01Approach to the Critical Patient/attcp45

Immediate priorities

›Stabilization and safety

›Airway compromise from vomiting or aspiration risk

›If active emesis with inability to protect airway, escalation for airway management

›Hemodynamic instability

›If shock or syncope, alternate diagnosis pathway

›Severe dehydration

›IV isotonic fluids with reassessment

›Time of symptom onset

›Last known well for stroke pathway

›Posterior circulation stroke exclusion priority

›If focal neurologic deficit, immediate stroke protocol activation

Time critical exclusions

›Dangerous mimics

›Posterior circulation ischemic stroke

›If central signs on oculomotor testing, urgent MRI brain with diffusion if available

›Intracranial hemorrhage

›If thunderclap headache or severe hypertension with neurologic change, noncontrast CT head

›Meningitis or encephalitis

›If fever or meningismus, infection pathway

›Toxic exposure

›If intoxication or polypharmacy, tox and medication adverse effect pathway

›Acute coronary syndrome

›If chest pain or diaphoresis, cardiac pathway

Key bedside decision points

›Syndrome patterning

›Acute vestibular syndrome definition

›Continuous vertigo for hours to days

02History/hx49

Presenting features

›Symptom characterization

›Vertigo quality

›Continuous spinning sensation

›Onset timing

›Sudden or subacute over hours

›Duration

›Persistent over days

›Triggers

›No positional trigger predominance in vestibular neuritis

›Associated nausea or vomiting

›Severity and oral intake tolerance

›Gait impairment

›Ability to walk unassisted

Auditory and neurologic modifiers

›Symptom modifiers

›Hearing loss

›Presence suggests labyrinthitis or stroke rather than isolated vestibular neuritis

