Medical Excellence- Issue 1

with dizziness, even isolated attacks of vertigo [108]. TIAs can present with isolated episodes of dizziness weeks to months or even years prior to a completed infarction [109, 110]. Dizziness is the most common symptom in basilar artery occlusion [111] and occurs without other neurological symptoms in 20% of cases [112]. Dizziness is the most common presenting symptom of vertebral artery dissection [113], which affects younger patients, mimics migraine, and is easily misdiagnosed [5]. Because 5% of TIA patients suffer a stroke within 48 h, prompt diagnosis is criti- cal [114]. Patients with posterior circulation TIA may have an even higher stroke risk than those with anterior circulation spells [115, 116]. Rapid treatment lowers stroke risk after TIA by about 80% [117, 118]. Cardiac arrhythmias should also be considered in any patient with spontaneous EVS, particularly when syncope occurs [24]. Although some clinical features may increase or decrease the odds of a cardiac cause [105], additional testing (e.g., cardiac loop recording) is often required to confirm the final diagnosis [82]. Putting It All Together: An Overarching Algorithm Taking a history of a dizzy patient should be no different than taking a history in nearly any other patient. The timing, trig- gers of the dizziness (and not the descriptor used), as well as the evolution of the symptoms, associated symptoms, and epi- demiologic context inform the differential diagnosis. Bedsides, physical examination can frequently establish a specific diagno- sis. This newer paradigm (see Figure on Page 11) has not yet been validated in large numbers of ED patients treated by emergency physicians, but current evidence and experience suggest that this is possible. Conclusions Dizziness, vertigo, and unsteadiness are extremely common complaints caused by numerous diseases that span organ systems. Diagnosis can therefore be difficult, a fact leading to over utilization of resources and misdiagnosis. The current para- digm used by most physicians is based on symptom quality, a paradigm created 40 years ago; a newer paradigm, based on timing and triggers, is more consistent with current evidence. History and physical examination is more accurate, more effi- cient, and more likely to result in a specific diagnosis than the traditional paradigm. Pearls and Pitfalls zz The timing and triggers of a patient’s dizziness are much more important than the word that a patient uses to describe their dizziness (e.g., “vertigo” versus “light-headed” versus “imbalance”). zz In patients with an acute vestibular syndrome (nausea or vomiting, gait instability, nystagmus, and head-motion in- tolerance that lasts days or weeks and gradually improving), physical examination allows better distinction between ves- tibular neuritis and stroke (the two most common causes) than MRI during the first 2 days of illness. zz Patients with BPPV can be diagnosed and treated using bedside maneuvers (Dix-Hallpike and Epley maneuvers) without the need for imaging or consultation. References 1. Cheung CS, Mak PS, Manley KV, et al. Predictors of important neurological causes of dizziness among patients presenting to the emergency department. EMJ. 2010;27:517–21. 2. Newman-Toker DE, Hsieh YH, Camargo CA Jr, Pelletier AJ, Butchy GT, Edlow JA. Spectrum of dizziness visits to US emergency depart- ments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008;83:765–75. 3. Saber Tehrani AS, Coughlan D, Hsieh YH, et al. Rising annual costs of dizziness presentations to U.S. emergency departments. Acad Emerg Med. 2013;20:689–96. 4. Improving diagnosis in health care. Washington, DC: National Acad- emies Press; 2015. 5. Savitz SI, Caplan LR, Edlow JA. Pitfalls in the diagnosis of cerebellar infarction. Acad Emerg Med. 2007;14:63–8. 6. Newman-Toker DE, Edlow JA. TiTrATE: a novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurol Clin. 2015;33:577–99, viii. 7. Newman-Toker DE, Camargo CA Jr, Hsieh YH, Pelletier AJ, Edlow JA. Disconnect between charted vestibular diagnoses and emergency department management decisions: a cross-sectional analysis from a nationally representative sample. Acad Emerg Med. 2009;16:970–7. 8. Cooper H, Bhattacharya B, Verma V, McCulloch AJ, Smellie WS, Heald AH. Liquorice and soy sauce, a life-saving concoction in a patient with Addison’s disease. Ann Clin Biochem. 2007;44:397–9. 9. Demiryoguran NS, Karcioglu O, Topacoglu H, Aksakalli S. Painless aortic dissection with bilateral carotid involvement presenting with vertigo as the chief complaint. Emerg Med J. 2006;23:e15. 10. Heckerling PS, Leikin JB, Maturen A, Perkins JT. Predictors of occult carbon monoxide poisoning in patients with headache and dizzi- ness. Ann Intern Med. 1987;107:174–6. 11. Wolfe TR, Allen TL. Syncope as an emergency department presenta- tion of pulmonary embolism. J Emerg Med. 1998;16:27–31. 12. Choi KD, Oh SY, Kim HJ, Kim JS. The vestibulo-ocular reflexes during head impulse in Wernicke’s encephalopathy. J Neurol Neurosurg Psychiatry. 2007;78:1161–2. 13. Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy pa- tient. Ann Emerg Med. 1989;18:664–72. 12  |  Issue-1 MEDICAL EXCELLENCE