The Patient with Vertigo

This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS), for 1.5 CEUs. There are two ways to take the CE test that accompanies this article and receive 1.5 hours of CE credit accredited by CECBEMS: 1. Click here to download a PDF of the test. The PDF has instructions for completing the test. 2. Or go to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@EMSWorld.com.

Objectives

1. Define vertigo.

2. Describe the difference between vertigo and other sensations associated with dizziness.

3. Discuss the difference between peripheral and central vertigo.

4. Differentiate between the different etiologies of peripheral and central vertigo.

5. Discuss management of the patient with vertigo.

Lafe, a paramedic, and his EMT partner Steve are eating breakfast when their unit is dispatched to a residential address for a patient complaining of dizziness. Upon arrival, they are met at the front door by the patient’s husband, who tells the crew that his wife “is not feeling well; she’s in the bathroom vomiting right now.” Lafe and Steve walk into the bedroom just as the patient, a 42-year-old female named Linda, crawls back into bed and lays back supine. She appears anxious and offers them a weak “hello.”

Lafe sits on a chair next to the bed and starts his exam while Steve takes Linda’s vital signs. Linda describes a two-day history of upper respiratory infection with some mild sputum production. She says, “I was feeling pretty good last night, but woke up today feeling dizzy and nauseous. When I got up to go to the bathroom, the dizziness was really bad and I felt like I was going to pass out.” She denies any chest discomfort or pain, back pain, abdominal pain or syncope. Lafe notes that her radial pulse is strong at about 80/min. Her skin is warm and slightly moist with good color and normal capillary refill. Linda’s breathing rate, tidal volume and effort appear normal. She tells Lafe she has a history of hypertension and non-insulin-dependent diabetes, for which she takes enalapril and glyburide, and has no allergies to medications. She also says both her father and mother died of heart attacks—her mother at 48 years old and her father at 54. “I’m not having a heart attack, am I?” Linda asks nervously as Steve places her on oxygen via nasal cannula at 2 lpm. Lafe starts running through the differential diagnosis for dizziness in his head, thinking, “AMI, hypertensive crisis, stroke, gastrointestinal bleed, hypoglycemia, hyperglycemia...”

There are few chief complaints that will elicit more sense of helplessness in the prehospital care provider than dizziness. Our diagnostic and clinical exam capabilities are limited in the prehospital environment, signs and symptoms are often vague and difficult for the patient to define, and the differential diagnosis is extensive. Behind this veil of uncertainty is the acknowledgement that dizziness can be the harbinger of many serious, potentially life-threatening conditions that initially appear benign; however, dizziness is a nonspecific term that is commonly confused with vertigo. The two are distinct clinical entities, but patients often use the terms synonymously. Arguably, most prehospital care providers are acutely aware of the potential causes of dizziness not caused by vertigo, as they are very often potentially life-threatening. We spend hours in training learning how to identify and manage patients with tachydysrhythmias, bradydysrhythmias, stroke and hypoglycemia, just a few possible etiologies of dizziness, but very little time is spent understanding vertigo.