›Tinnitus

›Presence suggesting Ménière spectrum

›Aural fullness

›Ménière spectrum clue

›Headache

›New severe headache increasing central concern

›Diplopia

›Central sign

›Dysarthria or dysphagia

›Central sign

03Physical Exam/exam37

General and neurologic screen

›Baseline assessment

›Vital signs pattern

›Fever suggesting infection alternative

›Mental status

›Alteration suggesting central or toxic alternative

›Cranial nerve screen

›Facial droop

›Dysarthria

›Dysphagia

›Diplopia

›Motor and sensory screen

›Focal weakness

›Focal sensory loss

›Cerebellar testing

›Limb dysmetria

›Truncal ataxia

Oculomotor and vestibular exam

›Peripheral vs central findings

›Nystagmus characterization

›Unidirectional horizontal or horizontal torsional

›Direction changing gaze evoked nystagmus suggesting central cause

›Pure vertical or pure torsional suggesting central cause

›Head impulse test

›Abnormal catch up saccade toward affected side suggesting peripheral lesion

›Normal head impulse in acute vestibular syndrome suggesting central cause

›Test of skew

›Vertical ocular misalignment suggesting central cause

04Differential Diagnosis/ddx35

Life threatening and time sensitive

›Central causes

›Posterior circulation ischemic stroke ICD-10 I63.9

›Brainstem or cerebellar infarction

›Transient ischemic attack ICD-10 G45.9

›Transient focal deficits

›Intracranial hemorrhage ICD-10 I62.9

›Headache and neurologic change

›Vertebral artery dissection ICD-10 I77.74

›Neck pain and trauma or manipulation history

›Meningitis ICD-10 G00.9

›Fever and meningismus

›Encephalitis ICD-10 G04.90

›Altered mental status and fever

Common peripheral vestibular causes

›Peripheral causes

›Vestibular neuritis ICD-10 H81.2

›SNOMED CT concept Vestibular neuronitis

›Labyrinthitis ICD-10 H83.0

›Hearing loss plus acute vestibular syndrome

›Benign paroxysmal positional vertigo ICD-10 H81.1

›Brief positional episodes

›Ménière disease ICD-10 H81.0

›Episodic vertigo plus fluctuating hearing symptoms

›Vestibular migraine ICD-10 G43.809

›Migraine features or history

Other mimics

›Non vestibular mimics

05Laboratory Tests/lt24

Core tests for alternate diagnoses

›Screening labs when indicated

›Capillary glucose for altered mentation or diabetes risk

›Hypoglycemia alternative

›Electrolytes including sodium and potassium for persistent vomiting

›Hyponatremia

›Hypokalemia

›Creatinine for IV contrast planning

›CT angiography pathway support

›Pregnancy test for reproductive age with medication planning

›Medication safety pathway

Targeted labs for specific concerns

›Conditional labs

›CBC for fever or infection concern

›Leukocytosis support for infection pathway

›C reactive protein for infection or inflammation concern

›Nonspecific marker

›Troponin for chest pain or high risk cardiac symptoms

›Acute coronary syndrome alternative

›Toxicology screen for suspected intoxication

›Sedative or alcohol alternative

Interpretation and pitfalls

›Limitations

›Normal labs do not exclude stroke in acute vestibular syndrome

›Imaging and exam driven decision making

›Mild electrolyte derangements can worsen dizziness symptoms

›Correction supportive rather than diagnostic

06Diagnostic Tests/dt29

Scoring Systems

›Bedside algorithms and scales

›HINTS family testing in acute vestibular syndrome

›Head impulse abnormal supporting peripheral lesion

›Direction changing nystagmus supporting central lesion

›Skew deviation supporting central lesion

›New unilateral hearing loss supporting central AICA pathway

›NIH Stroke Scale for suspected stroke

›Higher score supporting stroke pathway intensity

›ABCD2 score for suspected TIA

›Not validated to rule out posterior circulation stroke

MRI

›MRI brain pathways

›MRI brain with diffusion for suspected posterior circulation stroke

›Highest yield in cerebellar and brainstem ischemia

›Early false negative risk

›If high suspicion with negative early MRI, repeat imaging strategy

›MRI internal auditory canal in atypical or recurrent presentations

›Vestibular schwannoma alternative in chronic symptoms

CT

›CT based pathways

›Noncontrast CT head for hemorrhage concern

›Headache or altered mental status triggers

›CT angiography head and neck for suspected dissection or stroke

›Neck pain or trauma triggers

›Posterior fossa limitation

›Noncontrast CT low sensitivity for early posterior circulation ischemia

07Disposition/dispo22

Admission and observation criteria

›Higher acuity pathways

›Suspected central etiology

›Stroke protocol admission

›Inability to ambulate safely

›Observation or admission for fall risk and rehab planning

›Intractable vomiting

›IV antiemetics and hydration requirement

›Significant dehydration or electrolyte derangement

›Correction and monitoring

›New hearing loss

›Otolaryngology or neurology evaluation depending on findings

