Rosen & Barkin's 5-Minute Emergency Medicine Consult (769 page)

• Cerebellar infarct/hemorrhage
  
• Vertebrobasilar insufficiency
  
• Acute suppurative labyrinthitis
  
• Intractable nausea/vomiting
  
• Inability to ambulate
  

Patient with peripheral etiology and stable

Otolaryngology follow-up for suspected acoustic neuroma or perilymphatic fistula

• Primary care, neurology, or otolaryngology follow-up for all
  
• Epley and Semont maneuvers are extremely effective in treating BPPV.
  

• Isolated vertigo can be the sole symptom of stroke or bleed
  
• Central cause clues: Imbalance and/or ataxia out of proportion to vertigo
  
• Learn the specialized exam and repositioning techniques
  

• Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: Benign paroxysmal positional vertigo.
  Otolaryngol Head Neck Surg.
  2008;139:S47–S81.
  
• Chawla N, Olshaker JS. Diagnosis and management of dizziness and vertigo.
  Med Clin North Am
  . 2006;90(2):291–304.
  
• Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: Three-step oculomotor examination more sensitive than early MRI diffusion-weighted imaging.
  Stroke.
  2009;40:3504–3510.
  
• Kerber KA. Vertigo and dizziness in the emergency department.
  Emerg Med Clin North Am.
  2009;27(1):39–50.
  
• Olshaker S. Vertigo. In: Marx J, et al., eds.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice.
  St. Louis, MO: CV Mosby; 2010:93–100.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Dizziness
  
• Labyrinthitis
  

CODES

• 386.10 Peripheral vertigo, unspecified
  
• 386.11 Benign paroxysmal positional vertigo
  
• 780.4 Dizziness and giddiness
  

BASICS

• EDs and waiting rooms are areas of high prevalence for violence
  
• Higher risk associated with busier EDs
  
• Patients with primary psychiatric complaints are likely to be boarding >24 hr and may not be receiving psychiatric care
  
• Risk factors for violence in the ED:
  
  • Prior history of violence OR being a victim of violence
    
  • Patient arriving in police custody
    
  • Substance abuse history/intoxication
    
  • Poor impulse control
    
  • Male gender
    
  • Psychiatric illness (complex relationship to risk)
    
• No clear difference in risk associated with:
  
  • Ethnicity
    
  • Language
    
  • Education
    
  • Medical diagnosis
    

• Primary psychiatric problem:
  
  • Most commonly psychosis or mania, but associated with many different diagnoses
    
• Acute primary medical problem:
  
  • Infection
    
  • Metabolic:
    
    • Hypoglycemia
      
    • Hypoxia
      
    • Hypothermia or hyperthermia
      
  • Toxicologic:
    
    • Alcohol intoxication or withdrawal
      
    • Illicit drug intoxication or withdrawal
      
    • Sedatives
      
    • Pain medications
      
    • Anticholinergics
      
    • Steroids
      
  • Neurologic:
    
    • Seizure
      
    • Stroke
      
    • Head injury or bleed
      
    • Brain lesion or mass
      
• Chronic primary medical problem:
  
  • Dementia
    
  • Intellectual disability
    
  • Traumatic brain injury
    
• Criminal behavior or psychopathy
  

DIAGNOSIS

• Early signs of impending violence risk (nonspecific):
  
  • Loud speech
    
  • Physical agitation or tension (pacing, clenching fists, darting eyes)
    
• Later signs of impending violence risk:
  
  • Abusive or provocative language
    
  • Behaving irrationally; unable to comply with reasonable limit setting
    
  • Invading personal space
    
  • Eliciting anger in staff
    

• Prior history:
  
  • Violent behavior
    
  • Self-injurious behavior
    
  • Medical and psychiatric histories
    
  • Substance use history
    
  • Legal or criminal history
    
• Current HPI:
  
  • Recent substance use
    
  • Potential head injury
    
  • Pain or discomfort from medical or psychiatric symptoms or environment
    
  • Plan or threat of violence
    
• Indicators of a higher likelihood of medical etiology:
  
  • Age >40 without a history of similar symptoms or behaviors
    
  • Concurrently emerging medical complaints
    
  • Comorbid medical conditions commonly associated with mental status changes:
    
    • Neurologic problems (including seizure disorders, CNS infections)
      
    • Chronic cognitive impairment
      
    • Vascular or cardiovascular disease
      
    • Diabetes mellitus
      
    • Chronic pain treated with opiates
      
    • Inflammatory disorders treated with steroids
      
    • Cancer
      
    • HIV/AIDS
      
  • Recent traumatic injury
    

• Exam signs suggesting a medical cause for the mental status change:
  
  • Abnormal vital signs
    
  • Focal neurologic findings
    
  • Seizure activity
    
  • Speech or gait deficits without evidence of alcohol or substance abuse
    

• Identify early warning signs
  
• Pay careful attention to findings during neurologic and mental status exams and note vital signs
  
• May be performed with the patient in restraints in an emergency
  

• Follow clinical indicators for further testing, but if planning a psychiatric admission, labs and/or imaging may be required
  
• Basic labs and ECG may be useful in assessing and monitoring risks associated with chemical restraint use
  

• CBC, electrolytes, BUN, creatinine, and glucose if medical cause is suspected or if psychiatric admission or chemical restraint use is likely
  
• Consider LFTs, Ca, Mg, and Ph if chronically medically ill or pursuing delirium
  
• Drug screen if ingestion is likely
  

CT head if bleed or stroke suspected

Obtain ECG if chemical restraint use is likely

TREATMENT

• Physically restrain violent patients and seek police assistance if necessary
  
• Keep weapons and other dangerous items (sharp objects, medications, cords, etc.) out of the patient’s reach
  

• Prevention:
  
  • Environmental:
    
    • Control access to ED: Secured doors, protected entrances, metal detectors, cameras
      
    • Visible security staff
      
    • Post visible rules stating clearly that weapons are not allowed
      
    • Exam room exits clear of obstruction
      
  • Procedural:
    
    • Identify high-risk patients at triage
      
    • Shorter ED wait times are helpful
      
    • Search/derobe patients after triage; if involuntary, ensure careful documentation of reasons in terms of risk to patient and providers
      
    • See to patients’ comfort quickly
      
    • Alleviate pain
      
    • Online alerts for patients with past history of violence in ED
      
    • Clear ED protocols for managing violence and documenting interventions
      
    • Enlist family support when possible; if not, remove family to safe place
      
    • Train all clinical staff to recognize and manage potentially violent situations
      
• Approaching the potentially violent patient:
  
  • Do not go alone
    
  • Remove your own personal articles that could be used as weapons (neckties, jewelry, trauma shears, etc.)
    
  • Keep 2 arm’s lengths between you and patient; open stance
    
  • Introduce yourself and try to address the patient’s concerns as soon as possible
    
  • Maintain open exit for patient and staff
    
  • Leave immediately and initiate seclusion or restraint if there is an open threat of violence or imminent violence seems likely