A Focused Approach to the Dizzy Patient | EM & Acute Care Course

A Focused Approach to the Dizzy Patient by Jerome Hoffman, MD
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A Focused, Evidence-Based Course Designed to Significantly Advance Your Practice of Emergency Medicine.
Using primarily the Emergency Medical Abstracts (EMA) database of over 17,000 abstracts, 28 presentations, each of 30-minute duration, are presented along with four 90-minute faculty panels. The focus of the course is the new, the controversial and the provocative. The course faculty synthesize the literature and combine it with their clinical experience to provide participants with specific recommendations regarding diagnosis and therapy related to emergency care.

[@moayadalmahsiri4455]

I wish you were my teacher at the university. You are wonderful and your explanation is more than wonderful

[@rg8276]

Love this guy....you can tell he's been doing this for a minute.

[@tamilentdr.v.r.p7514]

This speaks experience. I loved it.

[@baselhusseini6639]

Intertaining chest X-rays

[@tfoxen7518]

Adding, please do a reflex exam for subjective hand/foot/low back paresthesia or weakness symptoms. Guillain-Barre Syndrome onset - so often missed. Too many of us live life with possibly preventable nerve damage and pain due to late diagnosis and treatment.

[@lorab.6420]

with regard to BPPV: cupulolithiasis - may last for hours. Canolith repositioning is also available for horizontal canolithiasis. hope that helps.

[@dfrost2949]

Interesting lecture & very realistic examples...most of the times doctors have no clue people feel dizzy. I have been feeling dizzy in the past 2 years. It lost balance but never faint or it went away. My dizziness last for hours, but I still function & work. I am still trying to resolve my dizzy spell.

[@johannesbar9354]

There is a wonderful teaching video about HINTS exam of Peter Johns, Canada. Nevertheless, i agree to the referent that it‘s extremely difficult to see things like skew or changing direction of nystagmus or head impulse. I feel insecure every time doing the HINTS exam

[@adamborg9275]

This man says a few things in this video that's outright wrong or doesn't reflect the correct way of managing an acutely dizzy patient 1.) Asking the patient to subjectively describe their dizziness is highly unreliable regarding diagnosis. Always screen for red flags and in most cases do a neurootological exam and test for BPPV - both the posterior and horizontal canals (unless you see obvious spontaneus nystagmus). You will be surprised how much BPPV you'll find despite of the patient NOT describing position evoked short lasting vertigo! 2.) He completely disregards the HINTS exam, including the head impulse test. Incrediably unprofessional! It's a MANDATORY exam in the acute vestibular syndromes that in a highly valid way can differ between a unilateral peripheral loss from acute central vertigo. Believe me, in most acute vertiginous patients you can clearly differentiate an abnormal head impulse test from a normal one. He simply doesnt seem to care about actually learning the test. Learn the damn HINTS exam if you work in ER! 3.) This man doesnt seem to care about correctly performing positioning tests for BPPV and interpreting positional nystagmus. Now if you don't examine the patient with the Supine Head Roll and Dix Hallpike tests you cannot correctly diagnose BPPV and disregard other diagnoses. You have to interpret the positional nystagmus pattern and if it is fatiguable or persistent. That will tell you what canal and which ear that is affected (posterior, horizontal or anterior canal) and If you're dealing with canalothiasis or cupulolithiasis. Different treatments. If you see positional nystagmus that doesnt follow Ewalds laws, you should be concerned about centrally mediated positional vertigo. Could be vestibular migraines, posterior circulation strokes or other brain pathologies. And for gods sake, always use frenzel goggles! Otherwise youre at high risk of missing the nystagmus or misinterpreting it. High chance of false negatives not using frenzels or VNG (particularly for horizontal canal cupulolithiasis, spontaneus or gaze evoked nystagmus and CNS-mediated positional nystagmus)!!

[@richricogranada9647]

I was dizzy before having my first syncope this morning.

[@Miollvynir]

With labyrinthitis or neuritis, it can be so, so much worse than bppv. You'll never forget if you see a case of neuritis. This is just one of the good reasons to have DPTs in the ED- PTs are excellent at diagnosing and treating vestibular disorders. In fact, every bppv patient or other vestibular patient should get a PT referral in addition to any other relevant referrals. I never realized treating vestibular patients was such a big part of physical therapy until I saw it, and how much utility in general they have in the ED.

