Video Lecture: Evaluation of Emergency Department Dizziness Patients

• What is the background to this FERNE dizziness lecture?

What are the educational objectives for this FERNE dizziness lecture?

• What are the essential elements of the history when evaluating dizziness patients?
• Why is the history relevant when evaluating patients with dizziness?
• What is the OPQRSTU method for obtaining the history from patients with dizziness?
• What disease states must be excluded when evaluating a dizzy patient?
• What is the ATTEST method for obtaining the history from a dizzy patient, and what do the letters in this mnemonic stand for?

• How is dizziness defined?
• What are the normal vestibular organs and mechanisms for preventing dizziness?
• What are the three general systems pathologies that cause dizziness?
• What case studies allow the provider to better understand dizziness causes and the utility of the ATTEST method for the evaluation of dizzy patients?

• What are the essential elements of the physical exam when evaluating dizziness patients?
• What are the key elements of the eye exam in patients with dizziness?
• What are the key elements of the neurological exam in patients with dizziness?
• How is nystagmus evaluated in dizzy patients?  How is the exam for nystagmus conducted?  What mechanisms for dizziness control are being evaluated?
• Where does the word nystagmus come from?  How is nystagmus described?  Which eye movement indicates how the nystagmus is named? How is the exam for nystagmus conducted?
• With central gaze, what nystagmus findings are abnormal, suggesting a likely central etiology of the nystagmus? If nystagmus improves with central gaze, does this suggest a peripheral or central cause of the nystagmus?

• What are the three key questions addressed by the history and physical exam in patients with dizziness? 
• What history and exam findings suggest a general medical cause for the dizziness?  
• What is meant by Acute Vestibular Syndrome (AVS) in patients with dizziness?
• In intermittently dizzy patients, what is the significance of dizziness that occurs spontaneously as opposed to dizziness that is triggerable?
• What four nystagmus findings suggest a central etiology in patients who present with Acute Vestibular Syndrome (AVS)?
• What diagnosis must be established prior to determining the significance of nystagmus findings?
• How do nystagmus findings differ depending on the presence of AVS as opposed to triggered episodic vestibular syndrome (t-EVS)?
• What one nystagmus finding suggests a central nystagmus etiology even in the setting of t-EVS?
• What one nystagmus exam finding helps to differentiate a central from peripheral etiology of dizziness?

• What neuroimaging should be conducted in patients with dizziness?  What is the initial neuroimaging test of choice, and why? When should neuroimaging be performed in dizzy patients?
• What are the limitations of MR-DWI testing in dizzy patients with suspected cerebral ischemia?

• What are meant by the letters in the mnemonic ATTEST? 
• What is meant by Acute Vestibular Syndrome (AVS)?
• What is the difference between triggered and spontaneous episodic vestibular syndrome (EVS)?
• What should be documented in the EMR to exclude general medical causes for dizziness? 
• What should be documented in the EMR to establish the diagnosis of Acute Vestibular Syndrome (AVS)?
• What should be documented in the EMR to differentiate triggered EVS (t-EVS) from spontaneous EVS (s-EVS)? 
• What two diagnoses should be considered in patients with Acute Vestibular Syndrome (AVS)?
•  What two diagnoses should be considered in patients with triggered EVS (t-EVS)?
• What two diagnoses should be considered in patients with spontaneous EVS (s-EVS)?

• Which five exam findings each by themselves suggest a possible posterior circulation stroke finding in dizzy patients?
• What findings are seen in central pattern nystagmus in AVS?
• What is skew deviation with vertical correction, and why does it suggest a central dizziness etiology? 
• What is meant by a negative exam, with no unilateral correcting fast saccade on head impulse test (HIT) exam, and why does this suggest a central dizziness etiology? How should this exam finding be entered into the EMR?
• What CNS signs on neurological exam suggest a posterior circulation stroke?
• Why do patients with truncal or gait ataxia likely have a central dizziness etiology?

