What is the best approach to manage an elderly female patient with persistent dizziness, nausea, and vomiting since a fall 3 weeks ago?

Management of Post-Traumatic Dizziness with Nausea and Vomiting in an Elderly Patient

This elderly patient requires immediate neurological assessment with head CT imaging to rule out delayed intracranial hemorrhage, followed by evaluation for post-traumatic benign paroxysmal positional vertigo (BPPV) if imaging is negative. 1, 2

Immediate Diagnostic Priorities

Critical Red Flags Requiring Head CT

The 3-week delay between fall and persistent symptoms does not exclude serious intracranial pathology. Obtain non-contrast head CT immediately if any of the following are present: 2

• Glasgow Coma Scale score < 15
• Any focal neurological deficit
• Persistent vomiting (as in this patient)
• Anticoagulant use
• Dangerous mechanism of injury
• Post-traumatic amnesia or loss of consciousness at time of fall

Delayed intracranial hemorrhage can present hours to days after seemingly minor head trauma with lightheadedness, altered mental status, or neurological deficits. 2 The sensitivity of CT for neurosurgical lesions is 94-96%. 2

If Neuroimaging is Negative: Evaluate for Post-Traumatic BPPV

Post-traumatic BPPV is the most likely diagnosis given the positional nature of symptoms (dizziness triggered by head movements) and absence of other neurological complaints. 1

Perform the Dix-Hallpike maneuver to confirm BPPV diagnosis. 1 The test is positive if it induces characteristic nystagmus with brief latency, increasing then decreasing intensity (fatigable pattern). 1

Key distinguishing features of BPPV: 3, 1

• Brief episodic vertigo triggered by specific head movements
• No auditory symptoms (hearing loss, tinnitus, ear fullness)
• Episodes typically last < 1 minute
• Fits the "triggered episodic vestibular syndrome" pattern

Treatment Algorithm

If BPPV is Confirmed:

Perform the Epley maneuver immediately—this is 80-90% effective and superior to any medication. 1 Do not prescribe vestibular suppressants or antiemetics for routine BPPV treatment. 3

Important caveat: Post-traumatic BPPV has a higher recurrence rate (up to 67%) compared to spontaneous BPPV and may require repeated treatments. 1

Short-Term Symptom Management Only:

Antiemetics may be used only for severe nausea/vomiting in the following limited circumstances: 3

• Patient refuses canalith repositioning procedure
• Patient becomes severely symptomatic after the Epley maneuver
• Prophylaxis before planned Dix-Hallpike maneuver in patients with previous severe nausea

Avoid benzodiazepines and vestibular suppressants in this elderly patient—these medications significantly increase fall risk, cause cognitive deficits, and interfere with vestibular compensation. 3 The risk of polypharmacy-related falls is particularly elevated in elderly patients taking multiple medications. 3

Critical Safety Measures

Fall Prevention (Essential in Elderly Patients):

This patient is at extremely high risk for recurrent falls. 1, 2 Implement immediately:

• Home safety assessment
• Supervision or assistive devices
• Activity restrictions until symptoms resolve
• Education on fall precautions

Mandatory Follow-Up:

Reassess within 1 week to evaluate response to Epley maneuver and repeat if necessary. 1 Then follow up at 1 month to document resolution or persistence of symptoms. 3

Red Flags Requiring Immediate Return:

Instruct patient to return immediately for: 2

• Worsening or new neurological symptoms
• Persistent nausea/vomiting despite treatment
• Gait disturbance
• New hearing loss
• Severe headache

Alternative Diagnoses to Consider

If Dix-Hallpike is negative or symptoms persist despite treatment: 3, 4

• Vestibular neuritis: Continuous vertigo lasting days, not positional
• Posterior circulation stroke/TIA: Especially if any neurological deficits present
• Orthostatic hypotension: Check supine and standing blood pressure (drop ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes indicates orthostatic hypotension) 2
• Medication adverse effects: Review all medications for vestibular side effects

If symptoms do not respond to canalith repositioning procedures or persist beyond expected timeframe, consider vestibular rehabilitation therapy and repeat neuroimaging. 1