Rosen & Barkin's 5-Minute Emergency Medicine Consult (767 page)

• Emergent head CT (noncontrast) to evaluate for hemorrhage (parenchymal, subarachnoid, traumatic), large acute infarcts, prior pathology
  
• Thorough neurologic and cardiac exam
  
• Neurology consultation
  
• 12-lead ECG for arrhythmias and myocardial ischemia
  
• CTA and/or MRA for imaging of the posterior circulation
  

• CBC:
  
  • Anemia, thrombocytopenia; polycythemia, thrombocytosis
    
• Coagulation studies (PT/PTT):
  
  • Hypo- and hypercoagulable states; baseline values for anticoagulant and fibrinolytic therapies
    
• Electrolytes, BUN/creatinine, glucose
  
• Cardiac markers for concurrent myocardial ischemia
  
• Urinalysis
  
• ESR for systemic vasculitides
  
• Rapid plasma reagin
  
• Thyroid stimulating hormone
  
• Lipid profile
  

• Emergent head CT (noncontrast)
  
• Head and neck CT angiogram (CTA) for evaluation of posterior circulation and possible acute vascular intervention
  
• Chest radiograph; consider chest CTA for cardiopulmonary and great vessel pathology
  
• MRI/magnetic resonance angiography (MRA) for improved characterization of ischemic lesion and cerebrovascular circulation (e.g., congenital VB anomalies, exclusion of VA dissection)
  
• Echocardiography for intracardiac embolic source
  
• Cervical Doppler US
  
• Transcranial Doppler US
  

• Neuroangiography for diagnosis
  
• Directed intra-arterial thrombolytic therapy/angioplasty/stenting/embolectomy are still under investigation)
  

• CNS:
  
  • CVA (hemorrhagic or ischemic):
    
    • Cerebral
      
    • Cerebellar
      
    • Brainstem
      
  • Multiple sclerosis
    
  • Migraine syndromes
    
  • Seizure (focal)
    
  • Traumatic injury/postconcussive
    
  • Tumor
    
  • Vascular malformation hemorrhage (arteriovenous malformation, subarachnoid)
    
  • Brainstem herniation
    
• Peripheral nervous system:
  
  • Vestibular neuritis
    
• Ear, nose, throat:
  
  • Cerebellopontine angle tumor
    
  • Ear canal pathology (foreign body, tumor)
    
  • Labyrinthitis/otitis media
    
  • Ménière disease
    
  • Benign paroxysmal positional vertigo
    
• Cardiovascular:
  
  • Arrhythmia
    
  • Myocardial ischemia/infarct
    
  • Aneurysm/dissection (VA, basilar artery, subclavian artery, aorta)
    
  • Hypovolemia
    
  • Vasculitides
    
• Endocrine:
  
  • Adrenal insufficiency
    
  • Hypothyroidism
    
• Hematologic:
  
  • Anemia
    
  • Coagulopathy/hypercoagulable state
    
• Infectious:
  
  • Encephalitis/meningitis
    
  • Otitis media/mastoiditis
    
  • Septic shock
    
  • Syphilis
    
• Metabolic:
  
  • Hypoglycemia; hyperglycemia
    
  • Electrolyte imbalance
    
• Toxicologic:
  
  • Ataxia: Alcohols, lithium, phenytoin
    
  • Salicylism
    
  • Serotonin syndrome
    
  • Iatrogenic
    

TREATMENT

• ABCs
  
• Fingerstick glucose measurement
  
• Naloxone if indicated
  
• Notification:
  
  • Urgent contact with receiving facility if airway compromise or hemodynamic instability
    

• ABCs
  
• Administer oxygen
  
• Place on cardiac monitor and pulse oximeter
  
• Establish IV access with 0.9% normal saline
  

• Cerebrovascular perfusion management:
  
  • Supportive care
    
  • Supine position
    
  • Antiplatelet agent if no hemorrhagic source
    
  • Anticoagulation:
    
    • Consider in consultation with neurology if significant risk factors for embolic source, unstable or progressive ischemic symptoms
      
  • Ideal BP targets not well defined; maintain BPs within patient’s expected range (i.e., account for chronic hypertension)
    
• If hypotensive: Fluid resuscitation; vasopressors or blood as indicated
  
• If hypertensive: Administer titratable antihypertensive medications for severe HTN (mean arterial pressure >140 mm Hg, systolic BP >220 mm Hg, diastolic BP >130 mm Hg) or hemorrhage/aneurysm/dissection, myocardial or other end-organ dysfunction
  
• GI:
  
  • NPO (rehydrate with IV fluids; maintain normoglycemia)
    
  • Antiemetics
    
• Consultation:
  
