What is the initial approach to managing dizziness in a hospital inpatient under physiatry care?

Initial Management of Dizziness in Hospitalized Patients Under Physiatry Care

The initial approach to managing dizziness in hospitalized patients under physiatry care should focus on risk stratification to identify potentially life-threatening causes, followed by systematic evaluation and targeted treatment based on the specific type of dizziness identified. 1

Step 1: Risk Stratification and Differential Diagnosis

• Classify the dizziness based on timing and triggers rather than symptom quality (vertigo, presyncope, disequilibrium, or lightheadedness) 2
• Evaluate for "alarming symptoms" including syncope during exertion, syncope in lying position, absence of external factors, family history of sudden cardiac death, or slow recovery from syncope 1
• Differentiate between peripheral and central causes of dizziness, as central causes (such as posterior circulation stroke) require more urgent intervention 3
• Consider the three key categories of dizziness:
  • Acute vestibular syndrome (continuous dizziness lasting days)
  • Spontaneous episodic vestibular syndrome (recurrent spontaneous episodes)
  • Triggered episodic vestibular syndrome (episodes provoked by specific triggers) 2

Step 2: Focused Physical Examination

• Perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) when acute vestibular syndrome is suspected to differentiate between peripheral causes and stroke 3
• Conduct the Dix-Hallpike maneuver to diagnose posterior semicircular canal BPPV when vertigo with nystagmus is provoked by position changes 1
• Perform the supine roll test to assess for lateral semicircular canal BPPV if Dix-Hallpike is negative but history is compatible with BPPV 1
• Check orthostatic blood pressure to identify orthostatic hypotension as a potential cause 3

Step 3: Diagnostic Testing

• Do not routinely order radiographic imaging or vestibular testing for patients who meet diagnostic criteria for BPPV unless there are additional signs/symptoms inconsistent with BPPV 1
• Consider MRI for patients with acute persistent vertigo and neurologic deficits or when HINTS examination suggests central pathology 1
• Note that CT imaging has a low detection rate for central nervous system pathology in patients with normal neurologic examination (<1%) 1

Step 4: Initial Treatment Approaches

For BPPV (most common cause):

• Perform canalith repositioning procedures (Epley maneuver) for posterior canal BPPV 1
• Do not recommend postprocedural postural restrictions after canalith repositioning 1
• Consider vestibular rehabilitation as an adjunct treatment option 1

For vestibular neuritis/labyrinthitis:

• Consider a short course of corticosteroids 3

For Ménière's disease:

• Educate patients on dietary and lifestyle modifications (sodium restriction, avoiding caffeine/alcohol/nicotine) 1
• Consider a limited course of vestibular suppressants only during acute attacks 1

For medication-induced dizziness:

• Review and potentially modify the patient's medication regimen 4

For orthostatic hypotension:

• Consider alpha agonists, mineralocorticoids, or lifestyle changes 4

Step 5: Medication Management

• Do not routinely treat BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines 1
• For acute vertigo attacks associated with vestibular disorders, meclizine may be used for short-term symptomatic relief 5
• Be cautious with vestibular suppressants as they may delay central compensation and prolong symptoms 3
• All benzodiazepines carry significant risk for drug dependence and should be used sparingly 1

Step 6: Follow-up and Reassessment

• Reassess patients within one month after initial treatment to document resolution or persistence of symptoms 1
• Evaluate patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders 1
• Consider referral to specialists (neurology, otolaryngology, cardiology) for persistent or complex cases 1

Common Pitfalls and Caveats

• Misdiagnosis is common in dizziness patients, with studies showing 43% of emergency room diagnoses being corrected on follow-up 6
• Stroke can present with isolated dizziness without other neurological symptoms in 11% of cases 1
• Overreliance on symptom quality (vertigo vs. lightheadedness) rather than timing and triggers can lead to diagnostic errors 2
• Vestibular suppressants may provide symptomatic relief but can delay recovery by interfering with central compensation mechanisms 3
• Failure to recognize that 25-50% of patients with recurrent BPPV may have associated vestibular pathology that requires additional evaluation 1