NEUROLOGIC PROBLEMS
| THE DIZZY PATIENT —S. Andrew Josephson, MD, Clinical Assistant Professor of Neurology, University of California,
San Francisco, School of Medicine
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| Evaluation of dizziness: 2 key questions—first, ask patient what he or she means by “dizzy”; second, localize; complaint
of dizziness nonspecific; to categorize dizziness—first separate syncope or presyncope from true vertigo; third
textbook category dysequilibrium (feeling of rocking, similar to getting off boat or carousel), but should be ignored
(place in category of vertigo); miscellaneous category multicultural (nonspecific complaint of not feeling well called
“dizziness”); syncope—reported by nearly one-fifth of patients as dizziness; presyncopal symptoms key (color change,
lightheadedness, and tunnel vision); witnesses have difficult time describing and distinguishing from seizure (myoclonus
common in syncope)
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| Vertigo: by asking patient whether room spinning, miss significant number of patients with vertigo; illusion of movement,
falling, swaying, or rocking, ie, dissociation between patient and environment, classified as vertigo; most causes
of central vertigo, eg, cerebellar stroke or brainstem stroke, do not have true room-spinning vertigo (happens more often
in peripheral vertigo, eg, labyrinthitis, but can happen with central lesions)
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 | Classification of vertigo: central or peripheral; no need for imaging studies in peripheral vertigo; by history, not many
symptoms reliable in distinguishing central from peripheral vertigo; nausea and vomiting, inability to walk, and inability
to sit tend to be worse in peripheral vertigo, but cannot use severity to distinguish; peripheral vertigo—associated
ear findings (hearing loss, ringing in ears, pressure or fullness in ear, and pain in ear); symptoms brought on by head
turning; central vertigo—if associated brainstem symptoms present (ie, dysarthria, dysphagia, and diplopia), patient
has brainstem stroke until proven otherwise; if headache and depressed level of consciousness present (eg, sleepiness
or confusion not related to medications), assume central vertigo and rule out with neuroimaging; age and vascular risk
factors (much more likely that elderly patient with diabetes and hypertension has central vertigo from stroke, rather
than peripheral vertigo); nystagmus examination—high-yield test; if nystagmus fatigues with time, more likely peripheral
vertigo; if nystagmus goes away with fixation, vertigo more likely peripheral; if it changes direction with gaze,
peripheral vertigo (central vertigo does not change position); in peripheral vertigo, nystagmus classically has latency;
torsional or horizontal component to nystagmus indicates peripheral vertigo (classic eye finding in patients with benign
paroxysmal peripheral vertigo [BPPV]); vertical nystagmus more likely central in etiology
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| Case 1: man, 63 yr of age, presents to emergency department (ED) with 12 hr of severe vertigo, nausea, and vomiting, no
hearing loss, no tinnitus, and no auditory signs; examination shows right-beating nystagmus on all directions of gaze
(worse when looking right); patient has severe imbalance and unable to sit up; he recently recovered from upper respiratory
infection; diagnosis—vestibular neuronitis or vestibular neuritis; with hearing loss, called vestibular labyrinthitis;
second most common cause of peripheral vertigo in most series; worsens for 1 to 3 days before slow improvement; presumed
viral or postviral etiology (history present only 50% of time); treatment—no role for antivirals; study showed
that corticosteroids improve outcomes for patients with vestibular neuritis (used high doses for 3 wk); unclear if lower
dosages of prednisone or other regimens effective
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| Case 2: man, 75 yr of age, reports sudden onset of severe vertigo when rolling over in bed to turn off alarm clock; reluctant
to move, as symptoms return whenever he moves his head; no auditory symptoms; examination normal, except for
Dix-Hallpike maneuver (5-sec latency, rotatory or torsional nystagmus occurs when ear placed down); BPPV—
diagnosis; most common cause of peripheral vertigo; almost always recurs; pathophysiology calcium carbonate crystals
in posterior semicircular canal have plunger effect; latency due to movement of crystals; treated with Epley maneuver
(effective and easy to perform)
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| Case 3: man, 55 yr of age, experienced pressure sensation behind left ear, followed by vomiting, vertigo, and deafness; 3
hr later, vertigo improving but deafness persists; examination reveals conjugate horizontal nystagmus that beats to right;
veers to right when walking; Meniere’s disease—diagnosis; etiology unknown; recurrent; important progressive cause
of deafness; treatable; due to increase in volume of endolymphatic system; rare in occurrence; treatment includes low-salt
diet, diuretics, and occasionally, surgery
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| Peripheral vertigo: other etiologies—postconcussive labyrinthopathy (difficult to treat; can last for years); migraine
(patients have migraine equivalents, eg, tend to get motion sickness, cannot read book in car, ice cream headache; vertigo
common, even without accompanying head pain); autoimmune inner ear disease (rare); ototoxic drugs; infections
(eg, syphilis); mastoiditis; acoustic neuroma (slowly progressive vertigo; never neurologic emergency)
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| Treatment: specific therapies—steroids for labyrinthitis and Epley maneuver for BPPV; symptomatic therapies—
