Emergency Medicine Cases_ Navigating Dizziness in the ED

 

Emergency Medicine Cases: Navigating Dizziness in the ED

Dizziness is a common presenting symptom in emergency departments, challenging physicians to differentiate between benign conditions and life-threatening emergencies. The following cases illustrate key considerations in the emergency management of dizziness.

Case 1: Acute Vestibular Syndrome

A 55-year-old woman presents with sudden onset of severe vertigo, nausea, and vomiting. She reports difficulty walking and a spinning sensation. Initial examination reveals horizontal nystagmus and an abnormal head impulse test.

Key Considerations:

Differentiating between stroke and vestibular neuritis is crucial.

The HINTS exam (Head Impulse, Nystagmus, Test of Skew) is more sensitive than early MRI for stroke detection.

A normal head impulse test with direction-changing nystagmus suggests central pathology (stroke).

Management:

If vestibular neuritis is confirmed, treatment includes symptomatic relief with antiemetics and short-term vestibular suppressants.

If stroke is suspected, immediate neuroimaging and stroke protocol activation are necessary.

Case 2: Benign Paroxysmal Positional Vertigo (BPPV)

A 70-year-old man complains of brief episodes of vertigo triggered by head movements, particularly when lying down or getting up. Symptoms last less than a minute each time.

Key Considerations:

BPPV is the most common cause of vertigo in older adults.

The Dix-Hallpike test can confirm the diagnosis.

Management:

Perform the Epley maneuver in the ED.

Provide instructions for home exercises.

Arrange follow-up if symptoms persist.

Case 3: Cardiac-Induced Dizziness

A 62-year-old man with a history of hypertension presents with intermittent lightheadedness and palpitations. He appears pale and diaphoretic.

Key Considerations:

Cardiac causes of dizziness can be life-threatening.

ECG and cardiac monitoring are essential.

Management:

Immediate ECG and cardiac monitoring.

If arrhythmia is detected, treat accordingly (e.g., cardioversion for unstable tachyarrhythmias).

Consider cardiac enzymes to rule out myocardial infarction.

Case 4: Posterior Circulation TIA

A 58-year-old woman reports recurrent episodes of dizziness, diplopia, and slurred speech, each lasting about 10 minutes before resolving completely.

Key Considerations:

Transient ischemic attacks (TIAs) in the posterior circulation can present with isolated dizziness.

These patients are at high risk for subsequent stroke.

Management:

Urgent neuroimaging (CT or MRI) and neurology consultation.

Initiate stroke prevention measures (antiplatelet therapy, risk factor modification).

Consider admission for observation and further workup.

Case 5: Medication-Induced Dizziness

An 80-year-old man on multiple medications for hypertension and diabetes presents with persistent lightheadedness and near-syncope.

Key Considerations:

Polypharmacy is a common cause of dizziness in the elderly.

Orthostatic hypotension should be assessed.

Management:

Perform orthostatic vital signs.

Review medication list for potential culprits (e.g., antihypertensives, diuretics).

Consider medication adjustments in consultation with the primary care physician.

Case 6: Cerebellar Hemorrhage

A 45-year-old woman with a history of poorly controlled hypertension presents with sudden onset of severe dizziness, vomiting, and difficulty walking. On examination, she has ataxia and nystagmus.

Key Considerations:

Cerebellar hemorrhage can present with isolated dizziness and vomiting.