Vertigo

I recently was called to a hotel to see someone with such bad vertigo, he was stuck on the floor with eyes closed and head pinned to the side of the bed for stability. He and his family didn’t want to call an ambulance, because he couldn’t take any movement at all, even to get up onto his bed. It felt like cruise ship medicine.

In that position on the floor we infused a couple liters of saline, gave another Zofran, then gradually got him onto the bed and talked about red flags, happy words and options.

Red Flags:

• Gradual progression
• Fevers
• Confusion
• Altered mentation
• Cancer history
• Head injured
• Vertical room spinning instead of horizontal (never met anyone with this)
• Associated neurological deficit, like facial droop, arm or leg weakness
• Doesn’t improve with a fixed gaze

Happy Words

• Sudden onset
• Associated viral illness
• Associated ear infection
• Ear ringing or loss of hearing
• “I have Meniere’s”
• “I’ve had this before and it got better with meclizine”
• “One ear feels full”
• “I got hammered last night”
• “I’m so sick of these cruise ship family reunions!”

When patients say the room is spinning we try to decide whether the problem is “central” or “peripheral”, meaning deeper in the brain, or further out toward the ears, where we get our sense of position. ENTs do a better job of distinguishing between “vestibular neuronitis” vs. “labarynthitis” vs. some other “itis”. In ERs (and for Pre-R) I mainly focus on getting people through the acute crisis while ruling out life threats. You may hear mention of “semicircular canals” and “otoliths” during your vertiginous spell, but when your brain is spinning like a top, it’s in one ear, and out the same.

Antivert and Bonine are brand names for over the counter Meclizine, which you’ll find in bins on every cruise ship. This availability means it’s both effective and relatively benign. Benzodiazepines like Ativan are also quite effective, with the primary goal being sleep, because very often vertigo greatly improves with rest alone.

There are a variety of tests to distinguish between central and peripheral causes. Google “Dix-Halpike” if you’d like to go deep or read the article attached. The “Epley maneuvers” are also helpful in theory, but I can’t say I’ve had much luck with them. Some patients improve, while others toss their cookies. So being a fan of the golden rule, my approach for someone pinned in position with vertigo is sedation, hydration and hands off. If the vertigo improves and they want to experiment, I’m happy to oblige later.

That said, I do point some patients to this vertigo treatment video, which I consider to be a gentler approach. It’s also more consistent with my DIY whenever possible philosophy.

If symptoms persist, I usually refer to an ENT first. But going straight to an MRI isn’t unreasonable if a central cause is suspected.

My hotel patient improved the next day. He followed up with an ENT, because this was his second bout in 3 weeks. The cause was ultimately attributed to “some bug”.

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