meclizine and diazepam (not highly effective; work by sedation; interfere with normal compensation process); vestibular
rehabilitation—lying in bed detrimental; having patient up and ambulating helps resolve peripheral vertigo faster
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| Central vertigo: cerebellar signs—if present, patient may also have problem in brainstem
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| Case 4: man, 30 yr of age, with no medical history, presents with 6 hr of vertigo; on no medications; examination shows
right pupil 4 mm and minimally reactive and left eye reacts briskly, 3 to 2 mm; has vertical bobbing movements of both
eyes and no corneal response on left; on motor examination, all extremities moving antigravity; computed tomography
(CT) in ED negative; after 2 hr, patient deteriorates, goes into coma, and intubated; diagnosis basilar artery thrombosis;
University of California, San Francisco stroke protocol CT—obtained in all suspected acute stroke or transient ischemic
attack (TIA) patients; noncontrast CT of head followed by CT angiography (CTA) from heart to top of head, then
CT perfusion study, and postcontrast CT of head; CTA powerful when evaluating patient with vertigo; posterior fossa
difficult to image for ischemia with CT
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| Basilar artery thrombosis: carries high morbidity (100% mortality if not treated); common in older individuals with
atrial fibrillation who have embolus that goes up to basilar artery; also in younger individuals with vertebral artery dissection
(leads to artery-to-artery embolus, causing basilar artery thrombosis); treatable with embolectomy and angiographic stroke
interventions; successful out to 12 to 24 hr; identified by CTA (also vertebral and basilar artery narrowing [vertebrobasilar
insufficiency] in vertiginous patient); clue on examination vertigo or coma with any cranial nerve abnormality (basilar artery
thrombosis until proven otherwise); pearl—in patient presenting with vertigo or coma, if basilar artery white on CT (hyperdense
basilar sign), further imaging of posterior circulation required
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| Case 5: man, 64 yr of age, with history of diabetes and hypertension, presents with 1 day of imbalance and vertigo; examination
shows right-sided homonymous hemianopsia and severe ataxia, worse on right than left; has normal power; CT of
brain normal; discharged from ED and brought back 24 hr later after respiratory arrest at home; in coma and eventually
expires; cerebellar ischemic stroke—diagnosis; causes brain swelling and herniation into brainstem; treatment surgical
decompression; hospitalize for definitive surgery (removal of posterior portion of skull allows cerebellum to herniate outwards);
cerebellar hemorrhage—life-threatening emergency; identified with CT; 3-cm rule for intervention of neurosurgeon
controversial (no good data); patient deterioration another indication for neurosurgeon to intervene;
neurosurgical emergency; drain sometimes utilized to relieve hydrocephalus, but this can lead to cerebellum herniating
upwards
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| Choice of imaging study for central vertigo: for any cranial nerve lesion, presume brainstem problem and obtain
CT or CTA (enhances usefulness of noncontrast CT); with any asymmetric cerebellar finding, consider cerebellar stroke
(CT excludes hemorrhage, but if negative, obtain magnetic resonance imaging [MRI]); in complete absence of peripheral
signs, think midline cerebellum and obtain MRI
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| Take-home points: 2 major considerations in vertigo include definition of dizziness (history key) and whether central or
peripheral (examination key); nystagmus examination, cerebellar examination, and cranial nerve examination; vestibular
neuronitis and BPPV common; imaging indications for central vertigo; if brainstem abnormal, basilar artery thrombosis;
if cerebellar examination asymmetric, cerebellar stroke or intracerebral hemorrhage
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| PSYCHIATRIC EMERGENCIES —Karen Santucci, MD, Associate Professor, Yale University School of Medicine, and
Medical Director, Children’s Emergency Department, Yale-New Haven Children’s Hospital, New Haven, CT
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| Magnitude of problem: ≈20% of children have symptoms of diagnosable psychiatric disorder; ≈10% of pediatric population
suffers from major mental illness and experiences some functional impairment; only 20% of those who require treatment
receive it
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| Definition of psychiatric emergency: “any behavior that cannot be dealt with as rapidly as needed by the ordinary
mental health, social service, or criminal justice system in the community”; pediatric emergency services provide safety
nets for increasing volume of youngsters who reflect range of psychopathology and psychosocial adversity
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| Classification of urgency: class I—most severe (life-threatening) emergency (eg, individual actively suicidal or actively
homicidal); class II—state of heightened disturbance requiring urgent intervention (eg, child who had just been
raped or witnessed shooting of parent); class III—serious condition requiring prompt but not necessarily immediate intervention
(eg, child with difficult behavioral challenges); class IV— intervention demanded but not necessarily psychiatrically
warranted (eg, family frustrated with lack of ability to access care in community); having classification system
