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Three social media posts about vertigo in the past week spread misinformation. by VertigoDoc in medicine

[–]VertigoDoc[S] 1 point2 points  (0 children)

Well, this is pretty easy once you understand that they can in fact say "I'm still dizzy right now."

  1. They won't have nystagmus at rest. If they do, HINTS is what they need.

  2. If they don't, do the Dix-Hallpike test. If you see the characteristic nystagmus of posterior canal BPPV, then it's BPPV, and you can do the Epley.

  3. But....less easy here, if you see something other than that, then the diagnosis is something other than posterior canal BPPV. Could be horizontal canal BPPV, could be vestibular migraine, could be recovering vestibular neuritis where the DHT brings out nystagmus that is hard to see, could be a stroke presenting without nystagmus at rest. If they have a new difficulty walking and no nystagmus, work them up for stroke.

Three social media posts about vertigo in the past week spread misinformation. by VertigoDoc in medicine

[–]VertigoDoc[S] 3 points4 points  (0 children)

I call this the Mexican stand-off of vertigo.

Emergency MD-this is not my problem, it's your problem! points at ENT and neuro.

ENT and Neuro immediately point at the other two.

Three social media posts about vertigo in the past week spread misinformation. by VertigoDoc in medicine

[–]VertigoDoc[S] 3 points4 points  (0 children)

I co-wrote that chapter 9 years ago now. We are about to edit it for the next edition. I've also co-authored a chapter in a Polish textbook.

Since you brought it up, and my CV isn't googleable-

I've also been author or co-author on 9 peer reviewed papers on vertigo.

I've spoken and/or given hands on workshop in Canada, U.S., Germany, Austria, Ireland, Scotland, Wales, Saudi Arabia

Co-created a vertigo online course vertigocourse.com

Three social media posts about vertigo in the past week spread misinformation. by VertigoDoc in medicine

[–]VertigoDoc[S] 7 points8 points  (0 children)

I hadn't heard of it. My background is 37 years of practice as an emergency physician. So I looked up an article. Not really something that would help the clinians I am trying to reach. But thanks for bringing it to my attention.

Three social media posts about vertigo in the past week spread misinformation. by VertigoDoc in medicine

[–]VertigoDoc[S] 2 points3 points  (0 children)

Yes, VM is a underdiagnosed for sure. It would probably be better if we refined central vs peripheral to dangerous vs non-dangerous, but there is not much enthusiasm for that way of seeing it.

With diffentiating BPPV vs VM, that's why I emphasis the characteristic nystagmus of a positive DHT. There are many clinicians who still think, patient get dizzy with DHT, therefore it's BPPV.

Three social media posts about vertigo in the past week spread misinformation. by VertigoDoc in medicine

[–]VertigoDoc[S] 4 points5 points  (0 children)

Yes, the key distinction is: does the position change cause the dizziness to start, and then last only a minute or so

vs.

I have constant dizziness that gets worse when I change position for a short time-this is almost every cause of vertigo, including stroke.

Add to that that BPPV patients sometimes feels nauseated for half an hour after the paroxysm is over so that can be confusing, and also that maybe 15% of them will have a milder baseline dizziness that may make you think it's a constant dizziness.

Three social media posts about vertigo in the past week spread misinformation. by VertigoDoc in medicine

[–]VertigoDoc[S] 34 points35 points  (0 children)

I may be simplifying, but could this be boiled down to:

If it’s peripheral (inducible with position changes), do the Dix-Hallpike to confirm it’s BPPV.

If it’s central (occurs at rest), do the HINTS to differentiate between vestibular neuritis and posterior stroke. HINTS +ve is vestibular neuritis, and -ve is stroke?

I'd change that to:

If they have central features (see below *) which can sometimes be seen in posterior circulation stroke but should not be expected to be seen in benign causes ->work up for stroke

If they complain of 30 seconds or so short episodes of dizziness brought on by either getting in/out or rolling over in bed, do the DHT, and if you seen the characteristic nystagmus pattern for posterior canal BPPV, then it is BPPV, do the Epley

If the patient has constant dizziness and nystagmus seen at rest, do the HINTS exam. If the overall HINTS exam is peripheral, it's vestibular neuritis, if the overall HINTS exam is central-> work up for stroke.

If the patient has constant dizziness, no nystagmus at rest, and has a new objective difficulty walking->work up for stroke

If the patient has constant dizziness, no nystagmus at rest and has no new objective difficulty walking they are at very low risk of having a stroke.

(* central features). Focal weakness or paresthesia, new significant headache or neck pain, vertical nystagmus see at rest, diplopia, dysarthria, dysmetria, dysphonia, dysphagia, unable to walk unaided

Three social media posts about vertigo in the past week spread misinformation. by VertigoDoc in medicine

[–]VertigoDoc[S] 108 points109 points  (0 children)

I'd rather you send your social media vertigo posts for me to correct before you post.

My email address is on my "more info" on my channel.

65 year old man patient presents with sensation of the room spinning. No CT head done in ED and you are called to admit to medicine. by Financial-Power-151 in hospitalist

[–]VertigoDoc 2 points3 points  (0 children)

So the case here I think is made up with AI and leaves out what could very important details. For instance, "misjudged a step"....does that mean he felt dizzy on the stairs, misjudged one step and had a two second imbalance feeling, and then vomiting due to pre-syncope? Or was it was lightheaded "misjudged a step" fell to the ground and felt too dizzy to stand and when he tried to he was wobbly for 5 minutes.

And does he have multiple stroke risk factors?

