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The Nervous System
Barbara, a 51-year-old female, calls 9-1-1 because she has become extremely dizzy.1
Dizziness is a common complaint and can have many causes for medics to sort through, some of which may be linked to the central nervous system, peripheral nervous system, endocrine system, cardiovascular and respiratory systems, infection, brain tumors or toxicologic and behavioral problems. Sometimes, the causes remain unknown.2
A thorough history and systems survey must be done to eliminate as many possibilities as possible.
Past Medical History
Barbara started smoking when she was 16, smokes two packs per day and drinks alcohol socially. She has had no significant previous illnesses. She does suffer from allergies to dust and pollen and has frequent sinus problems. She is not diabetic and has never had this problem before. She takes over-the-counter allergy drugs and denies any drug or food allergies.
History of the Present Illness
Present history must be carefully elicited to avoid closed-ended questions and “putting words into the patient’s mouth.” Ask the patient to describe her symptoms without using the word “dizzy.”3
Barbara says she awoke and got out of bed this morning only to sense the room “spinning around” her. She quickly got back into bed and the spinning stopped, but each time she got up, the same thing happened again. She tried to get to the bathroom and almost fell, finally opting to crawl on her hands and knees to keep from falling. She was nauseous and vomited violently. Now, she is lying on the sofa in the living room. She says that every time she moves she feels the spinning and feels like vomiting.
She describes her symptoms as feeling “like the room is turning over and over and spinning around,” and “I’m fine when I’m not moving, but the minute I move, the spinning starts again.” She denies having fever, chills, weight loss, night sweats, or having been bitten or stung. She denies chest pain or abdominal pain.
This history is highly suggestive of vertigo, a condition involving the inner ear. Vertigo may be peripheral or central in etiology, or caused by problems in one of the systems mentioned above.4
Peripheral vertigo can be one of the following:
- Benign paroxysmal positional vertigo (BPPV), caused by dislodged calcium deposits in the inner ear that move with positional changes and cause a feeling of motion. Onset is sudden and often occurs when arising or rolling over in bed.
- Vestibular neuronitis (acute labyrinthitis) starts gradually and reaches a climax in 24-48 hours, sometimes causing nausea and vomiting.
- Labyrinthine hydrops (Meniere’s disease), characterized by sudden attacks of vertigo with hearing loss in the affected ear, ringing in the ears (tinnitus) and a feeling of fullness in the ear.
- Toxic causes, including drug effects and particularly ethanol (ETOH).5
Central vertigo is due to a central lesion in the brain involving cranial nerve VIII; the auditory nerve; brain tumors, cerebral hemorrhage or infarction; infection such as meningitis; and arterial-venous malformations.6
Physical Exam
Barbara appears to be a well-groomed female of her stated age, weighing approximately 165 pounds. Lying on a sofa, she is alert and answers questions appropriately.
Vital signs: BP 142/88, HR 84 and regular, RR 16 breaths per minute, temperature 99.4ºF, blood glucose 85, pulse oximetry 99% on room air. Her skin is pink, warm and dry with no rashes. Capillary refill is <2 seconds in her fingers.
HEENT: She is normocephalic and atraumatic. Her face is symmetrical and there is no facial droop. Pupils are round and equal at 5 mm and react briskly to light directly and by accommodation. Conjunctiva are pink. Ears are normal looking and without discharge. Nose is stable and without discharge. She is able to hear whispers in each ear. She denies tinnitus or a “full feeling” in her ear. Oral mucosa are pink; tongue is pink and she moves it in all directions on command; uvula is in the midline. She is able to repeat “no ifs, ands, or buts,” without slurring. Pharynx is slightly red but without exudates.
Neck is supple with free movement in all directions, but movement causes an acute and severe return of dizziness and nausea, coupled with nystagmus. Neither cervical or sub-mandibular lymphadenopathy nor signs of thyromegaly are present. Trachea is midline, and jugular veins are non-distended.
Chest: The chest is non-tender to palpation and expands normally and symmetrically. There are no surgical scars. Breath sounds are equal and vesicular bilaterally. S1 and S2 are heard without murmurs, clicks or rubs. There are no S3 or S4 sounds. A 12-lead ECG shows regular sinus rhythm without ectopy or ST changes.
Abdomen: Soft, non-tender, non-guarded and non-distended.
