Excellent overview. As a PT that provides Vestibular Rehab, I'm amazed at the seemingly million dollar work up that a lot of patients get when presenting to the ED with vertigo.
Great video, I'm an intern and my consultant had me order CT brain on a pt. I was fairly sure didn't need it but I wasn't confident enough to diagnose a peripheral cause clinically. Next time!
Hi, I am an emergency at the beginning of my practice and a new subscriber to your channel. I saw your vertigo algorithm in Tintinalli and have been using it to some extent. My question is, what about patients who present with symptoms suggestive of BPPV, but repeatedly negative Dix-Hallpike/supine roll tests? Off to imaging +/- neuro consult?
Good question. Negative, as in no dizziness induced and no nystagmus and no significant base-line dizziness? Patient cannot induce the symptoms by any movement? And also screens negative for central features such as seen on this video at this time stamp? ruclips.net/video/7V6Lrq7De6A/видео.html If a patient describes having had typical BPPV symptoms, screens negative for central features, has no acute gait problem, and has repeated DHT and SRT which do not induce dizziness or nystagmus, they probably have spontaneously resolved BPPV. In my opinion, safe for discharge, return if recurs.
@@PeterJohns Thank you for the answer. Sometimes I see a patient who will complain of the vertigo being triggered by motion only, and she'll say my DHT reproduces her vertigo ("oh yea doc, I see the room moving now"), yet I do not see any nystagmus in her eyes at that precise moment! Technically it is a negative result, but I'm not sure what causes her symptoms then... Usually I send these patients home (sometimes after a knee-jerk CT that shows nothing, shame on me), and after teaching them Epley maneuvers and return to ED instructions. In all of these cases so far, on followup call they say the maneuvers worked and the vertigo is gone... Edit: and yes I also do a basic cardiac workup and orthostatic vitals on this kind of case, which have always been negative in my short experience.
@@NN-rn1oz I rarely see this, but I have. There is something called subjective BPPV. Dizziness, but no nystagmus. Should have the same latency, duration and unilateral dizziness on DHT as in a positive DHT, but no nystagmus. Some think it's quite common, and others not so. The other possibility is that your patient might have vestibular migraine, which is very positional at times. See my video on vestibular migraine to learn how to make the diagnosis of vestibular migraine by taking a good history. ruclips.net/video/XPIyXiv0UKg/видео.html
@@PeterJohns Vestibular migraine makes total sense in some of the cases I've seen! One of the benign conditions that I nearly forgot completely. I realize I tend to overly focus on ruling out all the dangerous Ddx, sort of a caricature of the typical emergency physician. I often explain this approach to my patients and most are actually ok with it. But I can do better. Vestibular migraine can be very debilitating. I will make sure their GP's consider this Ddx on their followups. Thank you again.
Dr Johns, I am suffering from constant vertigo for 15 days now. I have done the test following your instructions and filming it so I can take a close look at the reaction of the eye during the test. The results are: 1. Unidirectional Nystagmus 2. NO abnormal Vertical Skew 3. Abnormal HIT I do understand this should be positive and it is no stroke. WHAT IS IT? WHAT CAN IT BE? I am now waiting for a "audiology" scan? What could be the reason of my vertigo? This condition has taken my everyday life and I feel desperate... I have tried the epley manouver but because my vertigo is lasting 15 days now, and because I saw your video, that one can't help me? Sorry for asking so many questions :( Greetings from Dubrovnik Croatia Indira
In english, dizziness is a word that people use to describe a number of sensations, including if they are suffering from a vestibular disorder. Vertigo has been defined by vertigo experts as a sensation of motion when there is no movement. But some patients with vestibular disorders will not describe their sensation like this. It's not uncommon for elderly patients suffering from BPPV to describe their brief sensation with turning over in bed as dizziness, but not spinning. So in order to be avoid missing vestibular disorders in all patients, many people, including myself, use dizziness/vertigo an umbrella term. If you speak another language, I'd be interesting in hearing about your experience with these terms.
@@PeterJohns Yes, I fully understand that patients use these words interchangeably but must clinicians do so also. ? By delimiting the diagnostic possibilities to those causing vertigo you usefully have narrowed the choices. Someone without medical knowledge seeing you use phrases like the Big Three of dizziness would get the wrong idea. If , in fact , you want to talk about dizziness the biggest cause , I think, would be medication such as anti hypertensives and hypnotics. Even clinicians viewing the video need to be advised of how vertigo or dizziness is now being used by you in the patients’ sense of meaning Please don’t think I’m not appreciative of your splendid work.