Discharge criteria and follow up

›Safe discharge pathway

›Peripheral pattern on exam without red flags

›No focal neurologic deficits

›Able to ambulate with minimal assistance

›Home safety assessment

›Oral intake tolerated

›Controlled nausea

›Reliable follow up access

›Primary care or otolaryngology

›Vestibular rehabilitation referral

›Early initiation plan

08Treatment/t55

Symptom control and hydration

›Supportive care

›IV crystalloid for dehydration

›Normal saline 1 L bolus

›Reassessment after bolus

›Antiemetics

›Ondansetron ODT 4 mg

›Repeat every 8 hours as needed

›Ondansetron IV 4 mg

›Repeat every 8 hours as needed

›Metoclopramide IV 10 mg

›Repeat every 6 to 8 hours as needed

›Prochlorperazine IV 10 mg

›Repeat every 6 to 8 hours as needed

›Vestibular suppressants short term only

›Meclizine PO 25 mg

›Repeat every 6 hours as needed

›Dimenhydrinate PO 50 mg

›Repeat every 6 hours as needed

›Dimenhydrinate IV 50 mg

›Repeat every 6 hours as needed

›Lorazepam PO 0.5 mg

›Repeat every 8 hours as needed

Anti inflammatory therapy

›Corticosteroid consideration

›Prednisone PO 60 mg daily

›Taper over 10 to 14 days

›Methylprednisolone PO 100 mg daily

09Special Populations/sp24

Pregnancy

›Pregnancy considerations

›Diagnostic priorities

›Stroke remains possible in pregnancy and postpartum

›Imaging risk benefit discussion for MRI and CT angiography

›Medication safety

›Meclizine generally considered compatible in pregnancy

›Benzodiazepines avoidance when possible

›Hyperemesis overlap

›Dehydration pathway and electrolyte correction

Geriatric

›Older adult considerations

›Higher pretest probability of stroke

›Lower threshold for MRI diffusion and neurology involvement

›Polypharmacy risk

›Sedative load review before vestibular suppressants

›Fall risk

›Mobility assessment and assistive device plan

Pediatrics

›Pediatric considerations

›Lower incidence of vestibular neuritis

›Alternate diagnoses prioritization

›Weight based medication dosing

›Ondansetron PO or ODT 0.15 mg per kg

›Maximum single dose 8 mg

›Dehydration risk with vomiting

›Oral rehydration strategy when tolerated

10Background/b25

Epidemiology

›Population features

›Typical age range

›Young to middle aged adults common

›Seasonality association

›Viral illness temporal association

›Recurrence

›Generally uncommon but possible

Pathophysiology

›Mechanism

›Acute unilateral vestibular nerve dysfunction

›Peripheral vestibular hypofunction

›Proposed etiologies

›Viral inflammation

›Reactivation of latent herpes viruses

›Ischemic mechanisms less common but considered in high risk patients

›Compensation

›Central vestibular adaptation over days to weeks

Therapeutic Considerations

›Treatment rationale

›Symptom control enabling hydration and mobilization

›Antiemetics and short term vestibular suppressants

›Early vestibular rehabilitation

›Promotes central compensation

›Steroid therapy hypothesis

›Anti inflammatory effect on vestibular nerve

›Avoidance of prolonged suppressants

›Prolonged use may delay compensation

11Patient Discharge Instructions/pdi25

Copy discharge instructions

›Discharge counseling

›Diagnosis explanation

›Inner ear nerve inflammation causing continuous vertigo

›Medication use

›Antiemetic as needed

›Vestibular suppressant only for worst symptoms and shortest duration

›Activity

›Slow position changes

›No driving until vertigo controlled

›Fall prevention at home

›Vestibular exercises

›Daily gaze stabilization and balance exercises as instructed

›Follow up

›Primary care within 2 to 7 days

›Otolaryngology or vestibular therapy referral

›Return to emergency criteria

›New weakness or numbness

›New trouble speaking or swallowing

›New severe headache

›Double vision

›Fainting

›Chest pain

›Inability to walk

›Persistent vomiting despite medications

›New hearing loss

12References/r14

Guidelines and evidence sources

›Clinical guidance sources

›Stroke society guidelines for suspected posterior circulation ischemia and acute stroke treatment pathways

›Class I recommendation framework for time critical stroke evaluation and reperfusion eligibility

›Emergency medicine literature on acute vestibular syndrome and HINTS family bedside testing

›Emphasis on central red flag identification

›Otolaryngology references on vestibular neuritis management

›Vestibular rehabilitation as core therapy

Key topics for updating local protocols

›Local protocol anchors

›MRI diffusion access and turnaround times

›Escalation pathway when early MRI negative with persistent central suspicion

›Vestibular therapy referral workflow

›Early outpatient initiation pathway

›Medication formulary alignment

›Antiemetic and vestibular suppressant options with geriatric precautions

Evidence & Review

Evidence & Review