  • Neurology
    
  • Vascular interventional radiology for neuroangiography
    

• Aspirin: 325 mg PO
  
• Clopidogrel: 75 mg PO
  
• Warfarin (dose for atrial fibrillation): 2–5 mg PO loading dose
  
• Heparin (dose for atrial fibrillation): 50–60 U/kg IV bolus, then IV infusion at 12–18 U/kg for target PTT 50–70 sec
  
• Labetalol: 20–40 mg IV over 2 min, then 40–80 mg IV q10min (max. 300 mg IV)
  
• Meclizine: 25 mg PO q8–12h
  
• Naloxone: 0.4–2 mg IM/IV q2–3min PRN
  
• Nitroprusside: 0.25–10 μg/kg/min IV infusion (max. 10 μg/kg/min)
  
• Ondansetron: 4 mg IV
  
• Promethazine: 12.5–25 mg PO/PR/IV q6–8h
  
• Ticlopidine: 250 mg PO BID
  

FOLLOW-UP

• ICU admission for:
  
  • Altered mental status with airway issues
    
  • Concurrent hemodynamic instability
    
  • Malignant cardiac arrhythmias
    
• Admit to hospital to identify or exclude etiologies of VB ischemia and to prevent recurrence or progression to VB circulation cerebrovascular accident, especially in the following populations:
  
  • Elderly
    
  • Inability to ambulate
    
  • Inability to tolerate oral intake
    
  • Inability to arrange (expeditious) outpatient follow-up
    
  • New or changing neurologic deficit
    
  • Persistent dizziness
    
  • Syncope
    
  • Vascular risk factors
    

• Consider discharge with outpatient follow-up in populations with the following:
  
  • None of above indications to consider admission
    
  • Alternative explanation for symptomatology
    

• VB ischemia-related referrals as arranged/recommended by admitting team
  
• Arrange expeditious referrals with PCP or appropriate specialist (e.g., neurology, otorhinolaryngology, vascular surgery) as indicated for alternative explanation for symptomatology
  

• VB ischemia-related follow-up as arranged/recommended by admitting team
  
• Urgency and nature of other follow-up as determined by alternative explanation of symptomatology
  

• Always consider VB insufficiency for dizziness, vertigo, mental status changes, syncope, and overlapping/atypical neurologic presentations
  
• VBI more likely to occur in patients with spontaneous vertigo lasting a few minutes with accompanying neurologic symptoms and who have cardiovascular risk factors
  
• Start antithrombotic/antiembolic treatments for VB insufficiency in the absence of contraindications
  

• Ishiyama G, Ishiyama A. Vertebrobasilar infarcts and ischemia.
  Otolaryngol Clin North Am
  . 2011;44:415–435.
  
• Love BB, Biller J. Neurovascular system. In: CG Goetz, ed.
  Textbook of Clinical Neurology.
  3rd ed. Philadelphia, PA: Elsevier; 2007:405–434.
  
• Marquardt L, Kuker W, Chandratheva A, et al. Incidence and prognosis of > or = 50%
  symptomatic vertebral or basilar artery stenosis: Prospective population-based study.
  Brain
  . 2009;132:982–988.
  
• Savitz SI, Caplan LR. Vertebrobasilar disease.
  N Engl J Med
  . 2005;352:2618–2626.
  
• Schneider JI, Olshaker JS. Vertigo, vertebrobasilar disease, and posterior circulation ischemic stroke.
  Emerg Med Clin North Am
  . 2012;30:681–693.
  

CODES

435.3 Vertebrobasilar artery syndrome

BASICS

• Dizziness, 3–4% of ED visits, difficult symptom to diagnose, describes a variety of experiences, including:
  
  • Vertigo
    
  • Weakness, fainting
    
  • Lightheadedness
    
  • Unsteadiness
    
• Vertigo, a hallucination of movement:
  
  • Spinning or turning
    
  • Sensation of movement between the patient and the environment
    
  • Oscillopsia (illusion of an unstable visual world)
    
  • Most patients have an organic etiology.
    
• Maintenance of equilibrium depends on interaction of 3 systems:
  
  • Visual
    
  • Proprioceptive
    
  • Vestibular
    
• Any disease that interrupts the integrity of above systems may give rise to vertigo.
  
• Peripheral vertigo:
  
  • Often, severe symptoms
    
  • Intermittent episodes lasting seconds to minutes, occasionally hours
    
  • Horizontal or horizontal–torsional nystagmus (also positional, fatigues, and suppressed by fixation)
    
  • Normal neurologic exam
    
  • Sometimes associated hearing loss or tinnitus
    
• Central vertigo:
  
  • Usually mild continuous symptoms
    
  • All varieties of nystagmus (horizontal, vertical, rotatory)
    
  • No positional association
    
  • Presence of neurologic findings most of the time