What are the appropriate orders for a patient with dizziness following a whiplash injury from a motor vehicle accident?

Management of Dizziness Following Whiplash Injury

For a 40-year-old female presenting with dizziness following a whiplash injury from a motor vehicle accident, the Dix-Hallpike test should be performed to evaluate for benign paroxysmal positional vertigo (BPPV), as this is the most appropriate initial diagnostic approach.

Initial Assessment

• Dizziness following whiplash injury is common, occurring in 25-50% of cases, and requires specific evaluation to determine the underlying cause 1
• The patient's description of "dizziness with certain head movements" strongly suggests a positional vertigo, which is characteristic of BPPV 2
• BPPV accounts for approximately 33.9% of vertigo cases following whiplash injury 3

Diagnostic Testing

Primary Diagnostic Test

• Dix-Hallpike positional testing should be performed as the initial diagnostic maneuver to evaluate for posterior canal BPPV 2
  • This test involves moving the patient from sitting to supine position with the head turned 45 degrees to one side and extended 20 degrees below horizontal
  • A positive test elicits characteristic nystagmus and reproduces the patient's symptoms

Secondary Diagnostic Tests

• Supine roll test should be performed if Dix-Hallpike is negative but lateral canal BPPV is suspected 2

  • This involves turning the patient's head rapidly to each side while in supine position

• MRI of the cervical spine should be considered if positional testing is negative and there is concern for ligamentous injury 2

  • MRI has high sensitivity for cervical ligament injury but may overestimate severity with false-positive rates of 25-40% 2

Treatment Approach

If BPPV is Diagnosed

• Canalith repositioning procedures (CRPs) should be performed immediately upon diagnosis 2
  • For posterior canal BPPV: Epley maneuver
  • For lateral canal BPPV: Gufoni maneuver or barbecue roll maneuver
  • 55.5% of patients with post-traumatic BPPV have relief after the first repositioning maneuver 3

If Cervicogenic Dizziness is Diagnosed

• Vestibular-balance rehabilitation exercises should be prescribed 4
  • These exercises have been shown to be effective in reducing dizziness and improving quality of life in patients with whiplash-associated disorders
  • A program of 12 sessions has demonstrated significant improvement in dizziness handicap inventory scores 4

Follow-up Care

• Patient education regarding the nature of positional vertigo and potential for recurrence 2
• Written home exercise instructions should be provided, as patients rarely remember verbal discharge instructions 2
• Follow-up evaluation within 1-2 weeks to assess response to treatment and need for additional repositioning maneuvers 3

Important Considerations

• Post-traumatic BPPV may require more repositioning maneuvers than idiopathic BPPV to achieve satisfactory results 3
• Patients with whiplash may have multiple causes of dizziness, including BPPV, cervicogenic dizziness, and potential vertebrobasilar insufficiency 1, 5
• Avoid unnecessary imaging studies in isolated dizziness without other neurological deficits, as diagnostic yield is low (CT <1%, MRI 4%) 2
• Consider the patient's risk for falls and provide appropriate precautions until symptoms resolve 2

Pitfalls to Avoid

• Do not rely solely on cervical spine X-rays to rule out significant injury in patients with persistent symptoms 2
• Avoid prescribing vestibular suppressant medications as they may delay central compensation and recovery 2
• Do not overlook the possibility of BPPV as a cause of dizziness following whiplash, as it is easily diagnosed with bedside testing and effectively treated with repositioning maneuvers 3