Abstract
Vertigo is a common clinical manifestation in the emergency department (ED). It is important for physicians to determine if the peripheral cause of vertigo is benign paroxysmal positional vertigo (BPPV), a disorder accounting for 20% of all vertigo cases. However, the Dix-Hallpike test—the standard for BPPV diagnosis—is not common in the ED setting. If no central origin of the vertigo is determined, patients in the ED are typically treated with benzodiazepine, antihistamine, or anticholinergic agents. Studies have shown that these pharmaceutical treatment options may not be the best for patients with BPPV. The authors describe a case of a 38-year-old woman who presented to the ED with complaints of severe, sudden-onset vertigo. The patient's BPPV was diagnosed by means of a Dix-Hallpike test and the patient was acutely treated in the ED with physical therapy using the canalith repositioning maneuver.
Vertigo is a common complaint among patients who seek care in the emergency department (ED). Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, accounting for approximately 20% of all vertigo cases.
1 According to the Vestibular Disorders Association, approximately 50% of elderly patients who present with a chief complaint of dizziness have BPPV.
1 The ED standard of care for patients presenting with vertigo is to rule out serious medical causes based on patient history, physical examination, and diagnostic workup. Once the clinician determines that there is no central etiology, patients are typically treated with benzodiazepine, antihistamine, or anticholinergic agents. However, several reviews
1 on the management of vertigo have indicated that medications currently used for the treatment of vertigo do not have well-established curative or prophylactic value and are not suitable for long-term treatment.
A 38-year-old woman presented to our ED with acute onset of vertigo, nausea, and vomiting, all exacerbated with head movement. The patient's past medical history was notable for vertigo, for which she received vestibular rehabilitation. Physical examination revealed the patient to be alert and oriented to person, place, and time. Resting nystagmus was not present, and cranial nerves II through XII were intact. All other pertinent physical examination findings were normal. Dix-Hallpike testing on the right side was normal and on the left side revealed an upbeating, left torsional nystagmus lasting approximately 15 seconds (
Figure 1).
Acute vertigo secondary to BPPV was diagnosed based on the examination findings. A physical therapist was contacted to evaluate the patient. Examination revealed normal balance and no gross gait deviations. The physical therapist repeated the Dix-Hallpike test, the findings of which were consistent with those of the first test conducted by the emergency physician. After the Dix-Hallpike test, the patient rated both her dizziness and nausea as 10 out of 10 on a visual analog scale. The physical therapist treated the patient with a canalith repositioning maneuver for the left, posterior, semicircular canal (
Figure 2). After completion of the treatment, the patient rated her dizziness as 1 out of 10 and her nausea as 2 out of 10 on the visual analog scale.
Visual analog ratings were repeated 15 and 30 minutes after treatment. Fifteen minutes after treatment, the patient rated her dizziness as 2 out of 10 and her nausea as 3 out of 10. Thirty minutes after treatment, she rated her dizziness as 1 out of 10; her nausea rating remained the same. Thirty minutes after treatment, the patient felt well enough to go home. Before discharge, the physician repeated the Dix-Hallpike test, the results of which were normal for both right and left sides. No medications were given to the patient while she was in the ED. At discharge, the patient received a prescription for meclizine hydrochloride (25 mg [administered orally] every 8 hours) for treatment of her breakthrough vertigo and received a referral for outpatient vestibular rehabilitation.
A follow-up phone call was placed to the patient 30 days after discharge. The patient had sought follow-up treatment with an ear, nose, and throat physician but had received no additional treatment because her symptoms resolved. The patient rated her satisfaction of care in the ED 10 out of 10 on a Likert scale, with 1 meaning not satisfied and 10 meaning very satisfied. This patient's overall length of stay in the ED was 180 minutes. The time from the examination by the physician to the patient's discharge was 133 minutes. Average length of stay for patients treated in our ED with a diagnosis of BPPV is 260 minutes.