@@alfredopampanga9356 Of course, I appreciate your appreciation. This video was one of my early videos with my approach, made in 2015. The Big 3 of Vertigo was made in 2018. I am currently working a paper tentatively entitled The Road to Vertigo Competence. These perhaps makes it clearer what I am talking about.
Dr Johns, I am suffering from constant vertigo for 15 days now. I have done the test following your instructions and filming it so I can take a close look at the reaction of the eye during the test. The results are: 1. Unidirectional Nystagmus 2. NO abnormal Vertical Skew 3. Abnormal HIT I do understand this should be positive and it is no stroke. WHAT IS IT? WHAT CAN IT BE? I am now waiting for a "audiology" scan? What could be the reason of my vertigo? This condition has taken my everyday life and I feel desperate... I have tried the epley manouver but because my vertigo is lasting 15 days now, and because I saw your video, that one can't help me? Sorry for asking so many questions :( Greetings from Dubrovnik Croatia Indira
Thank you! I'm scared that an ear infection could be the cause. I feel a pressure in my left ear. It is not present if I take my medicine "VOLTAREN" / a painkiller the doctor gave me; but if I don't take the medicene the pressure rises and the vertigo gets to the worst level it can get. They will do the scan on the 22th but I didn't report this pressure in the ear since it started after I was examined.
Excellent video and great point at 6:22! I feel so bad for patients who have had this done to them in the midst of Acute Vestibular Syndrome.
Thanks again professor !!! Nice lessons !! Can now see a vertigo in emergency ! Actually I'm a neurosurgeon !
Excellent overview. As a PT that provides Vestibular Rehab, I'm amazed at the seemingly million dollar work up that a lot of patients get when presenting to the ED with vertigo.
Thank you this was super clear and concise.
Thanks. I am a primary care physician and this video is going to help me in my practice.
Every emergency physican should watch this video carefullly. it will save millions in unnecessary CT scans.
Nice job Dr. Johns. Very useful.
You should present this as CAEP if you haven't already.
wow! this is extraordinary. thank you!!
good job
simple and informative.. thx alot
Excellent presentation. Looking forward to the next video in the series.
Thank you sir
Amazing! Thanks for such a clear explanation and presentation!
That's fantastic and very helpful. Thanks a lot
Great video, I'm an intern and my consultant had me order CT brain on a pt. I was fairly sure didn't need it but I wasn't confident enough to diagnose a peripheral cause clinically. Next time!
I'm curious what you thought the patient had.
Thats sooo great. Thank you!
Thanks a lot. Really usefull
Thank you very much,, it is usefull
Thank you doctor
Is a pretty sound
How about a video on a meniers attack the full rotational vertigo the extreme vomiting and nausea the tinnitus and fluctuations in hearing.
Thanks a lot 🙏🙏🙏
Thanks!
Thank you!
Hi,
I am an emergency at the beginning of my practice and a new subscriber to your channel. I saw your vertigo algorithm in Tintinalli and have been using it to some extent. My question is, what about patients who present with symptoms suggestive of BPPV, but repeatedly negative Dix-Hallpike/supine roll tests? Off to imaging +/- neuro consult?
Good question. Negative, as in no dizziness induced and no nystagmus and no significant base-line dizziness? Patient cannot induce the symptoms by any movement? And also screens negative for central features such as seen on this video at this time stamp? ruclips.net/video/7V6Lrq7De6A/видео.html
If a patient describes having had typical BPPV symptoms, screens negative for central features, has no acute gait problem, and has repeated DHT and SRT which do not induce dizziness or nystagmus, they probably have spontaneously resolved BPPV. In my opinion, safe for discharge, return if recurs.
@@PeterJohns Thank you for the answer. Sometimes I see a patient who will complain of the vertigo being triggered by motion only, and she'll say my DHT reproduces her vertigo ("oh yea doc, I see the room moving now"), yet I do not see any nystagmus in her eyes at that precise moment! Technically it is a negative result, but I'm not sure what causes her symptoms then... Usually I send these patients home (sometimes after a knee-jerk CT that shows nothing, shame on me), and after teaching them Epley maneuvers and return to ED instructions. In all of these cases so far, on followup call they say the maneuvers worked and the vertigo is gone...
Edit: and yes I also do a basic cardiac workup and orthostatic vitals on this kind of case, which have always been negative in my short experience.
@@NN-rn1oz I rarely see this, but I have. There is something called subjective BPPV. Dizziness, but no nystagmus. Should have the same latency, duration and unilateral dizziness on DHT as in a positive DHT, but no nystagmus.