• What five statements can be made in the medical record from the results of the five physical exam tests that support the diagnosis of vestibular neuritis or labyrinthitis in patients with Acute Vestibular Syndrome?  (This one is really good!  Use it!)

• What diagnosis is important to consider in patients who have repeated “spells” that may include dizziness?
• What are the common benign causes, the more serious causes, and important rare causes of spontaneous Episodic Vestibular Syndrome (s-EVS)?

• What are the common benign causes, the more serious causes, and important rare causes of triggered Episodic Vestibular Syndrome (t-EVS)?
• What is BPPV, and what is important about the significance of these nystagmus findings in this triggered Episodic Vestibular Syndrome (EVS) etiology as compared to these same findings in Acute Vestibular Syndrome (AVS)?
• What is Central Paroxysmal Positional Vertigo (CPPV), why is it important to consider, and what nystagmus findings are seen with this disorder?
• When should orthostatic hypotension be considered as the cause of triggered EVS, and what vital sign changes should be observed to make this diagnosis?
• What is Bow Hunter’s syndrome, and is it a rare cause of triggered EVS?

• What are the two types of Benign Paroxysmal Positional Vertigo (BPPV), and which is the most common canal type?
• What is the pathophysiology of dizziness in patients with BPPV? How is dizziness in BPPV related to the Vestibular-ocular Reflex (VOR)?
• What is the common maneuvers that are diagnostic and therapeutic in treating BPPV?
• How is the Dix-Hallpike Test performed, and when is it considered to be a positive test?  
• How does the Epley Maneuver improve dizziness caused by BPPV?  Why does the patient’s head need to be turned in three directions?  How is the Epley Maneuver like physical therapy for other illnesses and injuries?

• What are the two types of Benign Paroxysmal Positional Vertigo (BPPV), and which is the most common canal type?
• What is the pathophysiology of dizziness in patients with BPPV? How is dizziness in BPPV related to the Vestibular-ocular Reflex (VOR)?
• What is the common maneuvers that are diagnostic and therapeutic in treating BPPV?
• How is the Dix-Hallpike Test performed, and when is it considered to be a positive test?  
• How does the Epley Maneuver improve dizziness caused by BPPV?  Why does the patient’s head need to be turned in three directions?  How is the Epley Maneuver like physical therapy for other illnesses and injuries?

• What are the common pitfalls in the diagnosis and management of ED patients with dizziness? 
• How are dizziness symptoms, signs, and tests such as dizziness with head movement, dizziness with headache or hearing loss, dizziness in young patients, the absence of nystagmus, and negative CT or MR-DWI neuroimaging important items to understand fully when evaluating ED dizziness patients?
• In young patients with dizziness, what five tests must be performed when the diagnosis is Acute Vestibular Syndrome?
• What diagnosis is likely in patients who state that dizziness wakes them out of their sleep?

• What are the CNS mechanisms by which the COVID-19 virus causes nerve injury, and neurological dysfunction?
• How can COVID-19 infection cause dizziness both by direct labyrinthine effects and by central CNS effects?
• How might COVID-19 infection cause dizziness by secondary effects not directly related to peripheral or central CNS effects?

• How is Acute Vestibular Syndrome (AVS) diagnosed?
• What is the important distinction to be made in patients with intermittent dizziness?
• What three diagnoses top the list of diagnoses to be considered in dizzy patients?
• What are the five physical exam tests to be performed in patients with AVS?
• With what maneuvers is BPPV diagnosed and treated?
• How might COVID-19 infection cause dizziness?
• What EMR templates and dot phrases might be used to make the evaluation and treatment of ED dizziness patients more systematic and easily accomplished?
• What six dizziness pathologies are to be considered in the three diagnostic strata, leading to three treatment strategies?
• Why must nystagmus findings be interpreted considering whether the diagnosis of Acute Vestibular Syndrome (AVS) has been made?