The diagnosis and treatment of vertigo in the emergency department, the latest guide teaches you step by step

*For the reference of medical professionals, read 5 points to clarify the emergency points of vertigo! Dizziness is one of the common symptoms in emergency department.
Emergency doctors are often required to quickly determine the cause behind the vertigo, carry out symptomatic treatment, and more importantly, identify the emergency treatment that should be carried out in time, so that patients can be treated at the best time for intervention.

In April this year, the Vertigo Professional Committee of the Chinese Medical Education Association and the Emergency Physician Branch of the Chinese Medical Doctor Association published the "Guidelines for the Emergency Diagnosis and Treatment of Vertigo (2021)" in the Chinese Journal of Emergency Medicine, providing guidance for the diagnosis and treatment of vertigo under emergency conditions.
With professional suggestions, let's learn together.

What are the common symptoms related to "dizziness" in the emergency department? According to the classification of the symptoms of vestibular disease by the classification committee of the Bárány Association, the common symptoms in the emergency department are "vertigo" and some are "dizziness".

The main point of distinguishing dizziness from dizziness is that dizziness has no distorted sense of self-movement, that is, there is no illusion of movement or distortion.

It cannot be distinguished by whether it is caused by position, head movement, or visual induction, because dizziness and dizziness can be induced by the above factors.

If divided according to the vestibular syndrome, the common vestibular syndromes in the emergency department are acute vestibular syndrome (AVS) and episodic vestibular syndrome (EVS).

Common symptoms related to "dizziness" in the emergency department are shown in Figure 1.

Figure 1: Common symptoms related to "dizziness" in the emergency department, adapted from reference [1].

Emergency treatment of symptomatic medication dizziness can bring severe discomfort to patients, and is often accompanied by symptoms such as nausea, vomiting, and sweating.

Therefore, for patients with severe symptoms, it is necessary to give symptomatic anti-dizziness and antiemetic treatment.

The guideline recommends: For those with long-term and severe dizziness, especially those with more severe autonomic reactions such as nausea, vomiting, sweating, etc.
, vestibular inhibitors can be used for short-term control of dizziness symptoms (in principle, use no more than 72 hours), if necessary Can be treated with antiemetics.

The strength of recommendation is A, and the level of evidence is Ⅱ.

Commonly used anti-dizziness and antiemetic drugs in emergency department include promethazine hydrochloride injection, difenidol hydrochloride tablets, diphenhydramine hydrochloride injection and so on.

See Figure 2 for details.

Figure 2: Anti-dizziness and antiemetic drugs commonly used in emergency department [1].

Which vertigo needs urgent treatment? It must be clear which types of vertigo require urgent treatment so as not to lose the best time for treatment.

The three major types of diseases require emergency diagnosis to quickly determine the cause and carry out emergency treatment.

The details are as follows: First, central diseases.

For cerebral infarction in acute cerebrovascular disease, if the thrombolytic time window is in, thrombolytic therapy is required; it is in line with intravascular interventional therapy based on intravascular interventional therapy in time.

However, cerebral hemorrhage in acute cerebrovascular disease requires blood pressure control, lowering of intracranial pressure, and surgical treatment if necessary.

Other types of central vertigo include vestibular migraine, central nervous system demyelination disease, central nervous system infection, and space-occupying lesions of the fourth ventricle or cerebellum.

Second, diseases of the internal medicine system.

For example, water and electrolyte balance disorders need to be corrected; endocrine diseases, such as hypoglycemia, need to be supplemented in time; in addition, cardiovascular diseases, blood system diseases, autoimmune diseases, etc.
, while symptomatic treatment, don't forget to consult relevant departments .

Third, sudden deafness accompanied by dizziness, pay attention to hearing examination, and give timely treatment, will help to restore the patient's hearing.

Here, we also give you a high-level summary of the emergency vertigo treatment steps, as shown in Figure 3.

It can be seen that the types of vertigo in emergency patients are complex and diverse, and the patient's condition changes rapidly.

I hope that everyone will form a clear diagnosis idea, remember the situation that needs urgent treatment at all times, and deal with it calmly.

Figure 3: High-level summary of the steps of emergency vertigo treatment.
Professional examination.
Don't forget that vertigo diseases are very complicated.
The subspecialty of vertigo requires well-trained bedside vertigo-related physical examination training and mental logic training.

This edition of the guide has specially introduced an appendix to introduce the bedside examinations that should be carried out when receiving dizzy patients in the emergency department, including: 1) Spontaneous nystagmus, as shown in Figure 4.

Figure 4: The difference between peripheral nystagmus and central nystagmus, adapted from reference [1] 2) HINTS examination (head impulse, nystagmus, test of skew, HINTS), see figure 5.

Figure 5: HINTS inspection, adapted from reference [1] 3) Displacement test, including Dix-Hallpike inspection and Roll test inspection.

4) Balance function inspection, commonly used inspections include: Romberg and Mann test and gait assessment (straight-line walking test, in-situ stepping test, etc.
).

5) Ear examination.

6) Tuning fork inspection, see Figure 6.

Figure 6: Judgment of tuning fork examination results, adapted from reference [1] The complete vertigo diagnosis process guideline gives the emergency vertigo examination and diagnosis process in the main text.

To undertake the main text, the appendix separately lists the emergency treatment process for non-isolated vertigo and the emergency treatment process for isolated vertigo.

Here we show the three flow charts together (Figure 7-1~Figure 7-3) for your convenience.

Figure 7-1: Emergency vertigo inspection and diagnosis process, adapted from reference [1].

Figure 7-2: The processing flow of non-isolated vertigo, adapted from reference [1].

Figure 7-3: Processing flow of isolated vertigo, adapted from reference [1].

Vertigo is a common symptom in the emergency department.
Symptomatic treatment, treatment of the cause, and referral to specialist outpatient treatments all need to be justified.
The "Guidelines for the Emergency Diagnosis and Treatment of Vertigo (2021)" provide professional advice on the treatment of vertigo in the emergency department.
I have read the guide.
, Did you gain something? References: [1] Chinese Medical Education Association's Vertigo Professional Committee, Chinese Medical Doctor Association Emergency Physician Branch.
Guidelines for the Emergency Diagnosis and Treatment of Vertigo (2021)[J].
Chinese Journal of Emergency Medicine,2021,30(4):402-406.