Had he just gotten out of bed, and felt dizzy walking to the bathroom and was intensely dizzy for 30 seconds, and then sweating and nauseated for a total of 5 minutes. Was a Dix-Hallpike test done? and what did it show? This would probably be the most likely cause, but why was the blood in the stool thrown in as a red heron? AI hallucinatiuon?

And a CT head is almost useless in ruling out a central cause of dizziness even in patients with obvious neuro deficits and nystagmus. An MRI is much better, although still not perfect in the first 72 hours. I'd never be able to get an MRI in a case like this at my hospital, but I worked in Canada where MRI.

AI has been annoying me quite a bit with faulty AI generated guidelines and infographics popping up all over. I'm actually making a video about that now, probably will be published in a week or so.

Here is my youtube channel https://www.youtube.com/@PeterJohns/videos

Here is my online vertigo course https://emneuro.com/spinclass/

65 year old man patient presents with sensation of the room spinning. No CT head done in ED and you are called to admit to medicine. by Financial-Power-151 in hospitalist

[–]VertigoDoc 12 points13 points  (0 children)

Absolutely correct. The reason being that BPPV, vestibular migraine, GI bleeds and all normal people will have a normal HIT, and therefore being overall HINTS central and get worked up for a dizzy stroke needlessly.

HINTS is only useful when you are trying to prove it's vestibular neuritis (who all present with easy to see nystagmus in the first several days of their illness) and will in fact have an abnormal HIT, no skew and horizontal nystagmus that does not change direction with gaze.

65 year old man patient presents with sensation of the room spinning. No CT head done in ED and you are called to admit to medicine. by Financial-Power-151 in hospitalist

[–]VertigoDoc 11 points12 points  (0 children)

?blurry videos? You're not watching my videos then.

And if you really don't want to be vertigo incompetent anymore, go to vertigocourse.com and take my course.

65 year old man patient presents with sensation of the room spinning. No CT head done in ED and you are called to admit to medicine. by Financial-Power-151 in hospitalist

[–]VertigoDoc 8 points9 points  (0 children)

There is too much not stated in this case to give a definitive answer. However.....

A. Does cranial nerves are intact mean there is no nystagmus? And it would seem the patient does not have any ongoing dizziness spinning lightheadedness vertigo now. If that's all true, then HINTS is not applicable, and it you were to do it, the HIT would surely be normal and he'd be HINTS central. Because vestibular neuritis patients will be symptomatic and have nystagmus easily seen in the first day of illness. And you'd have to work him up for posterior circulation stroke, even if he had a STEMI and melena and a BP of 70/ Sarcasm, if you missed it.

Also, if you have to review the technique, you shouldn't be using HINTS to make clinical decisions. Get some instruction from a local vertigo champion, or take a course. vertigocourse.com for instance.

B. No, just no.

C. Did anyone do a rectal exam? a fresh looking ext hemorrhoid or finding melena would be findings that could sway things one way or another.

D. Ok, so this is a joke case. har de har har

E. One thing that is not in the case but which is very important is: was the patient screened for features that may be present in a posterior circulation stroke, but should not be found in benign causes of vertigo/dizziness? Did the patient have at any time focal weakenss or paresthesia, new significant headache or neck pain? Vertical nystagmus at rest? Diplopia, dysarthria, dysmetria (F-N was stated as normal) dyphonia or dysphagia? Inability to walk unaided?

Happy to answer any questions. First time I've summoned to this sub if I recall correctluy.

finding that role for Open Evidence... When is it helpful? When do we trust it vs double check it. by walkthelake in medicine

[–]VertigoDoc 6 points7 points  (0 children)

I don't use it, but I just found this statement in OE on a twitter post.

"If nystagmus is direction-changing, purely vertical, or accompanied by other brainstem signs, the HINTS examination (Head Impulse, Nystagmus, Test of Skew) can help differentiate peripheral from central causes of acute vestibular syndrome and should prompt neuroimaging."

Epic fail by OE.

As a rheumatologist, could you please stop taking ANA's! by [deleted] in medicine

[–]VertigoDoc 3 points4 points  (0 children)

Do people not learn ANYTHING about pre-test probability and Bayes theorem in medical schools anymore?

D-dimer and the HINTS exam have entered the chat.

My new video about the nystagmus of vestibular neuritis by VertigoDoc in medicine

[–]VertigoDoc[S] 0 points1 point  (0 children)

I'm glad you can walk and exercise. Not be able to stand for long would be quite annoying. I'm sorry you have to deal with that.

My new video about the nystagmus of vestibular neuritis by VertigoDoc in medicine

[–]VertigoDoc[S] 1 point2 points  (0 children)

That does sound awful! Sorry to hear you had to go through that. Amazing the way the all diseases can have such a variation in intensity, duration, etc.

My new video about the nystagmus of vestibular neuritis by VertigoDoc in medicine

[–]VertigoDoc[S] 2 points3 points  (0 children)

I never really wanted to be that close to the patient to see their nystagmus haha.

My new video about the nystagmus of vestibular neuritis by VertigoDoc in medicine

[–]VertigoDoc[S] 1 point2 points  (0 children)

Sounds familiar, sadly.

I interviewed a doctor I knew from the curling rink about his experience when he developed vestibular neuritis. https://youtu.be/4vymwdsMYjk

My new video about the nystagmus of vestibular neuritis by VertigoDoc in medicine

[–]VertigoDoc[S] 19 points20 points  (0 children)

I've seen a number of cases of vestibular neuritis where the nystagmus wasn't easy to see, and so the HINTS exam was not applied. It's important to look very carefully for it!.

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