in hospital helps physicians to access care better and establish type of care most appropriate
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Common Psychiatric Emergencies
| Suicide: urgency class I; spectrum (from thought or idea about suicide to carrying out to fruition); requires medical, social,
and psychiatric interventions; epidemiology—rates doubled in past 40 yr in 15- to 19-yr age group; tripled in 10- to 14-yr
age group; explanation for increased rates possibly environmental in nature (more access to things that put individual at risk
for carrying suicide to fruition); firearms critical factor; also, availability of alcohol and dysfunctional family; suicide fourth
leading cause of death among children, and third leading cause of death in 10- to 19-yr age group; in 2003, ≈1700 suicides
reported in United States; 50 to 100 suicide attempts for every completed suicide; surveillance between 2001 and 2003
showed 9% of all adolescents have attempted suicide; suicidal ideation occurs in prepubertal children; suicide rates increase
after puberty, most likely secondary to access to things that help individual succeed in committing suicide; sex
differences—high school girls consider suicide as option more than boys; high school girls have plan for suicide more than
boys; college men and women equal in having plan; adolescent girls attempt suicide more often than boys; adolescent boys
successful at suicide more often than girls (boys often choose more lethal means than girls); suicidality highest for white
men (increasing among black men); risk factors—underlying psychiatric disorder, especially undiagnosed depression (one
of greatest); suicide contagion accounts for 5% of suicides in children; indications for hospitalization—inability to engage
child (lack of rapport); serious attempt; child actively suicidal; inability to contract for safety; disturbed family; denial
of significance of attempt
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| Depression: predisposes to suicidality; presents to ED with many faces (eg, abdominal pain, changes in sleep patterns,
eating patterns, and level of activity); ask about conditions at home, school, activities, use of recreational drugs, sexual
activity, and suicide; rule out organic causes, eg, hypothyroidism; 10% of adolescent population has depression
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| Psychosis: patients often present with hallucinations, extreme variations in mood, and (occasionally) violent behavior;
important to rule out organic etiology (eg, toxins, intracranial tumors, hypoglycemia); in organic-type psychosis, onset
often abrupt; if associated with mental illness, progression more gradual; ED evaluation—obtain CT if focal findings
present; if patient febrile, lumbar puncture after CT; “cat-scratch” disease can present with florid psychosis
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| Conduct disorder: management goals—ensure safety of child, family, and ED staff; rule out medical condition;
gather information for disposition
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Violence in ED
| Warning signs of imminent violence: psychiatrists recognize 3 levels of threats (psychiatrists’ perceptions of gradations
of urgency in violence and out-of-control behavior different from those of most ED physicians); level 1—
individual cursing and swinging fist; considered only mild threat by psychiatrist; recommended treatment distracting individual
and offering limit setting; level 2—patient screaming, yelling, and punching wall; recommend more limit setting,
walking out of room, and having security guard pass by; goal to intercept situation before it progresses; level 3—
patient, eg, picking up chairs and throwing them against wall; approaching physician in way that makes physician feel in
imminent danger; recommended approach—alert security; disengage from situation and leave room; speaker believes
ED physician should maintain calm and let patient know that physician aware patient hurting and that he or she is there to
help; keeping patient safe—remove anything that patient can use to hurt him- or herself; remove patient’s shoes; justification
for physical and chemical restraint—to contain violent behavior toward oneself or others; indications for
admission—suicidality; depression with suicidal plan; depression with inability to take care of oneself; psychotic episode;
conduct deemed harmful to self or others; complications of substance abuse
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| Symptoms of depression in children and adolescents: vary with age of patient; in infants, depression presents as
apathy, listlessness, and failure to thrive; in preschool children, as rapidly changing moods, crying easily, and poor school performance;
in adolescents, symptoms often mistaken for other causes
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| Case reviews: psychotropic medication and antidepressants not generally started in ED; if starting antidepressants, psychiatrist
should be involved to follow patient; ED physician need not make psychiatric diagnosis but must ensure patient
stable enough to go home; no single predictor of severity of child’s or adolescent’s suicide attempt; developmental delay
can be result of depression; conversion disorder—involuntary act; more sophisticated children present with remarkable
signs and symptoms; conduct disorder—may involve physical threats and assault; adolescents with eating
disorders—uncertain outpatient follow-up one indication for admission; completed suicides—more common in boys
because they choose more lethal means
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Suggested Reading
American Academy of Pediatrics et al: Pediatric mental health emergencies in the emergency medical services system.
