (spontaneous-EVS) Acute vestibular syndrome Test carefully for nystagmus ^ Is there worrisome nystagmus (direction- changing, vertical or torsional)? Is skew-deviation present? Is the general neuro exam abnormal? Yes to any: stroke (or other CNS lesion) Most common cause is vestibular migrane What is the trigger? Meniere’s is much less common standing up is likely orthostatic hypotension Dix-Hallpike maneuver is pc-BPPV Supine head roll is hc-BPPV Worrisome causes of t-EVS include dangerous causes of orthostasis and central (mimic) BPPV called CPPV ^These patients haveone of two episodic vestibular syndromes.At the timeof theexam,when thepatient is notmoving, theyareNOTdizzy. Posterior circulation TIA is most worrisome cause Is patient unable to stand, sit or walk unassisted? No to all: vestibular neuritis Yes Yes Yes Yes Yes No No No No No ^. IMPORTANTCAVEAT : ifnystagmus is absent, do notdo the HIT. It isnot usefuland potentiallymisleading in thesepatients HIT ^ → normal (no corrective saccade)? to be certain nystagmus is absent, remove visual fixation Associate symptoms and context suggest a toxic-metabolic-infectious cause? Yes Symptom/finding Headache Neck pain Chest/back pain Abdominal/back pain ectopic pregnancy, intraabdominal sepsis PE, pneumonia, anemia Dyspnea Palpitations arrhythmia, panic disorder hypovolemia, anemia Bleeding/fluid loss New/changed medications Fever/chills Altered mental status Transient LOC Abnormal glucose symptomatic hypoglycemia, DKA ectopic pregnancy explain them Other abnormal VS * thisgroupaccounts for~50%ofacutely dizzy patients in anED population + pregnancy test arrhythmia , ACS, PE, vasovagal syncope, seizure, hypovolemia stroke, SAH stroke, drug/illicit susbstance intoxication encephalitis, seizure, Wernicke’s syndrome, CO exposure systemic infection meningitis, encephalitis medication side effects or toxicity ACS, PE aortic dissection vascular dissection (especially vertebral artery) stroke, vascular dissection,vestibular migraine meningitis, CO exposure, abnormal intracranial pressure More common causes Rare causes No At the time of exam, with the patient at rest, they are NOT dizzy (t-EVS or s-EVS) At the time of exam, with the patient at rest, they ARE dizzy (i.e., they have acute onset, continuous dizziness - AVS) Associated symptoms and context suggest a toxic-metabolic-infectious cause * Issue-1  |  11 MEDICAL EXCELLENCE