[@Sunnbuzz]

As a BPPV patient who had zero balance issues until my 39th Bday when I ended up in ER with a suspected TIA that was probably a BPPV attack, (I was fit and healthy) it wasn't until my 2nd episode 7 years later when an ER Dr that wasn't treating me but had observed me earlier as I enter the ER holding onto the walls & offered to try the Epley maneuver _(he had training in vestibular therapy). I agreed Back then I had no understanding of vestibular issues & I was beyond skeptical Less than 1hr later I left ER with most of my balance back and feeling a bit like a party trick lol *It is unfortunate they don't normally do Vestibular therapy in ER (they should but I also understand why they don't) And TBC I understand that BPPV should be correctly diagnosed before the start of any VT

[@ethanbates3484]

No mention of HINTS?

[@parhamomid1610]

Amazing and really helpful

[@Jasmine-ez5td]

Really awesome lecture. Dizziness is an overwhelming cheif complaint, but is made so much simpler with this approach

[@NN-rn1oz]

I'm not ageist nor sexist, but when I see a triage note saying female patient in her 70s here for dizziness, it makes me.... dizzy.

[@truthteller2711]

Why specially female pls

[@user-bv7jc]

awesome lecturer

[@samrahilmohdali]

Videos are very useful and thanks for sharing them with us. Could we also get the material provided with the course?

[@jasmanbirsingh9037]

Nice presentation...

[@sedatademoski1982]

Can anyone show me an article where it says that a central vertigo almost never comes with an isolated symptom of vertigo, and no other focal neurological signs? I searched the internet but I couldn't find any.

[@adamborg9275]

I think it's rare but in practise it's easy to miss those focal signs if you're not careful when examining. Assessing nystagmus using VNG (or at least frenzel goggles), using HINTS+ when necessary and the STANDING algorithm is often enough to be able to differ these non-obvious cases. Remember that central spontaneus or positional nystagmus in a way is a focal sign. Sometimes this can mislead you to thinking neuroexam was fine when the patient had wierd nystagmus the examiner didn't notice

[@natoyle]

Brilliant

[@jesse_kihara]

Wonderful teacher

[@daviderlbacher3585]

Good job

[@thomasburns2557]

Bravo

[@touseefbeig915]

Too Good

[@hujan2915]

It Make Sense

[@daviderlbacher3585]

Gerry Cooney

[@alal85831]

This doctor is sooo practical and speaks sense

[@ChristyD97]

There is so much wrong about this video in regards to the dizzy patient. He needs to sit down with an Audiologist or vestibular Physical Therapist. This is why I get so many wrong referrals form the ER.

[@danieliqram6922]

Hi, care to elaborate?

[@aizazali6500]

Would love to learn from your experience, if you could please elaborate...

[@adamborg9275]

1.) Asking the patient to describe their dizziness is highly unreliable regarding diagnosis. Always screen for red flags and in most cases do a neurootological exam and test for BPPV - both posterior and horizontal canals (unless you see obvious spontaneus nystagmus). You will be surprised how much BPPV you'll find despite of the patient NOT describing position evoked short lasting vertigo! 2.) He completely disregards the HINTS and head impulse test which is increadably unprofessional. It's a MANDATORY examination in the acute vestibular syndromes that in a highly valid way can differ between a unilateral peripheral loss from acute central vertigo. Believe me, in most acute vertiginous patients you can clearly differentiate an abnormal head impulse test from a normal one. He simply doesnt seem to care about actually learning the test 3.) This man doesnt seem to care about correctly performing positioning tests for BPPV and interpreting positional nystagmus. Now if you don't examine the patient with the Supine Head Roll and Dix Hallpike tests you cannot correctly diagnose BPPV and disregard other diagnoses. You have to correctly interpret the nystagmus because that tells you what canal and ear that is affected (posterior, horizontal or anterior canal). And If you dont see nystagmus that follows Ewalds laws, you should be concerned about positional vertigo of central causes. Could be vestibular migraine, posterior circulation strokes and other brain pathologies. And for gods sake, use frenzel goggles! Otherwise youre at high risk of missing the nystagmus or misinterpreting it