Pediatrics 118:1764, 2006; Cakir BO et al: Efficacy of postural restriction in treating benign paroxysmal positional
vertigo. Arch Otolaryngol Head Neck Surg 132:501, 2006; Chawla N et al: Diagnosis and management of
dizziness and vertigo. Med Clin North Am 90:291, 2006; Cooper NA: Dizziness is not diagnostic. BMJ 334:600, 2007;
Doyle AE et al: Diagnostic threshold for conduct disorder in girls and boys. J Nerv Ment Dis 191:379, 2003; Dubowitz
H et al: Screening for depression in an urban pediatric primary care clinic. Pediatrics 119:435, 2007; Fam Physician.
2005 Mar 15;71(6):1129-30; Flanagan S et al: Outcomes in the use of intra-tympanic gentamicin in the treatment of
Ménière's disease. J Laryngol Otol 120:98, 2006; Epub 2005 Nov 25; Han BI et al: Nystagmus while recumbent in horizontal
canal benign paroxysmal positional vertigo. Neurology 66:706, 2006; Honrubia V: Self-treatment of benign paroxysmal
positional vertigo: Semont maneuver vs Epley procedure. Neurology 64:583, 2005; Huppert D et al: Low
recurrence rate of vestibular neuritis: a long-term follow-up. Neurology 67:1870, 2006; Labuguen RH: Initial evaluation
of vertigo. Am Fam Physician 73:244, 2006; Erratum in: Am Fam Physician; Lee H et al: Cerebellar infarction presenting
isolated vertigo: frequency and vascular topographical patterns. Neurology 67:1178, 2006; Levine LJ et al:
Discharge disposition of adolescents admitted to medical hospitals after attempting suicide. Arch Pediatr Adolesc Med
159:860, 2005; Oh HJ et al: Predicting a successful treatment in posterior canal benign paroxysmal positional vertigo.
Neurology 68:1219, 2007; Patel V et al: Mental health of young people: a global public-health challenge. Lancet
369:1302, 2007; Pfeffer CR: The FDA pediatric advisories and changes in diagnosis and treatment of pediatric depression.
Am J Psychiatry 164:843, 2007; Swartz R et al: Treatment of vertigo. Am Fam Physician 71:1115, 2005; Williams
J et al: Diagnosis and treatment of behavioral health disorders in pediatric practice. Pediatrics 114:601, 2004.
Educational Objectives
| The goal of this program is to improve the management of vertigo and psychiatric emergencies. After hearing
and assimilating this program, the clinician will be better able to:
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| 1. Differentiate between central and peripheral vertigo.
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| 2. Utilize the appropriate imaging study for determining the etiology of vertigo.
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| 3. Review the classification of psychiatric emergencies based on urgency.
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| 4. Describe the 4 most common psychiatric emergencies seen in the emergency department.
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| 5. Recognize the indications for hospitalization of a suicidal pediatric patient.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a
proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgements
Dr. Josephson was recorded at 36th Annual Topics in Emergency Medicine, held October 1-4, 2007, in San Francisco, CA,
and sponsored by the University of California, San Francisco, School of Medicine, Division of Emergency Medicine. Dr. Santucci
was recorded at Pediatric Emergency Medicine 2007, held April 10-14, 2007, in Lake Buena Vista, FL, and sponsored
by Nemours. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this
program.
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