Extremities: Upper and lower extremities have full range of motion in all joints without edema or signs of trauma. Radial pulses are equal and strong; dorsalis pedis pulses are equal and strong. Normal sensation is present in all extremities without paresthesia.
Back: The back is negative for surgical scars, tenderness or deformity. Vesicular breath sounds are heard equally in all lobes.
Neurologic: Barbara is awake and correctly states her name and address as shown on her driver’s license and insurance card. She correctly identifies the day and date, where she is at the moment, and her relation of her history is consistent with objective observations.
Cranial nerves I through XII are intact. Horizontal nystagmus is noted with rightward gaze, which begins almost immediately with a change in head position and slowly increases to a peak before subsiding after about 30 seconds.
Discussion
Although it is important in the long run to distinguish between peripheral and central vertigo, it is not critical that the medics do so, since the diagnosis may be difficult even for physicians. However, several factors point to peripheral vertigo: Central vertigo is caused by disorders of the cerebellum and brainstem. It is gradual in onset, mild in intensity and not provoked by changes in position. Central vertigo may be caused by cerebellar hemorrhage and infarction, vertebral artery dissection, multiple sclerosis and numerous other things.7 Here, the patient experienced sudden onset triggered by change in position.
According to Tintinalli: “Peripheral vertigo is noted for its abrupt (often explosive) onset. It is an intense sensation of spinning or hurtling toward the ground or surrounding walls. It is typically worsened by rapid movement and by changes in head position. It is frequently associated with nausea, often severe vomiting, diaphoresis, and bradycardia and hypotension.”8
The cardinal sign of benign paroxysmal positional vertigo (BPPV) is horizontal or circular vertigo, which is present here. However, this type of nystagmus is also present with vestibular neuronitis. Vestibular neuronitis typically is very intense and lasts for several days, during which bed rest is often required. At this stage, therefore, it is not possible for the medics to clearly distinguish between the two, nor is it necessary that they do so.
Meniere’s disease is another possibility, but the fact that Barbara’s hearing is intact and she does not complain of tinnitus, diminished hearing or a feeling of fullness in one ear points away from it.
Once in the ambulance, medics place Barbara on oxygen at 2 liters per minute by nasal cannula and establish a saline lock in her left arm. As soon as the ambulance begins moving, she vomits violently. The medic administers ondansetron 4 mg by IV, and the nausea and vomiting soon resolve.
Barbara is transported to a Level III facility without further incident, where she is diagnosed with BPPV and discharged later that day with a prescription for meclizine 25 mg tablets to take three times a day, and a recommendation that she see her personal physician as soon as possible if the condition continues.
Her personal physician refers her to a therapist who employs Epley maneuvers, a series of exercises used to treat BPPV. After one session, her vertigo resolves and has not returned.9
Summary
Vertigo is a fairly common complaint encountered by medics. It is very upsetting and unpleasant for the patient, but it is usually benign and resolves on its own. However, it is vital that the medic be able to differentiate between common vertigo and a more serious condition like stroke. Careful attention to history and physical exam will allow medics to make the right determinations.
References
1. The scenario is suggested, in part, by scenarios in Prabhu FR, Bickley LS. Case Studies to Accompany Bates’ Guide to Physical Examination and History Taking, 9th ed., Lippincott Williams & Wilkins, pp. 83-84; and Beebe R, Myers J. Professional Paramedic Vol. II, pp. 544-549, Delmar Cengage Learning.
2. Bickley LS. Bates’ Guide to Physical Examination and History Taking, 10th ed., Lippincott, Williams & Wilkins, p. 252.
3. Tintinalli J. Emergency Medicine, 7th edition, p. 1146. American College of Emergency Physicians, Dallas, TX.
4. DeGowin’s Diagnostic Examination, 9th ed., p. 286, McGraw-Hill.
5. Bates, ibid.
6. DeGowin, ibid, p. 288.
7. Tintinalli, ibid, p. 1151.
8. Tintinalli, ibid, p. 1148.
9. For a comprehensive discussion on BPPV, see Benign Paroxysmal Positional Vertigo in Emergency Medicine, available at: https://emedicine.medscape.com/article/791414-overview, (accessed July 13, 2011.)
William E. (Gene) Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate’s degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and
urban settings. He lives in Tucson, AZ.
Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is the author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between, and the blog A Day in the Life of An Ambulance Driver.