Some think it's quite common, and others not so. The other possibility is that your patient might have vestibular migraine, which is very positional at times. See my video on vestibular migraine to learn how to make the diagnosis of vestibular migraine by taking a good history. ruclips.net/video/XPIyXiv0UKg/видео.html
@@PeterJohns Vestibular migraine makes total sense in some of the cases I've seen! One of the benign conditions that I nearly forgot completely. I realize I tend to overly focus on ruling out all the dangerous Ddx, sort of a caricature of the typical emergency physician. I often explain this approach to my patients and most are actually ok with it. But I can do better. Vestibular migraine can be very debilitating. I will make sure their GP's consider this Ddx on their followups. Thank you again.
"you might as well waterboard them" lol
Thank you sir
How can you exclude cardiovascular causes of Vertigo or Dizziness? Like postural hypotension, Arrhythmia, Anemia? Any approach Tips..
...with an ECG, FBC and by measuring their lying and standing blood pressure. Basic emergency department investigations.
Dr Johns,
I am suffering from constant vertigo for 15 days now. I have done the test following your instructions and filming it so I can take a close look at the reaction of the eye during the test. The results are:
1. Unidirectional Nystagmus
2. NO abnormal Vertical Skew
3. Abnormal HIT
I do understand this should be positive and it is no stroke.
WHAT IS IT? WHAT CAN IT BE?
I am now waiting for a "audiology" scan?
What could be the reason of my vertigo?
This condition has taken my everyday life and I feel desperate...
I have tried the epley manouver but because my vertigo is lasting 15 days now, and because I saw your video, that one can't help me?
Sorry for asking so many questions :(
Greetings from Dubrovnik
Croatia
Indira
You seem to use dizziness and vertigo interchangeably. This confuses me
In english, dizziness is a word that people use to describe a number of sensations, including if they are suffering from a vestibular disorder. Vertigo has been defined by vertigo experts as a sensation of motion when there is no movement. But some patients with vestibular disorders will not describe their sensation like this. It's not uncommon for elderly patients suffering from BPPV to describe their brief sensation with turning over in bed as dizziness, but not spinning. So in order to be avoid missing vestibular disorders in all patients, many people, including myself, use dizziness/vertigo an umbrella term.
If you speak another language, I'd be interesting in hearing about your experience with these terms.
@@PeterJohns Yes, I fully understand that patients use these words interchangeably but must clinicians do so also. ? By delimiting the diagnostic possibilities to those causing vertigo you usefully have narrowed the choices.
Someone without medical knowledge seeing you use phrases like the Big Three of dizziness would get the wrong idea. If , in fact , you want to talk about dizziness the biggest cause , I think, would be medication such as anti hypertensives and hypnotics.
Even clinicians viewing the video need to be advised of how vertigo or dizziness is now being used by you in the patients’ sense of meaning
Please don’t think I’m not appreciative of your splendid work.
@@alfredopampanga9356 Of course, I appreciate your appreciation. This video was one of my early videos with my approach, made in 2015. The Big 3 of Vertigo was made in 2018. I am currently working a paper tentatively entitled The Road to Vertigo Competence. These perhaps makes it clearer what I am talking about.
U jump from dizziness to vertigo and back as if interchangeable
ruclips.net/video/_sklwUilfg4/видео.html Watch this video, it explains why.
Dr Johns,
I am suffering from constant vertigo for 15 days now. I have done the test following your instructions and filming it so I can take a close look at the reaction of the eye during the test. The results are:
1. Unidirectional Nystagmus
2. NO abnormal Vertical Skew
3. Abnormal HIT
I do understand this should be positive and it is no stroke.
WHAT IS IT? WHAT CAN IT BE?
I am now waiting for a "audiology" scan?
What could be the reason of my vertigo?
This condition has taken my everyday life and I feel desperate...
I have tried the epley manouver but because my vertigo is lasting 15 days now, and because I saw your video, that one can't help me?
Sorry for asking so many questions :(
Greetings from Dubrovnik
Croatia
Indira
As the video says, the most likely diagnosis is vestibular neuritis. But only a health care professional in real life can advise you further.
Thank you!
I'm scared that an ear infection could be the cause. I feel a pressure in my left ear. It is not present if I take my medicine "VOLTAREN" / a painkiller the doctor gave me; but if I don't take the medicene the pressure rises and the vertigo gets to the worst level it can get.
They will do the scan on the 22th but I didn't report this pressure in the ear since it started after I was examined.
Excellent!!!!!